Roadside Therapy – Psychological First Aid for Shock Trauma

Tara Miller, Roadside Therapist.

That was my title a few weeks ago.

I attended to some victims of a dramatic car accident and was reminded how our instincts to support and console victims of high impact, falls, or shock trauma is often wrong. Misinformation about the nervous system and how it responds to trauma and recovers from trauma is present in our first responders as well as in most people in general.

This picture is a shot of the scene – my white shoes bottom right where I sat with two of the victims.

In hindsight – we were way to close to a flaming vehicle that could have exploded at any time… I’ll know better next time.

It was early on a Friday night and I was driving my 14 year old daughter home from her training at the gym.

She’s a competitive trampolinist and trains many hours a week at a gym 45 minutes from our house and so the route is more than familiar to me now.

It’s one I drive on autopilot at least three times a week.

This evening was no different than any other.

My auto-pilot abruptly shut off and my full presence of awareness bolted through my body not just when we saw that traffic seemed to be slowing down abnormally… (to which I was grumbling about dumb drivers not paying attention).

But when we maneuvered through the intersection to get around an obvious fender bender but to see a more serious accident that had occurred just moments before.

A truck flipped completely upside down. Glass everywhere. And a crowd of people that looked like a gang fight… but as we pulled around we saw that it was a handful of witnesses frantically trying to pull open the jammed in doors of a car that had run head on into a light post.

As we inched along in slow motion, time sped up on that side of the street, people running down the road yelling, and then we saw why… the car was in flames and there were passengers trapped inside.

We could see the flames and the silhouette of their bodies behind it.

Bystanders risking their lives to rescue them, others running to safety, others running to get help.

It was like a movie scene.

Instantly my daughter started crying from what she had seen out the window … “oh my God there are people in the car on fire mom!”

My instincts went into high gear as my survival brain assessed the scene, saw people viewing this, balanced what I needed to do for my daughter… all while still operating my own vehicle.

I pulled over to the side of the road – and then into a hotel parking lot. My daughter was frantic wondering if everyone was ok.

I told my daughter I was going to see if anyone needed help. I promised to let her know if everyone was okay but that I was concerned about people in the accident and witnessing these events might need some support while emergency crews arrived.

As I walked over the corner I saw that someone had managed to get a fire extinguisher from a nearby restaurant in time and the fire seemed to be out. They still couldn’t get anyone out of the car though. In the meantime I looked around at the people on the sidelines. Open mouths in shock, wide eyes, concern all around.

In the midst of this surreal scene I saw a couple sitting on the grass. The man trying to comfort a sobbing woman lying down.

I immediately went over to them and sat down. I put my hand on her arm and introduced myself. “My name is Tara…I’m a trauma therapist… if it’s okay I’m going to sit with you for a while…”

The man looked relieved and nodded his head. She looked like a wild animal, but nodded her head.

I asked if either of them were hurt anywhere and what their involvement was… he answered “we were in the truck”.

I looked over at the upside truck that would have been hit with significant impact enough to flip it in the middle of the turning lane on it’s top and the realization of the high impact shock trauma they had just experienced hit me.

No one had noticed them. She was from Mexico visiting. They were on their way out to dinner. They had gotten out of the truck and were on the ground off to the side alone. She had no pain, they had both been able to walk away from their vehicle. But now she was coming out of shock.

As I did what I know to do from a psychological first aid standpoint I was disappointed and dismayed at how the an off duty paramedic handled this couple as well as the officers on the scene.

Fully knowing it’s not their fault – disappointed not in their lack of knowledge about trauma and the nervous system, but in the system that trains them not including some basics in their training of such key personnel.

Because I work with so many motor vehicle accidents I’ve heard these stories before.

In an intense urgency to get information and in a manner that helps prevent first responders from fully absorbing vicarious trauma that they deal with every day, there is a disconnect that is abrupt and harsh. And in the case of trauma like this – not helpful in short or long term recovery.

Here’s how I navigated some psychological first aid with this couple and some tips that will help anyone in similar instances either as a witness or victim.

1. Help Re-orient

One of the biggest mistakes we all make when we fall or have high impact is that we rush to get up – or someone immediately tries to help us up. In the case of car accidents, we’re often told to stay still until spinal injury risk has been assessed. But in the case of a trip and fall, or fall down the stairs, we as the “helper” have a sense of wanting the person sitting or back up as a way to assure they’re ok.

Aside from the obvious physical reactions that accompany that – like dizziness and feeling unstable, there’s also an important piece of this for the nervous system that is disrupted in this.

When there has been a fall or impact there’s a natural disorientation that occurs.

What the survival brain needs to do is gradually re-orient and this is done by allowing them time and helping them find points to orient to.

For example, when someone falls – what you want to do is let them know that you are there – just in the position they are in.

Help guide them – ask them them to look around and notice certain objects in their environment – to get a sense of where they are.

As they get their “bearings” and get a sense of where they are, remind them they have all the time they need.

Trauma happens quickly – healing from trauma requires we build in the missing resource of time.

Obviously they are in a place of safety to do this and not the middle of the street.

When they are ready, if no prohibitive injury is present, they can slowly make their way to a seated position.

At this point you want to help them orient again – ask them to notice where they are in their surroundings, how their bottom is supported by the ground now that they are upright.

This is often where you’ll see someone start to tremble or shake or cry.

2. Don’t rush the trembling.

First responders will often say – oh you’re just going into shock.

But really, from the nervous system’s perspective – shock is really a freeze response in the moment of impact – the shaking and crying is the nervous system coming out of shock and discharging all of that fight or flight energy out of the body.

So you can reassure them – this is normal, your body is just letting go of all of this energy. Your body knows what to do, just let it happen.

Normalize the experience, allow the discharge.

In this accident scene, an off duty paramedic came and barked at this poor woman asking her how fast she was going and what happened. Then she told her not to cry.

She didn’t ask her name. She didn’t know she was a passenger. She didn’t know that the speed was irrelevant or that her brain would not be able to accurately retrieve information in this state. The only good skill she had was to let her know that the ambulance was on it’s way.

I looked at this barking women and said “actually, this woman, was a passenger, she will not be able to recall or tell you anything about the accident right now and shouldn’t, and she is coming out of shock. Her body needs to shake and cry – and I’m here to help her move it through it.”

The paramedic scowled at me as if I was the village idiot (a look I’m familiar with around here 😉 ) and left.

And I continued to talk this woman through it. “You’re coming out of shock, this is perfectly normal. Your body knows what to do to discharge all of this energy. Notice how you’re supported by the ground, by your boyfriend. That’s right. Good – you’re doing great.”

This is what people need to hear. Not interrogation at the scene – but allowing the survival part of the brain to do what it needs to do to recover first. 

The best phrases you can use are “noticing that you survived”, “take all the time you need” and “you’re doing great”. These soothe that part of the brain that is still reeling from the event.

The man thanked me for speaking up, thanked me for staying with them.

I helped her get a sense of where she was in her own body, in relation to her vehicle, the city she was even in. (The fact she was from a foreign country would have only added to her activation – factors you have to consider in psychological first aid).

I was grounded and present and gave reassurance and contact to both of them.

3. Speak only best case scenario.

In addition to the above, I reminded her that emergency crews were coming, that the other passengers were all okay (which whether they were or weren’t, her nervous system needed to be assured in this moment that things were going to be fine.)

This is where you phrase everything as best case scenario.

“You’re going to be fine. Everyone is doing great. You’re going to get the best medical care.”

See if there is a loved one they’d like you to call – their favorite person who soothes them the most – if you can’t get a hold of them, have the victim imagine their voice and what they would say.

And then fast forward them out of the moment. After I found out that they were supposed to go for a nice steak dinner I talked to them about when they might reschedule. What their favorite restaurant was. I asked what they were planning to do over the next week before she went home. Won’t it be nice to be somewhere warm. You’re searching for resources – things that their mind can focus on that is pleasant.

Avoid anything that has potential to be upsetting. Avoid talking about the accident details.

If they’re concerned about injury you can ask them where they feel relatively more comfortable in their body. 

At one point this woman felt short of breath – so instead of asking her to take deep breaths (and anytime you try to override that autonomic nervous system’s functions you can cause more activation and even start a panic attack), I asked her to notice where it felt like her breath moved easily…effortlessly…all by itself. In some cases this can be someone just noticing where their breath moves in and out of their nose and sinuses – in her case she was able to notice that it moved freely and easily just until the top of her chest.

Reassure – normalize… “great. If it’s ok, just noticing how your breath can move easily through that space, without trying to change it – noticing how it comes in, swirls around in the top of your chest and comes back out, all by itself”.

With anxious breath, after a breath or two the breath will start to slow and deepen on its own.

And it did for her too. So then I had her notice now how easily her breath can move in all the places it goes easily, effortlessly.

The key to all of this is staying calm and grounded. 

The brain needs to hear best case scenario to get best case scenario no matter what the injury is.

Studies have shown that people that are given worst case prognosis or even realistic prognosis have healing that is limited to what they were told to expect whereas others that are given best case scenario have bodies that respond with optimal healing responses and have a greater prognosis overall.

This happens unconsciously even as similar reports have been done measuring outcomes in patients based on what’s discussed in the operating room during their surgeries.

You want to only speak positive, soothing things. You want to resource through grounding techniques like breath and feeling your feet or seat on the ground. You want to orient and help provide soothing and support while their body lets out the discharge of energy as they come out of fight/flight/freeze.

If you feel like you can’t stay calm and grounded (by trying the grounding techniques yourself), find the calmest person in the room, or at the scene and pair them up.

Don’t rush. Don’t interrogate. Don’t ask for recall or let your curiosity drive a Q&A about the event.

Being on the scene is an opportunity to help and support or get out of the way.

After these two were taken by ambulance to the hospital to be assessed, I got back in my car, felt my butt in my own chair. Tracked my breath. I felt shaky from the vicarious trauma and my nervous system needed some time to come back to its own baseline. I can do that on my own. I noticed my heart beat feeling fast, I noticed feeling shaky. I observed it and allowed it to move through – unrushed. I facilitated the same with my daughter and we went home.

If these two had been my clients I would have them follow up with a few sessions in my office where we’d work on completing fight/flight/freeze in the specific way we work through high impact trauma. We’d build in missing resources and renegotiate the event. We’d work with boundary rupture (where we’ve been injured or struck and it feels like a break in the invisible boundary we all feel we have that separates our bodies from the rest of the environment).

When trauma is worked with in this way you see faster recovery and the absence of new or lingering symptoms.

It’s common the accident to pass and injuries if there are any to heal – and symptoms of anxiety, post traumatic stress, insomnia, hypervigilance, GI issues, and chronic pain to arise after a car accident – even the most minor of fender benders. Self Regulation Therapy helps to restore the nervous system to baseline so that it doesn’t stay stuck on high alert from the trauma and start to manifest in chronic mood or physical disorders. Working through high impact trauma with SRT is a good way to prevent long term impacts.