NCEMSF: Stress Injury and Psychological First Aid

As EMS providers, we know the signs and symptoms of different kinds of shock, whether hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic—but can we identify those of psychological shock?

At the 2020 National Collegiate EMS Foundation conference in Boston, Mass., Steve Lanwermeyer, a NOLS wilderness medicine instructor and wilderness EMT, discussed how to recognize the presentation of stress injury in patients or fellow providers, how to provide first aid for it, and why it’s so critical that we do so early on. He emphasized how often stress injuries are overlooked, especially among professionals in emergency services. “People equate not processing situations with toughness,” he said. “Toughness and the need to process psychologically taxing events are not synonymous.”

Stress injury may be seen in patients who have just experienced a traumatic incident, or a first responder who has not processed one or cumulative stressful calls on the job. Lanwermeyer said psychological first aid is a non-therapeutic form of care—a simple demonstration of compassion to provide emotional support to someone in distress.  

Research shows that quicker intervention during the treatment phase helps prevent a traumatic event from “cementing” in the brain and causing long-term stress, so it’s important to initiate this aid immediately after or following an incident. Lanwermeyer said we have three brains (or regions of the brain) affected by trauma. One is the neocortex, which involves our rational and logical thinking. The limbic brain is home to our emotions, while the brainstem, or the “lizard brain,” is responsible for primal survival instincts, including the fight or flight response. After a psychological trauma occurs, a battle of sorts occurs between these three brains—first aid helps to diffuse this battle. This is why early recognition is important. Some or all of the following signs and symptoms can be observed in a patient with stress injury:

• Changes in communication (this will look different patient to patient, from clamming up to screaming)
• Pale, cool, clammy skin
• Extreme fixation on one thing (one person they’re particularly concerned about, one moment of the incident they keep talking about, etc.)
• Anxiety
• Nausea
• Hyperventilation; respiratory alkalosis
• Dizziness/trembling
• Tachycardia and tachypnea
• Anatomically guarded – body language is closed off, protective
• Dissociation from the present

Lanwermeyer suggested going beyond the ABCs in the assessment of a traumatized individual—consider what part of the brain your patient may be occupying. He provided five actions to take when treating a person with stress injury:

1. Create a sense of safety

When a person is undergoing acute stress, they behave according to the lizard brain (fight, flight or freeze), and it’s difficult to leave that state. First and foremost, remove the patient from the threat, whether that means completely removing them from a scene or simply turning them away from it or holding a sheet up to shield them. Once you’ve physically created a safe space for them, verbally reinforce it. Tell them they are safe now, and then reflect the evidence of their safety by telling them why and how they are safe (e.g. “The car accident is over, you’re out of your vehicle and now we are taking care of you in our ambulance to the best of our ability.”).

2. Create a sense of calm

Lanwermeyer discussed the well-known but worth-mentioning tenet: “It’s not your emergency, it’s the patient’s emergency.” Entering the scene in a state of calm makes a difference. Help calm the patient in a non-demeaning way, said Lanwermeyer. That can involve kneeling to get on their level, coaching them through breathing exercises, minimizing the number of people in their space—use your discretion to assess their needs based on each case.

3. Provide self and collective efficacy

Involve the patient in any problem-solving, self-care, or rescue. It's less work for you and keeps them engaged instead of panicked—teach them how to treat a blister or guide them in splinting themselves. Encourage them by highlighting the positive and reminding them of feats they have overcome so far (e.g. “Great job on the splint” or simply “You’re doing great so far”) so they aren’t dwelling on their pain or how far they are from the hospital.

4. Create a connection 

Build an on-scene relationship with the patient, said Lanwermeyer. Be mindful of your presentation—develop a good rapport with them as soon you step onto the scene by remaining nonjudgmental, kind, calm, and compassionate, and of course, professional. Offer to help them contact friends or family. Resist the urge to tell them everything will be okay and tell them you will do your best to get in contact with their loved ones.

5. Create hope

“Emphasize the present, practical and possible,” says Lanwermeyer. Psychological distress may keep an individual stuck in the past as they replay the incident(s) over and over. Ground them in the present by reminding them of what’s happening right now and what the next steps will be—use specific and accurate facts coupled with predictable and realistic steps (e.g. how you will get them off the scene and into definitive care, how they’re going home, who goes home first and why, and what resources are being utilized to get them to safety). Giving them a game plan to shift their focus on inspires hope—it reminds them that they aren’t trapped in this event.

Overall, Lanwermeyer said it's important to assess an individual with potential stress injury from a 30,000 foot view. Stress injury may not manifest itself in vital signs, he said, so pay attention to changes in behavior, events leading up to the chief complaint, and recognize that overlooking psychological injury and failing to provide first aid (if it's there) is detrimental to the patient.

Psychological first aid is “a powerful tool, one that you are all equipped as human beings to employ. Listen, get on their level and provide compassionate care,” said Lanwermeyer. Tell them that “they are safe, there is hope, and we can help. Let’s destigmatize and recognize that this is a problem.”

Valerie Amato, NREMT, is assistant editor of EMS World. Reach her at vamato@emsworld.com.