In spite of the best laid plans rocks fall, holds break and snow can slip. That's the nature of adventure, it's unpredictable. But what is predictable is that where there's an accident there's a good chance that an injury has occurred.
As mountaineers, we know that there's a moment after a slip where you feel yourself flying through the air and time seems to stand still. Suddenly you experience it all in incredibly vivid detail. The rope eventually comes tight. You experience a massive jolt as you collide with the ice or snow. But to your relief after shaking off the ‘stars’, you realise that you are still alive and attached to the rope. Hesitantly, you reach down to clutch the bit of your body that made contact and begin to expect the worst - wet, warm and soggy blood soaked clothes and the possibility of sharp ends of bone...
For most of us, accidents leave only physical damage but for others there are much greater consequences. Stress hormones released at the time of an injury can cause the brain to lay down special, detailed memories and create a highly emotive record of the event. Importantly, this ‘stress injury’ can form in even those who don't suffer a physical injury. Sometimes they can even happen in witnesses or bystanders to an event.
Healing only begins once the sufferer is back in a place of safety. However for some their experience is so overwhelming that they remain stuck in a place that leaves them constantly on edge and unable heal. This feeling can carry on for weeks, months or even years and can lead to intrusive negative thoughts and feelings. Often the sufferers find themselves self medicating and abusing their usual coping strategies - e.g. alcohol, gambling or risk taking behaviour. This in turn can spiral into anxiety or depression. Sadly, for a few, this becomes too much to bare and can sometimes lead to suicide.
Stress injury describes a spectrum of different responses. Post Traumatic Stress Disorder (PTSD) is recognised as a life threatening condition and occupies the most severe end of the spectrum (red). The severity of the stress injury may be reduced by a series of interventions and these form the basis of psychological first aid (PFA)
Stress injury is a predictable and normal reaction to a traumatic event - so what can we do about it?
Let's go back to our mountaineering scenario. Instead of being the victim, you find yourself in the wrong place at the right time, as the rescuer. You are keen to offer assistance and know what to do for bleeding injuries and broken bones. But what are you going to do to reduce the stress injury that this person might suffer? Evidence suggests that there are 5 principles that you can follow in the first few minutes to reduce the prospect of a stress injury. These are...
Safety - Making someone feel safe is vital. This can be as simple as getting them under some shelter (a hut, a tent or even the lee of a boulder) or moving them to a safer place on the mountain (away from the cliff, out of a gully etc .…), or even just bringing some order to an accident scene. Explaining the threat reduction to the victim reinforces this sense of safety.
Calmness - We learn to read body language before we learn to talk, so as a rescuer you need to be calm yourself. Slowly counting down or taking some deep ‘breaths’ can really help achieve this. Once you are calm, you can then use the same simple techniques to calm the injured person - “Lets take a breath, count to four and then slowly let it out”. Getting the victim to turn their focus away from the danger and onto something benign is a great way to induce calm.
Self and Community Efficacy - Efficacy is all about the ability to successfully achieve a goal. In this case it's the safe rescue of an injured person. Involving the victim in their own rescue can give them a degree of control over the situation and reduce feelings of helplessness. Helplessness is a strong predictor of stress injury. By reducing it the brain feels increasingly safe. “Can you hold this rope, while I tie this off”. Occupying children involved in accidents and giving them a purpose is particularly important.
Connectedness - Connecting with someone is the most basic form of social support. Be sure to use their name and find out about their lives - talking about loved ones, hobbies and pets all go a long way to fostering a solid bond. Building a strong connection with the victim during a rescue is probably the most important step of PFA.
Hope - Use simple facts to demonstrate hope to the victim. It's a powerful way to counteract hopelessness. “Well, we are warm and dry in the tent and we set off the Personal Locator Beacon 4 hours ago, so it shouldn't be long before help is on it's way.”
Once management of the injury is underway and these principles are in place, I personally feel that the most useful thing I can do next as a doctor is just to sit with the patient, in ‘the rubble’ of the event that has just happened. Just being present with someone, letting them know they aren't facing things alone is a very powerful thing to do for somebody - and is something that any of us can provide if the situation arises."
Thanks Robin! Before signing off, here's the story of a rescue that I was recently involved in. Do you think I covered the 5 principles that Robin described? Would you have done anything differently?
"We were on a winter climbing trip to the Cairngorms. In what seemed like slow motion we watched a mountaineer fall almost a 100m down a steep snow gully. He came to rest near our belay. My partner and I began by calling out and trying to make eye contact. When we had his attention, we told him our names and I remember trying to say something reassuring like we'd stay with him and do our best to help. We asked him his name and whether he had any pain. Paul told us that he had a very sore shoulder but was able to stand and walk with some help. At this point, we were on a gentle slope and, with his agreement, walked downhill towards a large boulder and found some shelter from the wind. Soon, we were joined by his partner. We took off our rucksacks, put on warm layers and sat inside a survival shelter in order to share some warmth. During this time we tried to explain that we'd moved to a safe place and had done our best to make ourselves warm and comfortable.
We gave Paul some painkillers, shared a flask of hot coffee and supported his injured shoulder. As we did this, his partner found our GPS location and used his mobile phone to organise a helicopter rescue. I remember how we shared this news excitedly with Paul. For the next hour or so, we talked about the mountains we had climbed and the areas we hoped to visit in the future. This led on to talk of work and family life and so by the end, everyone knew a good deal more about each other! But it was clear during this time that Paul had been badly shaken by the fall. Often we had to encourage him to take deep breaths and think about something else. We all tried to stay chatty - often repeating things like we were safe and there was a rescue plan in place. But there was still a lot of tears. Eventually, the helicopter arrived and we helped Paul get on board. Unfortunately, there was only room for one and so the rest of us walked down. That night we visited Paul in hospital and continued to check on him by email and phone. After extensive surgery, he went on to make a good recovery and we kept in touch. My partner has even climbed with him since!"
Further information about Post Traumatic Stress Disorder (PTSD) can be found here.
Dr Robin Baraclough is a GP and rural hospital practitioner in New Zealand. His PFA workshop will take place on Monday 8th June at the Hathersage Mountain Medicine Festival.
Thanks Robin! We're looking forward to a fascinating workshop! Places can be booked here.