“TRiM”: a structured, informal, peer-to-peer assessment framework, delivered following traumatic incidents.
999 has been called for a 7-year-old Amy, who has been found seizing by her parents in her bedroom.
Although this is not her first seizure – she has a known aggressive brain tumour – she has been seizing far longer than normal: 17 minutes on ambulance arrival.
Her parents had given her rescue Buccolam at 5 minutes, and the ambulance crew have also given buccal midazolam with no improvement.
2-minutes prior to arrival at A&E following a pre-alert call, Amy goes into respiratory arrest.
Following handover in resus, Amy is ventilated and sent for a head CT, following which a discussion between the medical team and parents is had, and further treatment is stopped.
The ambulance crew ask the medical team for an update on their patient and are told the outcome. Then their radio buzzes, and they’re being asked to clear to attend another call.
Should the ambulance crew have received some support after attending the patient?
Mental health support for emergency care workers varies widely between NHS trusts in the UK. This is despite responders facing a higher risk of stress-related psychopathology than other workers. Much of the gap comes down to uncertainty — nobody is quite sure how best to engage staff.
Each year, the UK’s 999 and 111 phone lines handle around 110 million emergency and urgent calls. Roughly one in ten involve children. On average, 3,200 of these calls involve the death of a child aged 0 to 15, and many more involve children who are critically unwell or injured.
Responder anxiety around treating paediatric patients is a recognised priority in pre-hospital emergency care. Lack of exposure and knowledge gaps are key drivers.
Attending paediatric patients causes higher stress levels than attending adult patients. Children with special healthcare needs are reported to be especially challenging to treat. Staff cite medication dosages and communicating with the child and family as the main stressors.
Much of the fear around assessing and treating paediatric patients stems from a lack of exposure, combined with the pressure to provide the best possible care. Staff report feeling an increased sense of responsibility to get the assessment right and not miss anything, which heightens their anxiety in the moment.
This drive to deliver the highest level of care also shows up in ambulance response times: crews drive faster, on average, when attending a paediatric patient than when attending an adult. Interestingly, this stress response wasn’t reported for children with minor injuries or illnesses.
Reported concerns included;
- Emotions: Managing emotions, and feelings of powerlessness and frustration
- Managing the situation: The initial flood of concern depending on the immediate findings, managing parental expectations, having a patient the same age as the clinician’s own child
- Communication: Younger children being communicated with through parents compared to older children giving clinicians a sense of security
Many of these stressors are out of the clinician’s control. They’re simply inherent to being a child: innocence and the need for protection. Because they can’t be modified, the tools available to clinicians for managing this stress become even more important.
Acute stress and anxiety in the clinician attending a critically unwell child have been shown to cause medication errors in the in-hospital setting. It isn’t unreasonable to assume that clinical performance could be similarly compromised, or worse, in the pre-hospital setting, where conditions are far less controlled.
For pre-hospital clinicians, the psychological pressure of attending to a critically unwell child doesn’t end at hospital handover. This pressure can stay with personnel for an indeterminate length of time.
“When we face a dead child, the innocent image of the child stays in our mind for several days and causes us mental pressure, especially for the personnel who have children themselves”.
These stressors, and the fear of making mistakes, can build over time or appear after a single attendance. PTSD has a rising prevalence within the pre-hospital community.
14% of first responders have probable PTSD, which has profound impacts on other areas of personal life, including physical health, drug and alcohol misuse, and suicidality. Even the lower confirmed prevalence of ten per cent (as of 2008) is still far greater than in the general population. Among medical first responders specifically, prevalence is even higher, at 15%.
Concerningly, studies published as recently as 2024 have found that paramedicine students have a higher prevalence of PTSD still, with moderate PTSD present in 17.9% of paramedicine students.
Much of the research around paramedicine PTSD concludes with the same message: we need to do more to recognise and support those at high risk of PTSD within the pre-hospital community.
Amy’s ambulance attendance certainly hits these triggers: emotional, powerless, high parental stress and emotion, and a lack of patient improvement.
Despite what we know about clinician PTSD and its prevalence within the ambulance service, there remains a degree of stigma around seeking help and accessing the care available. This puts clinicians at risk of worsening symptoms. We need to monitor clinician mental health and identify those at high risk, so we can provide support when it’s needed most. What immediate support should be offered to those at high risk of stress-related psychopathology, to improve this?
Debriefing
Debriefs are easy to perform in the pre-hospital setting, and should be normal procedure, not reserved solely for catastrophic events. Debriefing provides psychological safety within the medical team, and allows for both clinical development and winding down after a high-pressure attendance.
“Hot” debriefing happens shortly after the event. It has the benefits of improved recall of what occurred, greater participant involvement, and an early opportunity to recognise any issues that could arise.
“Cold” debriefing tends to happen days or weeks after the incident, allowing staff who weren’t at the hot debrief to attend. It’s seen as complementary to the hot debrief, though it comes with downsides: poorer event recall, delayed learning, and the unavailability of some participants.
A hot debrief may reveal that a clinician needs immediate mental health support following an incident. A cold debrief, on the other hand, may help recognise those who are struggling in the days or weeks that follow.
A “hot” debrief between the ambulance crew and the consultant was held, but no further support requirements were identified.
Critical Incident Stress Debriefing
CISD is still used within the emergency services, although it has been widely criticised. Critics argue that CISD can be of no benefit, and may even cause harm by interfering with natural recovery. Some studies have found that CISD use can exacerbate PTSD symptoms rather than alleviate them, though others argue this may come down to how it’s applied, rather than the method itself.
Trauma Risk Management:
Trauma Risk Management (TRiM) is a peer-support system, delivered by trained peers within the organisation who don’t need to be clinicians, just trained in TRiM delivery. It originated in the UK armed forces and is designed around actively monitoring those exposed to traumatic events.
The police adopted TRiM following evidence of its benefit in the military, with no detrimental effects found. Police officers using TRiM reported lower levels of PTSD, felt there were fewer barriers to accessing further help, and found that having mental health difficulties was less stigmatised, compared to a non-TRiM group.
TRiM has been well used following major incidents within the police service. It offers immediate and continual support to individuals who need it, while also benefiting the organisation by identifying those more likely to need long-term support or long-term sick leave. Engaging with the TRiM programme has been associated with a reduction in sickness absence, especially among new and junior-ranking officers.
TRiM has also been used effectively with ambulance clinicians. When North West Ambulance Service implemented TRiM, they found an increase in referrals to mental health services following attendances they thought might trigger acute stress, such as RTCs and cardiac arrests.
TRiM practitioners are the face of the process, the person the individual actually talks to. Support can be self-directed, in which the clinician requests help, or offered proactively, in which the TRiM practitioner identifies signs of distress and reaches out.
It may have been beneficial to use TRiM after Amy’s case, though it’s worth remembering that TRiM is entirely voluntary and that support could have been declined at that point.
The TRiM method works in line with NICE guidance for post-trauma management (NG116), which advises active monitoring for those with subthreshold PTSD symptoms within one month of a traumatic event, followed by a one-month review. Active monitoring is also known as “watchful waiting”: regularly checking in on a person without providing clinical intervention. This allows those without an immediate PTSD response to continue as normal, while those with a staggered or delayed response are picked up and appropriately signposted to available support.
NG116 also recommends against offering psychologically-focused debriefing, such as CISD. The rationale is that watchful waiting without intervention is better than ineffective intervention. This doesn’t mean the non-psychologically focused hot/cold debrief models, or structured debrief models, are incorrect; they’re still encouraged by multiple sources.
What is the procedure for TRiM implementation?
There are two key peer-to-peer risk assessments.
Initial assessment
Within 72 hours of the incident, a TRiM practitioner will evaluate immediate psychological risk. This helps identify individuals who are, or may be, struggling to cope in the aftermath of the event, and who may benefit from additional observation or require early referral to professional support.
Follow-up assessment
Approximately four weeks later, the same practitioner will talk with the individual again, to review their emotional recovery and assess for any improvement, stability, or deterioration in their wellbeing.
TRiM practitioners are trained to recognise which changes in these assessments trigger the need for further intervention.
This isn’t to say that every critical paediatric attendance will trigger a mental health decline in pre-hospital clinicians. But it does show that psychological safety is needed for those regularly exposed to high levels of stress, especially from paediatric cases. TRiM is a simple yet highly effective peer support programme. It can easily help those at risk of struggling, and provide a long-term benefit to those regularly exposed to traumatic situations.
Although informal, TRiM assessments are grounded in evidence-based practice and known risk factors. This approach allows for open conversation, a reduction in stigma, and support for clinicians, so they don’t feel alone and unsupported following a distressing incident. Any risk factors identified during these TRiM sessions can be signposted to more formal support, to better protect clinicians’ mental health.
The ambulance service is learning, and the stigma around mental health is lessening. TRiM can only help increase these support options and improve the wellbeing of pre-hospital clinicians.
Every clinician will respond to a patient like Amy differently. But using TRiM would have enabled quicker identification of a clinician at risk of PTSD, and therefore quicker access to formal mental health support, had it been needed.
The Bottom Line
Paediatric attendances are uniquely stressful for pre-hospital clinicians, driven by factors clinicians can’t control, a child’s innocence and vulnerability, not by any failing on their part.
This stress carries a real cost: PTSD prevalence is markedly higher among first responders than the general population, and higher still among paramedicine students and medical first responders specifically.
Stigma, not lack of evidence, is often what stands between clinicians and the support they need.
Debriefing (hot and cold) still has a place, but shouldn’t be reserved only for catastrophic events; it works best as normal practice.
TRiM offers a structured, voluntary, peer-led alternative to formal psychological debriefing, in line with NICE guidance, and has a track record of reducing sickness absence and improving access to help.
The goal isn’t to catch every clinician after every case. It’s to build a culture where checking in is routine, so the clinicians quietly struggling don’t go unseen.
References
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