This article appeared in the May/June 1991 issue of in Rescue Magazine.

One of the most noble aspects of rescue work is the impartiality of care. It does not matter who requires freeing or finding— rescuers go. The work is altruistic, meaning that the main goal is to help others. As experienced rescuers know, the satisfaction that comes from a job well done is immeasurable.

One of the most satisfying interpersonal tasks is to interact meaningfully with strangers. Accomplishing this within the time pressures of emergency care is a huge challenge. Having an understanding of crisis (and the way people respond to it) can help. This improves rapport, which creates a safer work environment as well as an even deeper sense of accomplishment for the good things rescuers do.

Emergencies cross all demographic boundaries. Virtually anyone, of any age, economic level, hygienic state, mental activity, social standing and gender is a potential victim. There are, two universal elements about emergency care, though, that the rescuer should always keep in mind:

• The victim is not in normal circumstances. By definition, an emergency is not a regular part of everyday life.

• Most (if not all) victims are strangers to the people who come to assist. Even rescuers who live in small towns, where the likelihood of knowing victims is higher, often find that familiar people react to emergencies in ways that make them seem like strangers.

A crisis state is actually not inevitable in every emergency. An emergency is an urgent, unanticipated event that requires immediate attention. A crisis is "a state of acute emotional upset that includes a temporary inability to cope by means of one's usual problem-solving devices." I Although many people in emergency situations are in crisis, many others handle their disrupted state of affairs well and are not. The difference lies in the person's emotional response to the event.

A crisis may occur for several reasons:

• An environmental or material situation, such as a fire or natural disaster

• A personal or physical cause, such as a heart attack or amputation, or loss of some bodily function

• An interpersonal or social situation, such as the death of a loved one, divorce, or separation

• Any life-cycle transition related to the normal phases of human development. Everyone is at some risk during the inevitable rites of passage that occur at various ages. The life-cycle passages of adolescence and menopause are especially notorious for causing disruption.

• Life-cycle passages that signal a shift in social status. (1) One of the most heart-rending is placement of an elderly relative in a nursing home. Another increasingly common shift in social status is homelessness.

Key to the understanding of crisis is the term "emotional." People have feelings about the things that happen to them in life. These feelings can paralyze them. However, crisis does not need to be devastating. People have choices about how a crisis will affect them. In the end, crisis can be an opportunity for growth and positive change. Which it will be depends on many circumstances; one that is within the rescuer's control is effective early intervention. In the short-term, the rescuer can assist the victim in proceeding down a good pathway, so that subsequent crisis intervention and, ultimately, resolution, can occur more easily.

The relationship between basic human nature and crisis is interesting to ponder. People spend considerable time, effort and resources setting up their lives in a certain way. When an emergency happens, many of those plans and expectations are disrupted and altered, perhaps forever. Change is terribly difficult for the human animal (the only exception being a wet baby). The responses people have to changes—particularly abrupt and unanticipated ones—are widely variable. By definition, people in crisis are lacking a happy, healthy life in which the basic human needs (a sense of physical and psychological well-being, a supportive network of family/friends, and a sense of identity and belonging to society) are fulfilled. In order to return their lives to normalcy, it is necessary to cope with three overlapping phases of crisis: a period of impact, a period of recoil and the post-traumatic period.(1)

Because rescuers encounter people early in the crisis-causing event (often during the period of impact), they may witness the most intense moments. If the rescuer, armed with some knowledge about the nature of crisis, can maintain professional objectivity, the draining—and sometimes dangerous—quality of these experiences can be alleviated. Yet rescuers receive little or no training in the interpersonal challenges of their efforts.

"Everyone gets a brief introduction to the death and dying end of it, but not for the actual realities of everyday emergencies," according to paramedic Steve Smit, regional coordinator with SW M Systems, which handles field operations for the Michigan Department of Health, EMS Division. "In EMS education, we don't deal nearly enough with what to expect on the scene and how to manage it. Maybe that's because it's so hard to point out the dynamics that will be out there. Ninety percent of the time, the real issue is trying to manage the politics of the scene, such as keeping the police officers and ED physicians (who want other things done) satisfied. Good interpersonal skills make the difference between someone who can do an adequate job and someone who can truly choreograph a scene."

One predictable result of an unexpected event is a powerful dose of the "fight-or-flight" hormone, adrenalin. If you've forgotten what it's like, think of your own adrenalin levels the first few dozen calls you handled. Yet, as obvious as it seems, this key concept is easily overlooked by many rescuers, especially veterans. After all, crisis is a familiar environment to those who witness it daily. It is surprisingly easy to forget that the average person is not used to emergencies.

A strong surge of adrenalin causes uncontrollable excitement and flurries of motion. This is especially true when there is no useful outlet for it, as is typified by the hand-wringing public. And it can be contagious. Entire groups can become emotionally inflamed by one overwrought person. High adrenalin levels are the seed of many of the other behavioral patterns rescuers regularly observe. The essence of self-control is knowing how to stay calm in moments of crisis, and this is a learned skill. Through their life experiences, some lay people can remain calm in an emergency. However, many others cannot; these people often need to be coached by the rescuer in ways to calm down.

Another element of human nature in crisis is that many people actually find it difficult to give up control, despite their need for help. Most people prefer to be in charge of their own lives, and hate to admit they cannot cope.

The following are some of the typical responses that people have when in physical, social, emotional or mental pain:

• Some people withdraw from pain as if curling up into a ball. In the extreme, the behavior is like returning to the protection of the womb. They try to be as small and low-profile as possible.

• Others adopt behaviors that worked, perhaps, at a different stage of life. This is known as regressive behavior. It allows the "freedom" to cry (as a child does when someone takes a toy), or to scream and yell (as in a toddler's tantrum). Whether the hysterical behavior we see stems from regression or from something else, it is actually relatively uncommon. However, it so punctuates our experience that the stories are often told in greater abundance than actual percentages would warrant.

• Another response—which is hazardous to rescuers—is the aggressive response to crisis. Some people lash out at things that hurt, the way a snake strikes when threatened. Aggression is an increasingly common tactic in our culture. The anger expressed is seldom caused by the rescuer. However, the rescuer is sometimes unwittingly the recipient of that blast of verbal—and possibly physical—abuse.

• Other people completely deny that they have a problem. However, a simple question demonstrates the flaw in this logic: "If there's no problem, then why are there rescuers on this scene?" someone besides the patient perceives a problem, yet the patient is in full-blown denial, the interpersonal challenge can become extreme.

“Most people prefer to be in charge of their own lives, and hate to admit they cannot cope.”

Paramedic/RN Marilyn Bourn, EMS educator and instructor for the Department of Surgery at the University of Colorado, sees categories of response to crisis along the model drawn for death and dying by Elisabeth Kubler-Ross. "Emergencies and crisis invoke some grieving in people, whether they've sustained the loss of a body part, of their car or whatever," Bourn says. Rescue personnel see all the behaviors associated with that model: anger, denial, bargaining, depression and acceptance. "I've seen people hit and otherwise lash out because they don't know what else to do," she said. "Other people are catatonic, just sitting. Another category of response to crisis might be the inappropriate laughter and humor that we see." Other people try to deny their situations, or bargain for a different deal.

It is unusual to encounter an emergency situation that is not infused with strong, and usually negative, emotions such as anger, frustration, grief, fear, hatred and profound anxiety. Bourn explains one possible reason that positive emotions are less evident: "Acceptance is rare because we know that's the most advanced stage of the grieving model. Acceptance takes longer. Sometimes we see it in the emergency department." Remember that the word "emotion" is what differentiates a crisis from an emergency Yet few people are ever taught that their feelings are both real and valid. People tend to fight their emotions, as if they can control them. The fact is, emotions do not occur at the whim of the individual; they occur in spite of what we might wish. It is best to help people understand that feelings cannot be controlled on demand.

Another aspect of the nature of crisis is the unfortunate tendency among the uneducated lay public to have expectations of the capabilities of rescuers that are too high. We live in an instant-results society. Many of the people we serve want us to "just fix it!" This is hard to do when a climber has several shattered bones or when someone faces lengthy skin grafting. The rescuer sometimes has to help people begin to realize that their problems may require a long time to heal.

The decision of whether to confront this issue head-on depends on the individuals involved. In some people, denial of the realities is important for the moment; in others, it is helpful to have an honest report of what they face from the outset. And no one remains in crisis forever. Part of the rescuer's task is to help guide events past the crisis to a more positive state, which can be very rewarding.

The more one understands the variety of responses people can have to their own crisis, the more one can understand the value of making the study of other people a lifelong hobby. Even if a rescuer encounters a thousand angry people, each will have unique circumstances and expressions of that anger. The human element of rescue work can never grow stale or redundant.

The interpersonal challenges of working with strangers in crisis requires a very flexible and adaptable approach. When working with an angry, intoxicated person, one adopts a different approach than when working with a frightened, elderly person, even if both are trapped in the same crashed vehicle. A single interpersonal style has little validity in emergency care; those being rescued need and deserve their helpers to be inter-personally versatile.

Developing appropriate style is difficult, and it is also difficult to teach. One reason, according to paramedic Cynthia Osborne, continuing education coordinator at Mercy Ambulance Services in Grand Rapids, Mich., is that the topic is so individual in nature. "Most people have avoided learning how to improve their interpersonal style for most of their lives—including the instructors," she says. "In the time frame we have for the basic learning environment, this topic is pushed under the carpet quickest."

Smit has a suggestion for change: "One idea is to use videotapes of actual scenes in the classroom. It's hard to come up with these, but it helps for students to see what actually happens. It gives them a firsthand picture of what can happen out there, and how to manage it. Otherwise, it's too difficult to bring in those interpersonal dynamics."

A rescuer's ability to figure out what each new stranger needs, in terms of interpersonal relations, is also a process of discovery. One important goal is to learn how to "read" others quickly, and thus discover how best to interact. Of course, during this time, the rescuer is also gathering information about the safety of the setting as well as the medical and rescue-oriented tasks to be done. The rescuer can also learn verbal and non-verbal methods for defusing the intensity of an emergency scene. The technique of repetitive persistence (repeating phrases until your message gets through) helps break through walls of hysteria.(2)(3) Nonthreatening stances and gestures, as well as tones of voice that indicate true compassion, all serve to guide overwrought people to calmer demeanor.

One concept is clear: the rescuer must establish good rapport. "The most technically flawless communications skills are useless in the absence of rapport with the person in crisis," wrote Lee Ann Hoff, in her book, People in Crisis: Understanding and Helping. "Conversely, if our values, attitudes and feelings about a person are respectful, unprejudiced and based on true concern, those values will almost always be conveyed to the person regardless of possible technical errors in communication."(1)

“Non-threatening stances and gestures, as well as tones of voice that indicate true compassion, all serve to guide overwrought people to a calmer demeanor.”

Teaching how to "read" another person is difficult. "It's such an individual thing," said Osborne. "I don't know that I could give a set answer because it depends so much on the individual. I don't know if I could 'cookbook' this information, although I know I do a good job." That's part of the problem—people good at the interpersonal dynamics of crisis know they do well, but often do not know why.

Nonetheless, the inspired learner can study those who do it well and learn from direct experience. Listen to success (and failure) stories of others. The more one works with people in crisis, the more refined this assessment expertise becomes. As writer William James said, "Whenever two people meet, there are six people present: each person as he sees himself, each as the other sees him, and each as he really is." The more self-aware the rescuer, the smaller the chance of a mixup in interpersonal styles.

Children present their own special interpersonal challenges. In dealing with them successfully, it is wise to remember two important points:

• A child has relatively little life experience. Children do not realize how serious some situations are—even life-threatening ones. Thus, it is not unusual for a child to appear very calm during an emergency (especially as long as there is no fear of being in trouble for causing such a big fuss).

• Most children will speak only when spoken to, and will yield only a little bit of information at a time. The rescuer must try especially hard to think of all the angles by which the child might see the situation.

It is reassuring, after acknowledging the difficult responses to crisis, that there are many times in rescue work when the victims' responses to crisis are positive. Many people handle their emergency situations with dignity and grace. Their overriding emotions are relief and appreciation. Some are even able to find a humorous side to the situation that lightens the circumstances at hand. Remember these calls; they can help rescuers maintain a balanced perspective about rescue work.

References

1. Hoff LA: People in Crisis: Understanding and Helping. Second ed. Menlo Park, Calif.: Addison-Wesley Publishing Co., 1984.

2. Clawson JJ, Dernocoeur K: Principles of Emergency Medical Dispatch. Englewood Cliffs, N.J.: Prentice Hall, 1988.

3. Dernocoeur K: "How to beat hysteria." Rescue, 3(1), 1990.