By: Robin Young
A non-EMS work acquaintance of mine went out on a ride along recently to observe the local paramedic service in action and bring those experiences back into the classroom. She was surprised at how many persons in crisis her paramedic crew had to see during their shift, the intensity of some of the crises and how the crew effectively dealt with each one in a very short period of time.
Working in paramedicine is the ultimate school of crisis intervention. Being on the scene and, in minutes, having to defuse situations of extreme emotions and behaviours can be not only challenging, but dangerous. In school you learn the basics of crisis intervention. You learn theory and perhaps do some role-playing. There is an aspect of familiarity that comes with the class room lessons, offering some resilience. But knowing there is no risk lessens the impact of the exercise. lt is at actual emergency calls such as at a suicide attempt or car crash, or dealing with the hysterical parent of an injured child where you gain valuable experience and learn what works and does not work in the moment. You will make mistakes. You will say the wrong thing at the wrong time or miss a perfect opportunity to have a meaningful impact on your patient’s crisis situation. But you will learn. In time, you will become confident in your choice of intervention skills; calming tense situations and being supportive, empathetic and caring in your response to the patient’s crisis.
What is a crisis? It is a perception of loss of control of the immediate situation. It is the lack, or breakdown, of immediate coping skills needed to address the problem. It is a sympathetic nervous system default once the patient perceives the stress created by the event has moved past their threshold to successfully resolve it. It is the fight, flight or freeze response. lt is a psychological intensity that is beyond the ability to consciously guard against it.
A crisis has component parts. You can analyze it, take it apart and understand it. There is a stressful event that triggers a nervous response-direct stimulus response. The stress has to be perceived as a threat; that there is a potential, or real danger of possible injury or death. The stressful situation has to have significant relevance to the patient – the injury of a stranger as opposed to the injury of a family member. This is an individual perception. What is significant for one person is not for the next person. Depending on the event, the patient may experience a severe stress response immediately, such as with an acute injury, or the stress can progress slowly and build past the patient’s thresh old. Faster, more intense stressors result in earlier, more intense psychological and behavioural responses. There is a progression of emotionality (anxiety, fear, anger)and physical behaviour responses (shaking, crying, freezing, violence ). Increased confusion, uncertainty and hesitation occur as thought processes become overwhelmed and attempts at intrinsic and extrinsic resolution fail. There is immediacy for assistance to lessen the intensity of the crisis .
Coping mechanisms are those strategies, skills and behaviours that decrease or remove stressors and their effects. They are meant to prevent or alleviate crisis factors, leading to interna! and externa! resolution and a return to normalcy. There can be appropriate or inappropriate coping mechanisms. Appropriate coping skills decrease or remove the stressors and aid in resolving the crisis. The implementation of EMS systems can be seen as a societal scale coping mechanism aimed at resolving societal health crises. Inappropriate coping skills create the crisis, contribute to and/or prolong the crisis. Typically, paramedics are called to the crises occurring due to their immediate intensity or the inappropriateness/failure of the responding coping mechanisms.
There are effective coping mechanisms such as exercise , meditation, discussion, critical thinking or deep breathing that address normal stressors during the day. We can employ more vigorous strategies for more intense stressors. Normally, we can address issues before they progress to a crisis. There are also negative coping mechanisms such as anger, violence, manipulation and drug usage/abuse which can momentarily shut down a crisis, but not resolve it. Due to the nature of many EMS calls, your patients’ normal coping mechanisms fail during their crisis moment. Effective coping mechanisms break down due to a variety of reasons. In many cases, they are not appropriate to address the presenting stressor, such as denial of familial dysfunction. The stressor may be overwhelmingly intense, such as the unexpected death of a loved one. There may be more than one, perhaps severa1, stressors presented together or close to one another, overwhelming a normally adequate coping ability. If the patient has an underlying psychological impairment, such as depression or an anxiety disorder, coping mechanisms may not even be employed. If the patient is ill, he or she may not be prepared for the stressors and cannot effectively respond to avoid a crisis. If drugs or alcohol are influencing the patient, the stressors may not be recognized or the intoxicating effects may lower the resistance to stress or alter perceptions enough to create a crisis situation.
There are many factors that contribute to a patient crisis that you see on EMS calls. Many have to do with the intensity of the situation-the sudden injury, death or loss of situational control. EMS calls find patients at an emotional disadvantage. They are confused, angry and/or frustrated regarding their circumstance. They feel they are no longer in physical or cognitive control of their immediate situation and default to “fight or flight.”
Their focus either tunnels in to their personal circumstance-the spouse’s heart attack or their own severely bleeding arm or they focus outwards, toward you for immediate help. This can lead to a potentially dangerous situation as the patient or bystander is not in control of his or her perceptions or actions and can even define your presence as a threat. Many patients reach a crisis point as a result of not taking their emotion or psychiatric stabilizing medications, leading them to false perceptions of danger or self-destructiveness.
Language, cultural differences and miscommunication by either the patient or the paramedic have led to situations that have resulted in emotional and physical escalation. In other emergency service incidents, injury and death have resulted due to misinterpretation of intentions due to language differences. With elderly patients who are ill, have had a stroke or suffer from dementia, the act of your assisting them creates crisis due to their sense of being physically handled or having their routine altered.
Intervention in a patient’s crisis is a skill developed with education, intuition, self awareness and experience. Effective crisis intervention builds trust between you and the patient early in the call. The sooner the patient trusts you, the sooner you can progress in your overall assessment and treatment. You need to address immediate concerns or health issues. Is the patient safe? Is there a continuing threat such as an abusive spouse? Physical injury? Drugs? Weapons meant for self-harm?
The intervention is time limited so being directive in your approach to the patient is important. What do you need the patient to do at this moment? Do they need to sit or lie down on the cot? Cooperate with a physical lift? Tell the patient exactly what you need them to do. Speak clearly and calmly so they hear what you are asking. Keep focus on both your short term goal (getting to the patient through a locked door) and your long term goal (delivering the patient to the emergency room).
Remember, as the crisis responder, to keep your own emotions and trigger points in control. There will be instances where the patient’s crisis situation stress reactions will stimulate your thoughts, judgments and emotions. They may stimulate your own personal issues, such as a death or illness of a loved one. There will be reminders and you may find yourself emotionally and/ or physically responding. Remain centered but acknowledge your reactions and focus on the patient’s crisis. Remind yourself that your immediate aim is to assist in short-term resolutions, even if it is defusing the situation enough to access the patient . You need to be intuitive in what is needed and when it is needed. Remember to avoid personalizing the situation.
Your choices in addressing a patient’s immediate crisis are: Assist in resolving it; aggravate and escalate it; or maintain its present intensity. Sometimes all you can do is to ensure the crisis does not escalate any further. It is a form of success. If you can intervene in the patient crisis to the point where you can effectively assess any evident injuries, you are closer to treating and trans porting your patient to definitive care.
About the Author
Robin Young is the coordinator of the Conestoga College Paramedic program located in Kitchener, Ontario. He has a M.A. in Adult Education from Central Michigan University and an Honours B.Sc. in Health Studies from University of Waterloo. Robin is an A-EMCA and formerly worked with Toronto EMS.