Part Two of a Two-Part Series
Stress injury, the damage that ensues when a stressor overwhelms a person's capacity to integrate or make sense of it, occurs on a spectrum, resulting in short- and long-term effects that can include pain, impairment, disruption, and dysfunction. Fortunately, research has illuminated that stress injuries are preventable, treatable, and even reversible.
Psychological first aid is an evidence-based practice that uses practical and adaptable interventions to mitigate stress injuries in real time. It is not intended to replace the definitive care of psychiatrists and psychologists or to counsel or cure. Instead, psychological first aid is analogous to physical first aid, serving to initiate earlier care and support while patients are experiencing stress. It has the power to change patient outcomes if initiated successfully.
Our first article last month addressed how establishing a sense of safety is the first pillar of psychological first aid. (“What If Words Could Prevent Post-Traumatic Stress Disorder?” EMN. 2020;42:24.) Four other pillars, however, are integral parts of relieving stress injury.
Reducing hyperarousal is arguably the primary goal of psychological first aid. Extreme levels of emotionality during and after traumatic events can lead to panic attacks, and may predict subsequent post-traumatic stress disorder. (Psychiatry. 2007;70:283.) Psychological first aid's primary goal is to decrease emotional arousal and prevent more severe forms of stress injury like PTSD. It is logical that creating calm serves as the primary intervention.
Patients often experience an amygdala hijack during distressing events. This emotional center of our brain overwhelms the decision-making part during extreme or significant stress. Our amygdala and limbic system fire during the fight-or-flight response, and our cortex, the decision-making part of the brain, is unable to function.
How do we bring calm to chaos? Studies have shown that labeling an emotion—naming it using logical words like fear, anger, and regret—disrupts the amygdala hijack. Tactics like grounding, voice modulation, deep breathing, and mirroring are also effective tools worth exploring.
Remember, the first pulse you should check on the scene should be your own. We must calm ourselves before we can calm our patients. Your demeanor as a clinician should be calming and healing.
Involving a patient in his own care, particularly during an emergency, instills confidence that he is capable of helping in his own rescue. (McGladrey L.  Psychological First Aid and Stress Injuries. In: Hawkins SC. Wilderness EMS. Wolters Kluwer, Philadelphia.) It directly targets the stress injury formation risk factor of helplessness while promoting patient autonomy. Physically speaking, involving your patient in his own rescue also counteracts the amygdala hijack. It taps into the decision-making functions of the brain while decreasing limbic firing. Having your patient hold pressure on a wound and count his heart rate are tangible actions that involve simple problem-solving. Properly empowering your patient promotes that he has the skills to succeed. Empowerment without resources, however, is counterproductive and demoralizing. (Rappaport J.  In Praise of Paradox: A Social Policy of Empowerment over Prevention. In: Revenson T.A. et al. [eds] A Quarter Century of Community Psychology. Springer, Boston.) This dichotomy often leads to confusion about self-efficacy.
We can overcome this paradox by understanding that efficacy involves the individual and the team. Collective efficacy is reinforced by successful operations. (Psychiatry. 2007;70:283.) Practicing rescues as a unit with a train-like-you-fight mentality builds the skills and confidence for success. It is impossible to foresee the final outcome, but identifying and praising small successes as they occur reinforce the belief and reality of efficacy. The key is to be able to identify these successes and then direct focus to the next thing.
Establishing a connection with someone experiencing trauma is paramount. Lacking social connectedness and feeling alone through physical and mental isolation are strong risk factors for developing stress injuries. (McGladrey L.  Psychological First Aid and Stress Injuries. In: Hawkins SC. Wilderness EMS. Wolters Kluwer, Philadelphia.) It is incredibly effective to address patients by name during care and to ask them questions so they feel seen and understood. Palliative care clinicians are experts at connectedness when patients are facing critical challenges. A palliative care nurse practitioner with more than 20 years of clinical experience told us that her principal goal while interacting with patients and families is fostering a personal relationship by using specific words and actions. Saying “we” more frequently than “I” and “you” develops a patient's trust in your ability to provide meaningful support.
Talking with patients instead of at them, using touch when possible, and validating patients' feelings opens a two-way dialogue for stronger connection. Cicely Saunders, MBBS, the founder of the modern hospice movement, said a dying man said what he needed from those caring for him was to try to understand him.
Instilling hope in a patient during trauma and suffering can be incredibly difficult, especially when clinical information is limited. Guiding individuals toward positivity and hope in a genuine and honest way can help diminish despair so they can see the possibilities around them. Hope means different things to different people, perhaps a desire for a certain thing to happen or faith that a situation will improve. How can we maintain hope in the midst of an unforgiveable reality?
James Stockdale, a U.S. Navy admiral and aviator who spent seven years as a prisoner of war, said, “You must never confuse faith that you will prevail in the end, which you can never afford to lose, with the discipline to confront the most brutal facts of your current reality, whatever they might be.”
Hope shapes the filter through which we see the world and affects how we are able to react to our reality. Without hope, our perceived resources are limited, and we may interpret our circumstances as more dismal than they really are. (McGladrey L.  Psychological First Aid and Stress Injuries. In: Hawkins SC. Wilderness EMS. Wolters Kluwer, Philadelphia.) When practicing psychological first aid, we have found more often than not that hope naturally follows. When individuals feel safe and supported by calm, knowledgeable caregivers who remind them of their strengths and capabilities and allow them to be seen and understood, then feeling overwhelmed, helpless, and alone can subside. Perhaps that is enough to spark a glimmer of hope.
We know that post-traumatic stress injuries develop from exposure to or threat of death, serious injury, and violence. (McGladrey L.  Psychological First Aid and Stress Injuries. In: Hawkins SC. Wilderness EMS. Wolters Kluwer, Philadelphia.) Stress injuries form in the face of real events, but stem from our perception of our surroundings, so it is natural that treatment to prevent them could adjust our perspective.
Our words hold that power. As medical professionals, we are exposed to actual and threatened death daily, and the COVID-19 pandemic means worldwide psychological support is needed now more than ever. The beautiful thing about psychological first aid is that it benefits us and our patients. We cannot change our exposure to death, but we can change how we process and integrate it into our lives and practices.
Find out what makes you feel safe and what calms you down. Think about how you have felt empowered in difficult situations. How were you able to find connection when you were isolated and alone? We must explore our understanding of these principles before we can implement them for our patients.
Many emergency physicians already use techniques like these, and we hope psychological first aid guides us to a standard of care and ignites a movement in medical culture that improves healing of our patients and ourselves.
Info & Resources
Find more information about psychological first aid and stress injuries from the Responder Alliance: https://bit.ly/3jcjSOd.
Crisis hotlines staffed by responders can be reached at:
- Firefighters: (888)731-FIRE (3473)
- EMS: (206)459-3020
- Law Enforcement: (800)267-5463
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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. Dr. Brissonis a family medicine resident, EMT, paramedic, and flight paramedic. He is also a board-certified health care safety professional and hazard control manager.