Part One of a Two-Part Series
First responders and emergency physicians are often the first interaction patients with mental health challenges have in seeking treatment. These are not limited to psychiatric cases. All of our patients facing life-threatening situations are at high risk for psychiatric, stress-related injury. Our interactions with survivors of trauma have a lasting impact on the outcome of patient experiences, and throughout these delicate encounters, words matter.
Experienced responders and clinicians know there is an art to interpersonal communication. Traditionally, however, this skill is rarely incorporated formally into medical education. What if communication were a teachable skill? Rather than seeing bedside manner as an extraneous art that one has or lacks, what if we viewed this kind of patient support as an essential part of care, even standard of care? Even more daring, what if these essential, teachable communication skills could prevent psychological injury? What if our words could prevent outcomes like post-traumatic stress disorder before they even begin to develop?
I began exploring these sensitive topics while working as a wilderness EMS responder through an experiential education externship in western North Carolina. I worked alongside EMTs and paramedics in the notoriously treacherous and wild Linville Gorge, a popular hiking and rock-climbing mecca in the southeast. My focus of study was a new psychotherapeutic technique known as psychological first aid and its utilization as a treatment for trauma and psychological injuries known as stress injuries.
Stress is a normal physiologic response, arguably even a survival mechanism. We experience a stress response that serves to protect us when we encounter a dangerous or threatening situation. This is analogous to our immune system's response to infection. We develop strong memories, flashbacks, and emotions, so we have the ability to recognize and respond in order to survive if we ever find ourselves in a similar situation. This is one of our oldest and most adaptive survival mechanisms still functioning to this day. It's actually pretty miraculous.
We get into trouble when our physiologic stress progresses into pathologic stress injury formation. We have historically used the nomenclature post-traumatic stress disorder. Post-traumatic stress responses can ultimately cause us tremendous pain and interfere in our daily lives, and using the word “disorder” reduces the entire spectrum of the pathology of stress to a binary illness. Doing so is no different from referring to diabetes as diabetic ketoacidosis disorder.
It is simply not true and narrows the spectrum of illness, which does nothing to help us prevent or treat the disease in real time. Utilizing the nomenclature “stress injury” allows us to view the illness progression just like any other injury formation pattern. Stress injury formation patterns develop on a spectrum, just like cardiac injury formation, pneumatic injury formation, or metabolic injury formation. We gain the ability to intervene and halt injury progression when we study these patterns. We can prevent diabetes from progressing and sometimes even from occurring in the first place, so why can't we prevent post-traumatic stress injury?
By definition, stress injuries are formed when a stressor or series of stressors overwhelms the person experiencing the stress or his capacity to integrate the stress or make sense of it. (McGladrey L. “Psychological First Aid and Stress Injuries,” in Wilderness EMS. Philadelphia: Wolters Kluwer; 2018, pp. 189-202.) Risk factors for stress injury formation include a sense of helplessness as well as isolation or prolonged distance from definitive care. In other words, we are at high risk of stress injury formation when we feel overwhelmed, helpless, and alone.
Psychological first aid is an evidence-based practice that employs practical and adaptable interventions that function to re-establish safety and decrease arousal in real time. Virtually any level of responder with the proper training can implement these techniques. Hobfoll and colleagues recommended five broad, evidence-based treatment principles in 2007 that became the foundation of the current psychological first aid model. (Psychiatry. 2007;70:283.) These five pillars are considered to be the standard of care for mitigating stress injury in real time: promoting safety, creating calm, encouraging self-efficacy, forming connection, and inspiring hope.
My fellow extern and I collaborated with an emergency physician, a licensed marriage and family counselor and addiction specialist, and a mental health nurse practitioner to provide psychological first aid training to EMS personnel throughout Burke County, NC. The focus of stress injury mitigation was that our words and demeanor as providers serve as treatment tactics, so our psychological first aid workshops were primarily directed toward analyzing the root of each of the principle words. Next month, we will delve into each of these key treatment pillars, but we start here with safety, which each individual uniquely defines.
What I consider safe likely differs from another individual's perception of safety. As a physician, I feel safest when I have confidence in my own knowledge and skillset and the training and support of my team. I build this confidence through practice and routine. Knowing that those in my support system have my back, I gain flexibility to move through risks and challenges toward success. If I know what makes me feel safe and be safe, I can help instill a sense of safety in my patients.
Establishing a sense of safety is vital for preventing stress injury formation because it reduces stimuli that are overwhelming the individual's nervous system. Neurobiology teaches us that it can be incredibly difficult to differentiate between reality and fantasy when the emotional centers of our brains are activated.
In other words, the physical fire may be doused, but the flames inside your patient's psyche may still be raging, and the physiological effects of this psychological fire can be detrimental to patient outcome. Taking the patient out of the line of sight of the offending entity, blocking ongoing stimuli such as loud sounds, and using the words safe or secure are ways that you as a provider can decrease hyperarousal and reinforce a sense of safety. Once the emotional fire is successfully doused, our bodies move toward a state of equilibrium that allows for understanding and healing to begin.
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Dr. Loewenbergis a graduate of the University of Tennessee Health Science Center College of Medicine and an upcoming emergency medicine resident at Virginia Tech Carilion Clinic in Roanoke. She is also a Wilderness EMT, NASAR Search and Rescue Technician, ACA Swiftwater Rescue Instructor, and an avid kayaker. Dr. Hawkinsis a full-time clinical emergency physician, an assistant professor at Wake Forest University School of Medicine, and the medical director of Starfish Aquatics Institute, Landmark Learning, Burke County EMS, and North Carolina State Parks. He also serves as the course director of the Carolina Wilderness EMS Externship. Follow him on Twitter at@hawkvox.