You are driving home from a weekend of camping in the mountains with friends when you see a cloud of dust ahead of you on the two-lane highway. As you slow down, you realize that a vehicle in front of you has lost control, rolling over and coming to rest on its roof. You sigh; paramedics are always on duty and most of us don't pass by an accident even when it isn't legally our responsibility to stop. You call 9-1-1 but know that it is a rural area and some time will pass before EMS arrives. You don't have any equipment ...
What can you do for the patient with serious injuries until ALS arrives? Most of us feel quite ineffective in the absence of our transport vehicles, our oxygen bottles, our canvas bags filled with equipment and our cardiac monitors. However, even without equipment, EMTs and paramedics can do their patients incredible good by using "verbal first aid," a technique proven to lessen anxiety and speed healing in a number of scientific studies. These studies have demonstrated that patients who are ill or injured enter a state of mind in which they are very prone to suggestion, similar to the state of trance. By establishing rapport with the patient and using language designed to foster healing, EMS can be the first contact of healing, beginning the treatment process even without the equipment we are accustomed to.
Verbal first aid is a "language of healing that uses prescribed directives, suggestions, and signals to directly affect the body," says Judith Acosta, a clinical social worker and one of the authors of the book, The Worst is Over: What to Say When Every Moment Counts. Acosta has trained hundreds of EMTs, paramedics, firefighters and law enforcement officers in the techniques of compassionate crisis intervention that can help a patient weather the initial stages of the emergency and begin the healing process long before they arrive at the hospital. Acosta and her colleagues responded to the 2001 World Trade Center disaster to help EMS personnel, firefighters and law enforcement officers begin to heal from the devastating impact of what they experienced.
An example of verbal first aid is this initial patient encounter:
"The worst is over. My name is Winnie, and I'm a paramedic. I've called for EMS, and they are on the way. The hospital is making ready for your arrival. Take a deep breath, and let your body begin to heal. I'm right here with you, and I won't leave you until the other paramedics get here. The ambulance is on the way to take you to the hospital. Breathe deeply, and let your mind take you to somewhere you love. You're safe now, and the worst is over."
In a crisis, the autonomic nervous system enters the "fight or flight" state, in which blood pressure, heart rate and respiratory rate are elevated as the body goes into survival mode. Adrenaline (epinephrine) lessens our ability to use the prefrontal cortex of the brain the center of logical thinking and analysis in favor of the midbrain, which houses our survival mechanisms.
Researchers have found that this state also places a patient into a "healing zone" in which they are maximally open to the power of words and thoughts. The "healing zone" is defined as an altered state of consciousness created by stress, crisis, shock, confusion, physical trauma or fear. Research supports the premise that paramedics who use certain words and suggestions during a medical emergency can help trigger healing mechanisms and empower the patient to begin to feel a sense of control. Further, research has shown that verbal stimulation can trigger the right brain to produce neurochemicals that control the pituitary gland and endocrine system, affecting autonomic nervous system function. In a sense, "verbal first aid" involves talking to the autonomic nervous system to evoke a positive change in the patient and to empower them in crisis situations.
Stage One: The Healing Zone
Many of us have encountered patients in a state of physical and emotional crisis at the scene of an emergency. Physical signs may include changes in vital signs, such as tachypnea and tachycardia. There may also be psychological signs such as time and sensory distortion, "tunnel vision" and dissociation. Hyperarousal is a psychological state well known in patients suffering from posttraumatic stress disorder, in which they are always "on the alert" for stimuli that may trigger their stress reaction.
Because of the hyperarousal and dissociation patients experience in trauma, they are extremely responsive to suggestion, and what we say in the first moments of a crisis may have a direct impact on their physiological response to their injuries. With respect to patients who are injured, frightened, in pain or in severe grief states, what we say to them as an authority figure or medical professional is assimilated very rapidly and is taken literally. Idle or flippant comments can easily be misconstrued, as words can not only heal but also harm. Even when we don't know what to say, sometimes a hug or the simple gesture of taking a patient's hand can communicate our empathy and caring and provide reassurance.
Stage Two: Building Rapport and Giving Therapeutic Suggestions
Many of us are familiar with the power of suggestion. Because injured people are in an altered state, they can accept suggestions if they are given in a straightforward manner. Suggestion is the blueprint for action: a way of stimulating images that initiate healing biochemical processes. It's important to avoid negative images, beginning with simple comforting words and gestures, such as holding the patient's hand. Suggestions, as well as being gentle, kind and caring, should be clear and specific, such as telling the patient that they will soon be feeling better. They should also be firm, so it is important that you have already established your position of control with confidence and authority, using imagery, such as, "Your breathing is much more even now." Further, suggestions should be positive and affirmative, such as telling the patient, "You'll notice that your leg is more comfortable as we get this splint on." And suggestions should be believable as you will lose credibility if you try to convince a patient of something that is patently untrue.
Stage Three: Scripts for Specific Situations
The short script above is one of many that can be used in specific emergency situations. Others include establishing a contract ("Are you ready to come with me into the back of the ambulance?") and repeating a patient's words back to them so they will know you fully heard them. Compassion is important and letting the patient know you care will go a long way to calming them. A multitude of sins can be forgiven with a modicum of compassion.
Acosta's book provides specific "verbal first aid" scripts like the one quoted above for bleeding, emotional trauma, medical emergencies, pain relief, chronic conditions and suicide attempts. And, for many of us that have found ourselves at a loss for words to explain a patient's death to family members, she devotes a chapter to dying, titled "Verbal last aid."
Stage Four: Self Care
EMS personnel know that "burnout" is an occupational hazard, and part of the concept of "verbal first aid" reminds us to take care of ourselves if we intend to remain in EMS for the long haul. Humor is one of the best practices for dealing with difficult situations, and keeping a sense of humor is a time honored tradition in EMS to lessen the emotional impact that emergency medical services have on the EMS providers. Most of us are familiar with the Critical Incident Stress Debriefing programs that began in the early 1980s, but a more chronic level of stress and even symptoms of post traumatic stress disorder (PTSD) can plague EMS personnel. We have all experienced a call that came too close to home, perhaps an injury to a child about the age of your own child, or a situation that mimics one in your personal life or involving a family member. Feelings of dissociation, difficulty sleeping, increased somatic complaints, trouble concentrating and anger can all be signs of a rescuer in trouble.
According to Acosta, the self-healing process begins with recognizing and affirming your feelings and recalling your strengths. Talking about calls that bother you with others or writing about them can be healing. For some people, it is prayer that helps them get back to center again. Lifestyle habits such as eating and sleeping well, engaging in healthy relationships with people outside of emergency services and getting plenty of outdoor exercise are all positive steps to healing from the difficult situations we manage during our shifts.
Verbal First Aid as a Risk Management Tool
In addition to helping the patient regain calm and begin the healing process, establishing close and compassionate rapport with those calling 9-1-1 is one of the best risk management tools EMS can employ. Although we spend a great deal of time practicing our intubation and EKG recognition skills and honing them to perfection, we spend very little time in our training and continuing education programs learning how to communicate effectively with patients. Most of us have known a paramedic or EMT with a particular "gift" for bedside manner, but it isn't something we teach effectively. We've all known those who have it and those who don't.
Plaintiffs in litigation against EMS inevitably complain that the EMS providers either didn't listen to them or that they displayed a dispassionate and uncaring attitude, downplaying their emergency. Conversely, when we "connect" with our patients in a way that is meaningful to them, they are far less likely to engage in litigation, even if they ultimately experience an adverse outcome. In short, good patient communication is not only good medicine, but a form of risk management that benefits everyone on the health care team, including our patients.
Even without all of our advanced life support equipment, we can provide our patients with comfort and begin the healing process with words. Further, we can employ one of the simplest and most effective risk management tools by learning to use healing words and the power of suggestion at the onset of a patient encounter.
Acosta J, Prager J: The Worst is Over: What to Say When Every Moment Counts. Jodere. San Diego, CA. 2002.