Stress and the Rescuer

Introduction

First aid training has traditionally concentrated on treatment and transport: the nuts and bolts of assessment, splinting and airway maintenance. The human elements of emergency medical care are equally important. We are beginning to recognize the impact of emergency stress on the rescuer as well as the victim.

Although there is little data on wilderness rescue, there is a growing body of literature on the effects of stress on emergency workers. Caring for the ill or injured, having responsibility for the life and safety of others is considered a significant stressor. Research is showing that high attrition rates, burnout and stress-related illness are common in emergency personnel.

Effects of Stress

A perceived threat or challenge or a change in the environment can cause stress-a state of physical or psychological arousal. Beneficial stress affects all living creatures and can be a positive factor in change, creativity, growth and productivity. Healthy exercise which increases our physical capabilities is a good stress. Continuous hard exercise without rest or adequate nutrition can become a destructive force with negative effects on our health, our families and our lives.

We may be stressed by noises, confined spaces, extremes in weather and other aspects of our environment. In our social environment, conflicts within a group, conflicts with our boss or our family are all stressors. We're also stressed by inactivity and boredom.

Stress produces intricate biochemical changes in the body. The brain becomes more active, chemicals secreted by the endocrine system cause muscles to tighten, pupils to dilate and heart rate, breathing rate and blood pressure to increase. Protein, glucose and antibody levels in the blood rise.

These physiological changes prepare us to meet challenge by making us more alert and ready for physical activity. In the short term they can be helpful. In the long term or if the short-term stress is significant, the effects of stress can adversely affect our physical and psychological health by wearing us down and making us susceptible to a variety of physical and psychological problems. The Surgeon General estimates 80 percent of non-traumatic causes of death are actually stress-related disease such as coronary artery disease, high blood pressure, ulcers and cancer.

Stress and the Rescuer

Research on stress suggests that dedicated people who work hard and have high standards and deep personal interest in their work are vulnerable to stress.

The job demands of emergency personnel create an environment in which turnover and stress-related illness are common. Emergency situations may subject them to noise such as wind, rushing water, screams and sirens; to the confusion of the emergency scene; to having responsibility for the health and safety of patients and fellow rescuers in prolonged weather extremes; to difficult bystanders who may never be satisfied with the rescuer's performance; to equipment failures and inadequate equipment, which add to the difficulty of the situation; and to long hours of hard physical work. Lengthy rescues, rescues in which the patient dies, multiple casualty incidents and incidents in which emergency workers or friends are injured are particularly stressful.

Personality profiles of emergency personnel developed by Jeffrey Mitchell, Ph.D. show a tendency toward personality traits that make these individuals susceptible to stress. Emergency personnel are often perfectionists and risk-takers who are highly motivated and goal- and action-oriented; they feel the need to be in control. They are dedicated, take great personal satisfaction and interest in their work, and feel great need to be needed. These are traits that also apply to many outdoor leaders and educators.

Certainly, emergency stress will affect an outdoor leader or anyone thrown into the role of rescuer. Experience may help a person cope with these stresses, but it does not make him immune.

The leader of a notably difficult expedition experiences significant extra stress when weather, group dynamics, faulty equipment or complex logistics combine to create a high-pressure situation. In addition to caring for the ill or injured under these difficult conditions, the leader continues to be responsible for the safety and welfare of the group.

Assessment: Recognizing Stress Reactions

Stress in the short term may produce fatigue, nausea, anxiety, fear, irritability, lightheadedness, headache, memory lapses, sleep disturbances, changes in appetite, loss of attention span and indecision. These are normal reactions by normal people to abnormal events. A person experiencing an acute stress reaction may wander aimlessly on the scene, sit or stare blankly or engage in erratic or irrational behavior.

Long-term effects of stress include difficulty concentrating, intrusive images--recurring dreams or sensations of the traumatic event--sleep disturbance, fatigue and diseases such as ulcers, diabetes and coronary artery disease. Emotional signs include depression, feelings of grief and anger and a sense of isolation. Emergency workers suffering from cumulative stress may respond by avoiding emergency situations, taking excessive sick leave or being easily aroused or startled. It is beyond the scope of this book to discuss intervention for cumulative stress reactions.

Treatment: Managing Stress in the Field

Preparation for stress management includes anticipation of the difficulties of rescue and a realistic appraisal of your ability to cope. Of the emergency personnel on the scene of a serious rescue, 97 percent will experience at least some symptoms of stress. Rescuers need to remember that successful outcome of the emergency is not guaranteed, particularly if the patient is far from modern medical care. Rescue work, especially wilderness rescue, can be long and tedious. Recognition and thanks for the efforts of the rescuer are often sparse, while criticism from bystanders is common.

Short-term stress symptoms can be managed by attending to the physical needs for rest, food and hydration, by briefing the group on the sights, sounds and emotions they may experience during a long evacuation and by debriefing the group after the incident.

Acute stress reactions on scene can be managed by removing an overstressed person from the site. Give simple, clear directions to the stressed person, and assign productive tasks that can help shift his or her focus away from the immediate incident. Such tasks might include providing food and drink, building a litter and setting up tents.

If an emergency care giver is overly distressed, detached from reality or disruptive, someone may need to stay with him or her to lend a sympathetic ear. You can help such persons cope by talking with them and offering assurances that their feelings are valid and real. Provide emotional support with honesty and direct, factual answers to their questions.

The Field Debriefing

Following the rescue, attend to the physical needs of the rescuers by providing food, water, clean clothing and shelter. Light aerobic exercise, such as a hike or a game of hacky sack, may help relieve tension built up over the course of the rescue.

Debriefings are designed to provide a forum in which rescuers and/or group members can share their experiences, emotions and thoughts following a stressful situation. A debriefing seems to provide best results if it is conducted within 24 hours of the close of the rescue. The debriefing allows for ventilation and validation of feelings, encourages discussion and helps the facilitator gauge the well-being of the participants.

Debriefing should never include a critique of performance. A critique has a separate role in evaluating an emergency response, but it should be conducted at a separate time and place.

To debrief, gather the group in a quiet place. Set a tone of support and openness, and offer guidelines for discussion without critique. Your communication and group facilitation skills will come into play during the debriefing. If an individual does not want to talk, that's acceptable as along as he or she been given the opportunity. It may help provide common ground for people who may have had different roles, if you begin by having each group member discuss an aspect of his or her experience. Asking for a person's first thoughts after he or she finished with the rescue and after the excitement abated may also be helpful. A debriefing should last long enough to give everyone a chance to talk.

Final Thoughts

Emotional reactions to accidents are perfectly normal and should be expected. We are beginning to train rescue personnel to recognize and manage incident stress. Trained teams of critical incident stress debriefers are set up throughout the country to help rescuers who have experienced a critical stress incident. The majority of reactions are short-term with no lasting consequences. For both patients and rescuers, the emotional first aid we provide is as important to their ultimate recovery as our physical care.

Summary: Acute Stress Reactions

Physical

• fatigue
• muscle tremors
• nausea
• profuse sweating
• glassy eyes
• chills
• difficulty breathing

Emotional

• anxiety
• fear
• grief
• depression
• hopelessness
• irritability
• feeling overwhelmed

Cognitive

• memory loss
• indecision
• difficulty problem solving
• confusion between trivial and major issues
• loss of attention span
• dizziness
• anger

Delayed Stress Reactions

• Macabre humor
• Excessive use of sick leave
• Reluctance to enter stressful situations
• Intrusive images
• Obsession with the stressful incident
• Withdrawal from others
• Suicidal thoughts
• Feelings of inadequacy

Order a copy of NOLS Wilderness First Aid by calling (888) 332-3636.

Reading this information does not qualify a person to perform these procedures or to utilize this information in medical decisions. These text excerpts are not a substitute for a complete and thorough training course, patient care and wilderness experience and continuing medical education.

Text copyright © 1991 National Outdoor Leadership School.
Illustrations copyright © 1991 Joan Safford.
All rights reserved.

Published by: NATIONAL OUTDOOR LEADERSHIP SCHOOL, 288 Main Street, Lander, WY 82520.

All rights reserved, including the right to reproduce this book or portions thereof in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. All inquiries should be addressed to NOLS Publications, 288 Main Street, Lander, Wyoming 82520.