Thursday, August 8, 2013

The Sights And Sounds of Trauma

I've never shot anyone. I've never seen anyone who has been shot. I've never witnessed, first hand, the sights and sounds of battle.

I know people who have and the consensus is unanimous: it's hell.

It's something very few people are prepared for. It's something that not many people attempt to prepare for.

This morning Greg Ellifritz posted an article about the Ross Township shooting in Pennsylvania. A reporter at the scene said that some of the people were off to the side throwing up. A comment to the blog expressed concern that one might find himself in a similar position if forced to deal with a mass shooting type of situation and having to face the sights and sounds of the carnage going on around them instead of responding or helping.

How do you prepare for that? How do you ensure you aren't the one curled in a ball and expelling your breakfast or passed out when you should be seeking cover or fighting or helping? Is there a way?

The commentator's concern resonated with me because I had the same concerns when I entered EMT school. I'm not a needle person. I fainted while my blood was being drawn in high school. I nearly passed out watching other people get shots. I was horribly afraid that I would get to the scene of an accident and pass out or throw up and not be able to preform my job, nevermind getting into a self defense situation where blood and stress were free flowing.

I was not a veteran, soldier or police officer. I was just an average civilian woman. But I was determined to find a way over my own aversion to trauma not only so that I could do my job as an EMT but so that I could also withstand the sights of trauma if ever in a self defense situation and forced to treat myself or those I care about effectively.

I started to do some searching on the subjects of getting over the fear of needles and getting over the shock of seeing blood and how emergency responders get over the sights, sounds and smells of horrific scenes.

Hypnosis and other suggestions aside, the two pieces of advice I found most helpful were:
1. Stay hydrated and well fed
2. Exposure therapy

The advice to stay hydrated and well fed kind of surprised me but it made sense as I started to learn about what goes on physiologically when you pass out or become ill from traumatic sights.

When presented with something traumatic your body goes into psychogenic shock which manifests itself physiologically. Your blood pressure plummets, pulse increases, skin becomes pale and clammy and light-headedness, dizziness and nausea can follow along with unconsciousness. There are many theories on what actually makes you pass out but, it's theorized that, your body shuts off your consciousness to get you prone in attempts to ease profusing your entire body (particularly your brain). Nausea is a by-product of psychogenic shock and often accompanies passing out though not everyone who vomits passes out and vis versa.

The more hydrated and energized your body is the better it can handle fluctuations in blood pressure, particularly quick decreases.

Also, the people at the scene of the Ross Township shooting were treating themselves well without knowing it. Vomiting usually makes people double over and forces blood to the head. When feeling the effects of psychogenic shock the best thing to do is get blood to your head. Lie down, get your head between your knees, scrunch up in a ball, do whatever you can to keep blood in your head so you don't pass out. Vomiting is helpful. If the vomit is coming, don't fight it.

But, of course, the goal is to not have any of those side effects to start with. Even if you know how to treat yourself if you feel like you're going to pass out or become sick you are in a bad position, especially if you are still in danger or, in the case of a responder, expected to do one's job.

In which case there is no better way to prepare yourself than by exposing yourself.

In EMT school, during the trauma section we were shown dozens of pictures of the most horrific accidents one can witness or respond to. Decapitations, crushed bodies, missing limbs, the most gruesome disfigurements, protruding eye-balls and burns. I forced myself to look. When everything inside of me didn't want to see what I was seeing.

We were encouraged to put aside the shock of the trauma and look for ways to treat. If it was an obvious traumatic death what would we do? If it was the loss of a limb what would we do? The key was to stay focused on what can be done. We were assured that every responder who works in the field long enough will vomit at least once in his/her career and maybe even pass out. It toughens him for the next, harder call.

While doing my clinical time in the ER the first time I heard someone was getting stitches I asked if I could go in and watch. I had to leave because I almost passed out. The second time someone came in for stitches I was able to stay through the entire procedure. The third time someone came in for stitches I was holding him down and the stitches were being preformed right under my nose. I was watching the subcutaneous tissue being washed and pulled together and then needled and sewn. I didn't so much as blink. Helping start IVs used to terrify me. I now hold arms and comfort patients while the needle goes in.

I went from getting woozy at the sight of blood to walking into a room covered in blood spray and holding a vomit bag for a boy who was vomiting large amounts of blood and not having a moment of hesitation or feeling the slightest bit unstable. Disfigurement was always a really hard one for me so I forced myself to be involved when the orthopedic surgeon was setting bones.

I have yet to go to a scene that requires me to actually put my hands into blood or bodily fluids (though I have held many a vomit bag and treated moderate cuts and bleeding injuries) or deal with traumatic death but I feel much more confident in my ability to stomach the sights and sounds of trauma than I did a year ago. Even thinking about some traumas used to make me feel sick. Now my thought is on how to best treat them.

It's not easy to get exposed to trauma these days. Unless you work in medical fields or as a police officer or are deployed to combat you will likely never see a major trauma. What's worse is that if you try to expose yourself without being in these fields you are considered weird or gross. This is what compounds the problem. Having never witnessed trauma, if/when we come across it, it is a complete psychogenic shock. Hunters, farm hands who assist in birth or slaughter of their animals, people who work in slaughter houses, all have at least some exposure to the blood and smells. Pictures help but, as macabre as it sounds, nothing completely prepares you for the blood and body fluids of a human like the blood and body fluids of a human.

That being said, even the most experienced and hardened individual can be overwhelmed and everyone has their limit. For some it's children. The sight of a wounded child is too much for many people to stomach. I've read stories from even the most battle-hardened veterans who still cannot get over the smell of burning bodies or the sight of brain matter. For some it is excrement or vomit or intestinal organs. For some, the worse trauma in the world to witness is childbirth. The worst part is that you won't know what effects you most until you see it. I do not look forward to finding my new limit.

Be aware that self defense that progresses to a physical fight will never be pretty. Disfigurement, body fluid, blood, broken bones, screaming are likely going to happen. Be aware that it might even be your blood, bodily fluids and disfigurement that you are going to have to deal with. Knowing is half the battle. At least you won't be completely shocked if it happens. But think about what/if you are prepared to handle it.

Once again, I'm no combat veteran. I don't have a long list of traumatic experiences that I've endured that have toughened me to the point where I know beyond any doubt that I can withstand every trauma out there. I was (and am) a very vulnerable and sensitive individual and I had/have to actively seek out ways to desensitize myself to trauma.

If you can't expose yourself to trauma (or even if you can) at least follow these steps:

Have a plan. And the first step of that plan should be to think about how you are going to get to safety or make your area safe. The use of cover, getting to a safe exit, ending the conflict, etc, should be your first priority.

Think about certain scenarios and how you are going to deal with them. If it's an active shooter and someone beside you gets wounded what are you going to do? If you are at home and your child is injured what are you going to do? If you are in a car accident and find yourself bleeding what are you going to do? If you are robbed at gunpoint and suddenly shot what are you going to do? The lack of a plan sets you up for psychogenic shock because you are overwhelmed and your mind wants to check out of the trauma. If you are injured yourself and if you are bleeding any delay might surpass psychogenic shock and you might be dealing with hypovolemic shock. A combination of psychogenic and hypovolemic shock could very quickly turn deadly.

Know how to treat. Setting your mind in motion as to the steps to take to treat a traumatic injury can distract you from the traumatic injury enough to not be so affected by it.

Once it's adequately treated, cover it. Not only will you protect the wound but you will also protect your psyche from having to stare at it or get distracted by it.

The biggest indicators that you are about to lose consciousness are tunnel vision, light-headedness, dizziness and nausea or a queasy feeling. You might even feel hot or flushed and find yourself sweating. Don't try to fight through these feeling. Get blood to your head. Get your head lower than your heart. The last thing you want to do is lose consciousness in a self defense environment.

Get help on the way and stay busy getting out, seeking cover, treating, escaping. Learn the steps of patient reassessment so that you can keep your mind active.

Talk to yourself. Freezing at the sight of trauma is pretty common. Even if you know what to do, getting yourself to actually do it can be the hardest part. A common tactic I have seen employed by experienced medics is talking to themselves, running themselves through the treatment steps or their plan of action.

How do you think you would respond to sights and sounds of trauma?


  1. Other than getting a little dizzy while watching an extended suturing in EMT class, I have never had a problem seeing anything "gory." I think more than anything it's something you either can do or you can't, otherwise you can be conditioned (desensitized) but as you say even seasoned trauma junkies sometimes find their unwinnable moment. I often have people tell me they could never do my job. I honestly tell them I couldn't do theirs, it's just what I'm not cut out for.

    1. When my mother found out I signed up for my EMT class she said, "But you faint at the sight of needles."
      I didn't take my EMT class to become an EMT. I took it because I needed medical training and figured it was a good start. I was really nervous because I was not that person who seemed like could handle that stuff. But I was determined to try. I didn't expect I would do anything with the training and I didn't realize how much I would really love it. Now I'm really glad I did it. It not only toughened me up, taught me and gave me a new appreciation for myself and for our system of responders, it also gave me a new job and a new way to help people.
      Becoming an EMT was one of the best decisions I ever made.

    2. Where you take it and how'd you find out about it. How flexible is the scheduling, I work 9-5 and work really like to get some of this type of training but not sure if it's possible with that schedule.

  2. I was the one with the concern on Greg Ellifritz's blog. Thank you for taking the time to address this. I'm not terribly squeamish when it comes to bodily fluids, needles, etc. Maybe that bodes well for me then. :)

    1. We can only hope and pray we never have to find out, right? ;)