Louisville Medicine Volume 69, Issue 2 - Page 18

( continued from page 15 )
Patients who received the intervention were more likely to survive the ambulance trip and had shorter hospital stays .
The worst is over . We are taking you to the hospital . Everything is being made ready . Let your body concentrate on repairing itself and feeling secure . Let your heart , your blood vessels , everything , bring themselves into a state of preserving your life . Bleed just enough so as to cleanse the wound and let the blood vessels close down so that your life is preserved . Your body weight , your body heat , everything , is being maintained . Things are being made ready in the hospital for you . We ’ re getting there as quickly and safely as possible . You are now in a safe position . The worst is over .
During traumatic events , people enter “ altered states of consciousness .” The person here has a blank slate , awaiting input and guidance that can swiftly carry them on an unhealthy , or healthy trajectory . “ There is no greater stimulus to learning than a trauma .” If you work with trauma patients , you have seen patients with unfocused or rambling speech , uncontrollable tears , changes in breathing and heart rate and irrational subjective perceptions .
The researchers chose the paragraph above to fulfill key components of a healing relationship . First , the responder must establish rapport , which involves three features : centering ourselves , establishing an alliance with the patient and confirming a contract . Without rapport , you cannot ask a patient to relax . The authors must have spent some time with us in the Room 9 Trauma Bay , as they discourage use of the phrase “ Just chill [ dude ].” Rapport makes it possible to become attuned to the patient .
Center yourself with a conscious breath , acknowledging and revering the “ hallowed space .” Take charge , stating “ I am here to help , you can relax .” Give a command and communicate realistically . Even with the severely injured patient , stating “ The worst is over ” is generally honest and helpful . You can examine unaffected body parts , alerting the patient to these uninjured areas . Avoid “ contra-alliances ” like anger , I told you so ’ s , anything that would disrupt the fragile connection . A contract convinces the patient to work with you , giving her permission to be calm .
Once you have established rapport , you can treat the patient . A useful technique called Pacing involves meeting the patients on their level : their respiratory rate , their speed / volume of speech , or their energy level , and then moving them to a more normal rate , volume or agitation level , called Leading them . Offer truisms and immediate observations : “ Anyone can see that your breathing is improving .” “ We know that the anticipation of pain is worse than the actual pain .” Speak positively . “ You can start breathing slowly and comfortably now ” is better than “ Don ’ t breathe so fast .”
Soliciting the patients ’ help gives them a sense of agency , making them active participants who will focus on your directions . Avoid negative pictures / statements , blame , anger , the words “ pain ” and “ hurt .” Use “ discomfort ,” or “ What area needs my attention ?” Begin with easy requests (“ You ’ ll notice that the burning sensation is subsiding ”) and congratulate minor successes . You can lead with implied healing : “ You might feel some better now - tell me when you do .”
Give clear , specific , firm , positive , believable and gentle directions rich in imagery . Harness the “ power of because ” with logical statements “ Because your wound is compressed , you are bleeding less .” One of the best tips , the “ I know a guy who [ had this very same problem and is back at work now ],” allows you to capture the victim ’ s mind with a story . Try the “ double bind ,” like giving a child the choice to brush his teeth “ Now or after putting on pajamas ?” Ask for instance , “ Does your leg feel better flat on the stretcher or with a pillow under it ?”
Prager and Acosta suggest helping the patient to change focus , dissociate by distraction , and visualize a better way . With a patient in the middle of a panic attack , remind them that “ Almost everyone can remember a time they didn ’ t want the moment to end , but it always does .” Everything has a beginning , middle and end .
The book ends with a welcome discussion on caring for ourselves . Witnessing trauma creates secondary victims , with potential causation of suicide . With our own healing after witnessing trauma , “ The worst is over ” still applies . That patient ’ s trauma is over , even if he has a long road to recovery . You helped her but you can ’ t get well for her . Remember your character strengths , talk about what you have seen , pray about it and write about it . Eat , sleep , breathe , connect , practice gratitude and laugh .
Humanities writer and ER doctor Jay Baruch wrote about his own mistake when he recommended that his resident just “ move on ” after a tragic death . A business as usual attitude neglects the sublime change point of tragedy . Even though “ senseless deaths and tragedies make up the ambient reality of work in a trauma center ,” we do not have to give in to the impulse to mindlessly keep moving . The deaths , and our duty to move past them , are not normal . Baruch mentions “ The Pause .”
“ Through silence , this shared event is able to be honored and marked by a multicultural medical staff . Silence allows individuals to personalize their practice while not imposing onto others . This act is a means of honoring a person ’ s last rite of passage . To bring an element of the sacred back into a profane world of medicine .”
When someone dies in our emergency department at UofL , we take a moment of silence . We use the patient ’ s name and step outside of the clinical moment to think about their life , even if very little is known . Do any of you use The Pause with deaths ? Should we use it with stressful resuscitations or patient encounters that don ’ t end in death ?
WAVE3 News Anchor Dave Mattingly shadowed in ULH ED through the GLMS Wear the White Coat Experience . After seeing some intense cases , he asked , “ What process is in place for you and your staff to work through these experiences ?” I didn ’ t have an answer for him . We usually just move on , after The Pause , unaware of