This article appeared in EMS World, August 2016

For the past five years, faculty of the Prehospital Care Program of LaGuardia Community College in New York City has studied the challenge of reducing the risk of Post-Traumatic Stress Disorder (P.T.S.D.) 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 the Trauma Studies Center of the Institute for Contemporary Psychotherapy. The result is an innovative educational approach which gives graduates of 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 P.T.S.D., Norris and Slone (2013, p. 2) found that at least 60% of adult American men and 51% of adult American women will at some point in their life experience or witness a life threatening event. While not all persons who experience trauma go on to develop Post Traumatic Stress Disorder, between 9% and 12% of Americans will at some time in their life suffer the symptoms of P.T.S.D. as defined by the Diagnostic and Statistical Manual of the American Psychiatric Association (2013, p. 271). Symptoms emerging shortly after a traumatic event include exaggerated startle response, hypervigilance, increased irritability, sleep disturbance, poor concentration and painful intrusive memories.

Norris and Sloane conclude that at any given time between 2% and 3% of the U.S. adult population currently suffer from P.T.S.D.  While the percentage is not large, this figure indicates that somewhere around 6.3 million American adults currently suffer from P.T.S.D. Lifetime prevalence of P.T.S.D. for civilians in war torn countries, are significantly higher: Gaza, 18%, Cambodia 28% and Algeria 37%.  The lifetime occurrence of P.T.S.D. rate among combat veterans is also high. For male Vietnam combat veterans, lifetime prevalence of P.T.S.D. was 31%, for female combat veterans, 27%. Rates of combat veteran P.T.S.D. from other wars is similar. In terms of current P.T.S.D. diagnosis 5% of service members returning from Afghanistan and 10% of service members returning from Iraq screened positive for P.T.S.D. (p.4)

As summarized by McFarlane and Yehuda (1996, p.158), rates of recovery from P.T.S.D. vary widely. For example, 28%% of survivors of the Buffalo Creek disaster still suffered from P.T.S.D. 14 years after the event; on the other hand, a 1990 study found that the P.T.S.D. rate in survivors of other floods ranged from 14.5% to 4.5% sixteen months after the disaster(ibid., p. 442). 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 P.T.S.D. be prevented? Some variables, such as severity of the trauma, previous traumatic experiences and pre-existing mental disorders, are beyond human control; however, there is a solid body of research that 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 P.T.S.D. 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, is valued and is part of a group. Ozbray et al. (2007) The word perceived is important. A person may receive excellent social support (for example first rate emergency medical care) but may still experience themselves as unimportant, unvalued and alone. In surveys of trauma survivors, Ozbray and his 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, Krysztof (2005) 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 factors.

Ozbary’s and Krysztof’s conclusions are supported in a survey conducted by the Trauma Studies Center consultants. The 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 with each other back and forth. 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 EMT’s 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 whole lot better than it could have been.

As these testimonials illustrate, pre-hospital care providers are in a unique position to reduce the emotional distress of their 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 P.T.S.D. regardless of how medically skilled the emergency care may have been.

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

  • On meeting the patient: “Hello, I am a paramedic. My name is David Brenner. 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 permit, finding common interests to share with the patient permit a patient to feel a social bond with the EMS worker: “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. (Benight and Bendura, 2002). 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 that person will or will not suffer post-traumatic symptoms. Benight and his colleagues (1997, 1999, 2000, 2002, 2004) studied the incidence of P.T.S.D. and other post-traumatic stress symptoms experienced by survivors of rape, terrorism, floods, fires and other natural disasters. 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 in the future.

The LaGuardia Faculty Committee carefully 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 typically experience helplessness, confusion, and disorientation. How in such circumstances can a person see themselves as in control of their lives? The LaGuardia Faculty Committee reasoned that psychological stress might be neutralized if emergency personnel use interventions which are 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 look ahead and 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 are based on a new understanding of the biological underpinnings of psychological trauma. This knowledge is revolutionizing ideas about how traumatized people should be treated and how P.T.S.D. might be prevented. In essence, trauma theory suggests that the rush of adrenalin 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 hyper-arousal. (van der Kolk, 2014, pp. 39-47). 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 is likely to support that process.

Unfortunately, prevention of psychological trauma is rarely an integral aspect of EMT and paramedic training. If the topic is mentioned at all, it usually occurs in a standalone course of an hour or so. Students usually have no chance to practice trauma informed psychological interventions. The LaGuardia Faculty Committee concluded that psychological trauma prevention can and should become a standard component of every aspect of EMT and paramedic training. As a matter of routine, trainees should learn to offer social support and to encourage patient self-efficacy when they meet the patient, as they treat the patient and before they transfer the patient.

The Committee revised the LaGuardia pre-hospital 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 which 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:

eSCAPe

S=Provide Social Support

C=Give patients Choices

A=Anticipate what will happen next

P=Help patients Plan and organize

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

  • Anticipation: “Mrs. Jones, I am about to put a cervical collar on your neck.”
  • Social Support: “I am sorry if this collar is a bit uncomfortable, but we want to make sure your neck is well protected.”
  • Choices: “Now that the collar is in place, would you like a second blanket?”
  • Planning: “I see you have a dog. Would you like him to be closed up somewhere before we leave?”

In 2015 and 2016, the eSCAPe curriculum was introduced to LaGuardia’s EMT and paramedic programs. Qualitative and quantitative evaluations of the curriculum were administered to all students and faculty 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 is 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 EMT and paramedic professions it is no exaggeration to say, that a new day is dawning in patient care. Emergency medical first responders can be justifiably proud of the advances that have been made in saving lives and minimizing permanent physical damage. Starting today there is an opportunity to prevent the invisible wounds of P.T.S.D. 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 Trade Adjustment Assistance Community College and Career Training (TAACCCT) Grant, 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 their communities’ short‐and long‐term vulnerabilities.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (fifth ed.). (2013) Washington, D.C.: American Psychiatric Publishing.

Benight, C. & Bandura, A. (2004) Social cognition theory of posttraumatic recovery: The role of perceived self efficacy. Behavior Research and Therapy, 42 (10). 1129-1148.

Benight, C., Swift, E., Sanger, J.J., Smith, A. & Zeppelin, D. (1999). Coping self efficacy as a mediator of distress following a natural disasters. Journal of Applied Social Psychology, 29 (12), 2443 -2464.

Benight, C., Freyldenhoven, R., Hughes, R., Ruiz, J., Zoschke, T. & Lovallo, W. (2000). Coping self efficacy and psychological distress following the Oklahoma City bombing. Social Psychology 30(7), 1331-1344.

Benight, C. & Harper, M. (2002). Coping self efficacy perceptions as a mediator between acute stress and long term distress following natural disasters. Journal of Traumatic Stress,15(3), 177-1867.

Krysztof, K.. (2005) Social support and traumatic stress. P.T.S.D. Quarterly, 16 (2) 3.

Norris, F.H. and Slone, L.B. (2013). Understanding research on the Epidemiology of Trauma and P.T.S.D.  P.T.S.D. Quarterly Research. 24(2) 1-13.

McFarlene, A.C. and Yahuda, R. (1996). Resilience, vulnerability and the course of posttraumatic reactions. In Van der Kolk, B.A., McFarlane, A.C. and Weisaet, L (Ed.s) Traumatic Stress: The Effects of Overwhelming Stress on the Mind, Body and Society. New York London: Guilford Press.

Ozbay, F., Johnson, D.C., Morgan, C.A., Charney, D. & Southwick, S. (2007). Social support and resilience to stress: From neurobiology to clinical practice. Psychiatry,4(5), 35-40.

Vander Kolk, B.A., NcFarlane, A.C., and Weisaeth, L. Traumatioc Stress: The Effects of Overwhelming Experience on Mind, Body and Society. Guilford Press:New York and London.

Van der Kolk, B.A. (2014). The Body Keeps the Score: Brain, Body and Mind in the Healing of Trauma. New York: Viking.