Preventing Invisible Wounds

For the past five years, faculty of the prehospital care program at LaGuardia Community College in New York City have studied the challenge of reducing the risk of post-traumatic stress disorder (PTSD) for patients served by emergency medical personnel. The effort has been led by a committee of senior faculty in consultation with specialists in psychological trauma affiliated with the Trauma Studies Center of the Institute for Contemporary Psychotherapy. The result is an innovative educational approach that gives LaGuardia’s EMS and paramedic graduates the knowledge, skills and confidence to respond to the terror and panic experienced by many emergency patients and their families.

Background

In their review of epidemiological studies of the prevalence of PTSD, Fran Norris, PhD, and Laurie Slone, PhD, of the National Center for PTSD found that at least 61% of adult American men and 51% of adult American women will at some point in their life experience or witness a life-threatening event.¹ While not all persons who experience psychological trauma go on to develop enduring psychological problems, 6.8% of Americans sometime in their life suffer the symptoms of PTSD as defined by the Diagnostic and Statistical Manual of Mental Disorder IV.² Symptoms that can emerge shortly after a traumatic event include exaggerated startle response, hypervigilance, increased irritability, sleep disturbance, poor concentration and painful intrusive memories.

Norris and Slone concluded that at any given time, between 1%–3% of the U.S. adult population suffers from PTSD. This figure amounts to somewhere around 6.3 million American adults.

As summarized by authors Sandy McFarlane and Rachel Yehuda, rates of recovery from PTSD vary widely.³ For example, 28% of survivors of the 1972 Buffalo Creek flood still suffered from PTSD 14 years after the event; on the other hand, a 1990 study found the PTSD rate in survivors of other floods ranged from 4.5% to 14.5% 16 months after the disaster.³ Given the wide disparity in recovery rates, how to prevent or at least minimize the debilitating psychological consequences of traumatic events is of great significance to professionals who encounter survivors of overwhelming stress.

Can PTSD be prevented? Some variables, such as severity of the trauma, previous traumatic experiences and pre-existing mental disorders, are beyond human control. However, research suggests two important protective factors—perceived social support and perceived control of one’s situation (referred to in social science literature as coping self-efficacy)—significantly reduce the risk of PTSD and in theory can be fostered by psychologically skilled personnel.

Perceived Social Support

Perceived social support is defined by social scientists as the perception that a person is cared for, valued and part of a group.⁴ The word perceived is important. A person may receive excellent social support (for example, first-rate emergency medical care) but still experience themselves as unimportant and alone. In surveys of trauma survivors, Fatih Ozbay, MD, and colleagues concluded that social support can enhance resilience to stress, help protect against developing trauma-related psychopathology, decrease functional consequences of trauma-induced disorders such as post-traumatic stress disorder, and reduce medical morbidity and mortality. Similarly, in a meta-analysis of post-trauma surveys, Krzysztof Kaniasty, PhD, found that among various risk/resilience variables that reduce risk of long-term post-trauma disorders, perceived social support tops the list as a protective factor.⁵

Ozbay’s and Kaniasty’s conclusions are supported in a survey conducted by consultants for the Trauma Studies Center. These consultants interviewed individuals who had received emergency care from EMT and paramedic personnel. The interviewees were eloquent and emphatic about the importance of the quality of social support they did or did not receive.

Consider the experience of one patient: “My partner was driving. A friend was in the back and I was in the passenger seat. The car hit black ice and skidded. My partner was severely injured and I had bad abrasions on my leg. The EMT team arrived with an atmosphere of camaraderie. They were joking back and forth with each other. They took no interest in me. They were very skillful. They had to get the door of the car open, which was very difficult, but the whole time they were joking with each other, tuned in to each other. One of them had a cell phone and was finishing up some conversation with a friend. The impact on me was disturbing and unsettling. I felt absolutely dismissed. I was irrelevant to their concerns.”

Contrast this experience to that of another patient: “I was hit by a car that ran through a red light on a busy New York street. My legs were fractured. I was in terrible pain and, since I was still flat on my back in the street, terrified that I would be hit again. The EMTs were great—consoling and tuned in. They reassured me that the police had all traffic stopped. They acknowledged that I was scared but told me they were going to stay right with me until we got to the hospital. It was an awful experience, but the EMTs made it a lot better than it could have been.”

As these testimonials illustrate, EMS providers are in a unique position to reduce the emotional distress of patients and can do so by skilled social support. On the other hand, indifference to patients’ need for social support adds to patient distress and puts them at higher risk for PTSD regardless of how medically skilled their emergency care.

Drawing on the consultants’ qualitative interviews and their own extensive experience in reassuring emergency patients, the faculty committee identified a number of simple interventions EMS providers can employ to reassure patients and their families that they are cared about, valued and in some way belong to the same social group as the emergency team. Examples include:

• On meeting the patient: “Hello, I am a paramedic. My name is David. My partner and I are here to take really good care of you.”
• In response to patient distress: “I know you are really scared. You are safe. We will stay right here with you.”
• If time and safety permits a common interest might be shared with the patient: “I see you are wearing a Yankees t-shirt. That’s my favorite team. How about you?”

Self-Efficacy

Perceived coping self-efficacy (self-efficacy for short) is defined by social scientists as a person’s confidence in their ability to manage their problems.⁶ Numerous surveys and interviews with survivors of traumatic stress support the conclusion that a patient’s sense of their own self-efficacy predicts the degree to which they will suffer post-traumatic symptoms. Charles Benight, PhD, and his colleagues studied the incidence of PTSD and other post-traumatic stress symptoms experienced by survivors of rape, terrorism, floods, fires and other natural disasters.^6–9 They consistently found that individuals who experience themselves as in charge of their circumstances and able to plan ahead are significantly less likely to experience psychological trauma symptoms.

The LaGuardia faculty committee considered how patients’ perceived self-efficacy might be fostered in the context of a medical emergency. Almost by definition, medical emergencies entail unanticipated situations in which individuals experience helplessness, confusion and disorientation. How in such circumstances can a person see themselves as in control of their lives? The committee reasoned that psychological stress might be neutralized if emergency personnel used interventions that were more or less the opposite of a trauma’s characteristics:

• To offset their sense of helplessness, patients can be offered choices: “Should I take your blood pressure on your right or left arm?”; “Do you prefer to be called by your first or last name?”
• Patients will be less disoriented if they can be helped to anticipate what is going to happen next: “I am going to insert a needle in your arm. It will pinch a bit, but then it should feel OK,”; “We are about to take you down the stairs. We will be careful not to let you fall.”
• Confusion can be reduced if patients can be helped to plan for their needs: “Do you need to bring anything with you to the hospital? What about an insurance card?”; “Should we call anyone for you?”

Interventions aimed at providing social support and fostering self-efficacy might seem nothing more than just being nice to a patient, but a lot more is going on. The effectiveness of these interventions is based on a new understanding of the biological underpinnings of psychological trauma. In essence, trauma theory suggests that the rush of adrenaline and cortisol released into the blood during a life-threatening situation dysregulates the formation of adaptive memory, resulting in the survivor continuing to “live in the past,” subject to flashbacks and hyperarousal.¹⁰ Trauma theory implies that the sooner cortisol and adrenaline levels fall to normal, the less likely the survivor is to have long-term psychological problems. The calming effects of social support and fostered self-efficacy are likely to support that process. This knowledge is revolutionizing ideas about how traumatized people should be treated and how PTSD might be prevented.

Unfortunately, prevention of psychological trauma is rarely an integral aspect of EMS education. If the topic is mentioned, it usually occurs in a short stand-alone course. Students usually have no chance to practice trauma-informed psychological interventions. The LaGuardia faculty committee concluded that psychological trauma prevention should become a standard component of every aspect of EMS education. As a matter of routine, trainees should learn to offer social support and encourage patient self-efficacy when they meet the patient, as they treat them and before they transfer them.

The eSCAPe Curriculum

The committee revised the LaGuardia prehospital curriculum to incorporate psychological trauma prevention in both didactic and practice aspects of its courses. A one-hour didactic class gives an overview of the neurobiology of psychological trauma and its prevention. Students are shown videos that demonstrate bad and good psychological treatment. Students are required to memorize a simple mnemonic device, escape psychological trauma, to help them remember the components of social support and self-efficacy:
e—every patient;
S—Provide social support;
C—Give patients choices;
A—Anticipate what will happen next;
P—Help patients plan and organize;
e—every time.

An essential component of the new curriculum is that it requires students to use the eSCAPe principles as they practice lab skills. For example, when students demonstrate placing a splint on a patient, they are expected to use one or more eSCAPe interventions:

• Social support: “Mrs. Jones, I am Dave and this is Bill. I see you are in pain from your leg. We are going to take very good care of you.”
• Anticipation: “Bill will take your blood pressure, and I am going to put a splint on your leg.”
• Choices: “After we put the splint on, would you like a blanket before we take you outside?”
• Planning: “Is there anyone you would like us to call? Is there anything you would like to bring with you to the hospital?”

Note that the eSCAPe skills do not necessarily have to be done in the same order as the mnemonic.

In 2015 and 2016, the eSCAPe curriculum was introduced to LaGuardia’s EMT and paramedic programs. Students and faculty completed qualitative and quantitative evaluations of the curriculum at the end of each program. The results were heartening and enlightening: Students found the LaGuardia eSCAPe principles easy to learn. The requirement to use them did not interfere with learning medical skills. Noteworthy was that students reported increased pride and confidence in their sense of themselves as professionals. An EMT student reported, “I didn’t know what to say to patients. Now I know what to do.” One paramedic said, “This has changed the way I practice in the field—every call is better.” Faculty concurred. It was not difficult to teach eSCAPe. Students understood the principles and were able to voice them as they practiced medical skills.

For the EMS profession, it is no exaggeration to say a new day is dawning in patient care. Emergency medical responders can be justifiably proud of the advances made in saving lives and minimizing physical harm. Starting today there is an opportunity to prevent the invisible wounds of PTSD too. In so doing, literally millions of people will be protected from enduring psychological pain.

The Northeast Resiliency Consortium

The eSCAPe project has been supported by the Northeast Resiliency Consortium (NRC), a group of seven community colleges in the Northeast region of the country dedicated to training resilient workers for resilient communities. Funded by a $23 million grant from the Trade Adjustment Assistance Community College and Career Training, the NRC, in partnership with Achieving the Dream and the Carnegie Foundation for the Advancement of Teaching, was formed to build a highly skilled, qualified workforce to help mitigate communities’ short- and long-term vulnerabilities. See northeastresiliency.org.

For more information, contact Christine Alvarez at christinea@lagcc.cuny.edu.

On Tuesday, October 4, from 5:30–6:30 p.m., Christine Alvarez, BS, EMT-P, and David Brenner, PD, MS, EMT-P, from LaGuardia Community College CUNY, will present “Preventing Invisible Wounds: Introducing Psychological Care into Prehospital Care” at EMS World Expo in New Orleans, LA. Register today at EMSWorldExpo.com.

References

1. Norris FH, Slone LB. Understanding research on the epidemiology of trauma and PTSD. PTSD Quarterly Research, 2013; 24(2): 1–13.

2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Publishing, 1994.

3. McFarlane AC, Yehuda R. “Resilience, vulnerability and the course of posttraumatic reactions.” In van der Kolk BA, McFarlane AC, Weisaet L (eds.), Traumatic Stress: The Effects of Overwhelming Stress on the Mind, Body and Society. London: Guilford Press, 1996.

4. Ozbay F, Johnson DC, Dimoulas E, Morgan CA, Charney D, Southwick S. Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry, 2007; 4(5):35–40.

5. Kaniasty K. Social support and traumatic stress. PTSD Quarterly, 2005; 16(2):3.

6. Benight CC, Bandura A. Social cognitive theory of posttraumatic recovery: the role of perceived self-efficacy. Behav Res Ther, 2004; 42(10):1,129–48.

7. Benight CC, Swift E, Sanger J, Smith A, Zeppelin D. Coping self-efficacy as a mediator of distress following a natural disaster. J Applied Social Psych, 1999; 29(12):2,443–2,464.

8. Benight CC, Freyaldenhoven RW, Hughes J, Ruiz JM, Zoschke TA, Lovallo WR. Coping self-efficacy and psychological distress following the Oklahoma City bombing. J Applied Social Psychology, 2000; 30(7):1,331–44.

9. Benight CC, Harper ML. Coping self-efficacy perceptions as a mediator between acute stress response and long-term distress following natural disasters. J Trauma Stress, 2002; 15(3):177–86.

10. van der Kolk B. The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. New York: Viking, 2014.

Rosemary Masters, JD, LCSW, is a psychotherapist who specializes in the treatment of psychological trauma. She is founding director of the Trauma Studies Center of the Institute for Contemporary Psychotherapy in New York City (see icpnyc.org/trauma). She has taught the theory and treatment of psychological trauma in Uganda and Russia and regularly presents seminars on psychological trauma to health, mental health, social service and educational agencies in the New York City metropolitan area.