Perspectives on care: Why first aid works

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Time: 10 mins; 1725-1735
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We've seen and practiced enough to feel how powerful and liberating first aid can be, how much it can restore agency and safety and calm for both the responder and the patient. Now we're going to take a step back and think about why first aid works. We're just going to check out two basic processes and how first aid intervenes in them: 1. The embodied experience of acute trauma or injury response at a cellular level 2. The role of meaning-making in the healing process

Cells

Act I: Happy cells

  • Happy cells are continually bathed in liquid, which is mostly water trapped in plasma proteins. Plasma is the liquid part of the blood; everything except the red and white blood cells.

  • The plasma is rapidly exchanged (as often as 80 times per second), carrying dissolved oxygen and nutrients from the bloodstream to cells and washing away cellular sewage, bacteria, and debris from dead cells. Without this flow, cells starve to death or are poisoned by their own waste and die.

  • Much of the cellular sewage drains into the lymphatic vessels, drains to the lymph nodes, which operate like sewage treatment plants, and then is returned to the blood stream.

  • Compression of tissues squeezes the dissolved cellular sewage through the lymph ducts, cleaning the drain out so more waste can drain more freely.

  • Tissue compression includes any muscle movement (including stretching); kneading or stroking; or deep breathing, coughing, or yawning.

Act II: Pain and inflammation from traumatic injury

Ever wonder why your muscles ache when you stay in bed all day? Because without muscle movement the sewage doesn't drain as efficiently, and cells that are starving or being injured by their own waste products call for help with pain. Let's look at what happens in physical trauma, like when the Federal Protection Service cop shoots you in the back with a beanbag full of heavy plastic pellets.

  • Cells are damaged and die, capillaries get damaged and spill blood, which dies.

  • Dead cells release lots of waste that needs to be cleaned up, and release bradykinin and histamine, two pro-inflammatory chemicals that open capillary pores so white blood cells escape into the space between cells to clean up the mess. Lots of plasma also pours in to dilute the waste

  • The waste and liquid from the dead cells can pool in the space between cells, preventing the rapid exchange of nutrition and waste, killing other cells and causing pain, until the swelling creates enough pressure to: stop bleeding; splint the damaged area; squeeze stuff out through the lymphatic capillaries again

  • If the swelling is big enough, a clot might form to help create that pressure, but then the clot will eventually have to be digested by white blood cells in order to drain

  • Eventually tissues are rebuilt and the mess has been cleaned up and drained out. After the bradykinin and histamine has drained, the capillary pores close and life hopefully returns to normal

Act III: First aid

The key intervention here is pressure.

  • When you bang your thumb in a door, you automatically grab it and squeeze. That is the foundation of first aid. You squeezing means that the space between cells doesn't need to swell up so much and bloodclots don't need to be formed before there's enough pressure to stop bleeding, stabilize the area, and squeeze cellular sewerage into the lymphatic system. Pressure or compression is a recurring theme in first aid because it saves the body the step of swelling, which means it limits pain and shortens healing time

  • The other things you do when you bang your thumb is jump up and down and shout cuss words, and often while you are squeezing the thumb you lift it up above the level of your heart. All these reactions promote lymphatic movement and thus lymphatic drainage -- limiting pain and speeding healing time

  • As medics we try to spread calm. Deep breathing, massage, gentle movement, and elevation also promote lymphatic movement.

  • Finally, the inflammatory cascade explains why you send someone to an ER after you have cleared choking with abdominal thrusts: The inside of the throat was likely damaged by the object; you can't put pressure on the inside of the throat to save the body the step of swelling; and if it swells enough to put pressure on itself ... you have an airway problem

  • These basic inflammatory processes play out pretty similarly whether the injury is a bleed, a sprain, or a burn.

The characters introduced in this section: plasma proteins, nutrients and oxygen, white blood cells, and so on, are good to learn if you want to understand what you are doing by icing or warming a twisted ankle, or applying St Johns Wort oil to a bruised wrist

The take-home message is that the body is extraordinarily adept in self-repair. We are not "treating" when we do first aid, we are simply assessing and providing support within our scope.

Good first-aiders have an extraordinary trust in the bodies of the people to whom we render first aid, and a careful awareness of possible limitations to their ability to heal unassisted.

Why first aid works

That's a brief intro to the cellular level of how first aid works. Next, an even briefer intro to the meaning level of why first aid works.

Act I: Placebo Domino

During the civil war, field surgeons ran out of morphine, so injected patients with saline and did amputations. Why? The patients injected with saline believed they were getting a painkiller, so the saline worked like a painkiller.

Act II: How much of medicine's effectiveness is due to meaning-creation?

Exhaustive literature reviews have shown that when people get pills, injections, surgery, physical therapy, psychotherapy, and other medical treatments in clinical trials, as much as half of their healing response is due to autonomous healing unrelated to the treatment (like the inflammatory response we just talked about), at least 1/4 is due to the meaning involved in being treated (like being injected with salt water), and only about 1/4 is due to the effectiveness of the care, support, or treatment itself.

These fractions vary widely. Placebo outperformed Prozac in 1986, but in recent clinical trials the same placebo has been outperforming the same Prozac.

In actual clinical settings, much more of the effectiveness of the treatment probably has to do with meaning. Much of nursing education in patient care, for example, has to do with meaning creation; as does the doctor's white coat. Medical anthropologists have renamed the placebo effect as the "meaning effect."

Research shows that meaning that can contribute to healing is contained in three places:

  • The form of the care or treatment: wearing a red cross, putting on gloves, doing a competent assessment, your tone of voice and the language you use, drinking a nonspecific medicinal tea, etc.

  • The meaning it has for the caregiver or provider: If you don't believe it is going to help the patient, it is likely to be less helpful than if you know it is going to help the patient (even if you do not communicate your doubt to the patient)

  • The meaning it has for the patient: This has to do with the patient's confidence in his healing process, his confidence in the medic, his past experiences, his cultural background and prejudices

Act III: How to create meaning

Spread calm, be confident, know your limits, explain everything, predict good outcomes (but don't lie). Make your first aid meaningful, and know why you are doing this work.