- Email: [email protected]
Relocating dislocations in a wilderness setting: use of hypnosis
Journal of Wilderness Medicine 2,22-26 (1991)
ORIGINAL ARTICLE
Relocating dislocations in a wilderness setting: use
of hypnosis KENNETH V. ISERSON Southern Arizona Rescue Association and Section of Emergency Medicine, University ofArizona College of Medicine, Tucson, Arizona 85724, USA
Joint dislocations or fracture/dislocations of extremities are disabling injuries in wilderness areas, both to the individual patient and to the patient's wilderness group. Recognizing the beneficial effect of early relocation of dislocations, wilderness practitioners are now encouraged to attempt joint relocations in the backcountry setting. To be successful, adequate sedation/relaxation must be achieved. Hypnosis was applied in six patients with shoulder or ankle dislocations. Successful relocations were accomplished in five of the patients. Those with upper extremity dislocations were immediately able to walk out with minimal assistance after relocation.
Keywords: dislocation, relocation, hypnosis, anesthesia, search and rescue
Introduction A joint dislocation or fracture/dislocation of an extremity is a common Injury in wilderness areas. It can be not only disabling to the individual patient, but also very disruptive to the patient's wilderness group. From·a medical standpoint, early relocation of a dislocation is known to have a beneficial effect on the end result [1]. It aids in maintaining neurological and vascular integrity of the extremity, reduces early and late edema within and around the joint, reduces pain, decreases the incidence of early onset of arthritis in the joint, and in some cases can improve ultimate function of the extremity post-reduction. Wilderness medicine practitioners are now encouraged to attempt joint reductions in the backcountry setting [2]. Yet, it is unclear how successful they can be without an adequate level of analgesia and relaxation. The reduction of a dislocation in a medical ~etting is usually performed with moderate to heavy sedation. In a wilderness rescue setting, it is often impractical to carry the supplies needed for such sedation, or to send in personnel with the requisite knowledge to perform the sedation. This usually requires a knowledge of pharmacology and medical procedures beyond the scope of most non-physician individuals on the 'front line'. In addition, in an adverse environmental setting, it is often necessary to be able to mobilize the patient quickly under his or her own power. Given the absence of appropriate medical supplies, necessary expertise, or luxuries of time and safe surroundings in which to sedate a patient, wilderness party members or search and rescue personnel have three alternatives in treating a joint dislocation. The first is to leave the extremity dislocated and transport the victim from the wilderness area 0953-9859/91 $03.00
+ .12 ©
1991 Chapman and Hall Ltd
Wilderness hypnosis
23
to a medical facility. This can be painful for the patient, take a great deal of time and effort, and completely disrupt an expedition. The second alternative is to attempt to reduce the dislocation without analgesia or muscle relaxation. This is often very difficult even for experienced practitioners, and unpleasant for the victim. Finally, there is the option of using an alternative form of sedation/analgesia, namely, hypnosis. This technique can be easily learned and used by nearly any wilderness Advanced Life Support provider.
Methods Over a seven-year period, six persons with major joint dislocations were encountered by the author in a wilderness setting. All victims were located during operations of the South Arizona Rescue Association (SARA), a volunteer rescue group with activities that have been documented elsewhere [3,4]. Five of the patients had shoulder dislocations (three for the first time), and one had an ankle fracture/dislocation (trimalleolar with vascular compromise of the overlying skin). The patients ranged in age from 16 to 56 years. Four were male and two were female. In the patient with the ankle fracture/dislocation, who was in extreme pain from the outset, an intra-articular injection of 8 ml 1% lidocaine without epinephrine was administered simultaneously with the preintroduction phase of hypnosis [5,6]. All reductions used a traction-countertraction technique. The reductions performed under hypnosis were completed in less than 10 minutes from the beginning of the hypnotic suggestions.
Hypnosis technique Although there are many different methods of inducing hypnosis [7], the following method has been found to be extremely easy for physicians and EMS personnel. The same method of hypnosis was attempted on all six patients. It was described to the patients as a 'relaxation technique', so as not to scare them with the word 'hypnosis'. Misconceptions about hypnosis can have a negative effect on the ability of patients to cooperate fully with the technique. It is essential that the concept of patient and clinician cooperation, frequently described as permissive hypnosis, is explained. Any feelings the patient may develop of domination, control, or coercion by the clinician should be dispelled [8]. During the 'preintroduction' phase, rapport is established with the subject, and if the subject has had prior experiences with hypnotic techniques, they are briefly discussed. Usually, persons who have undergone hypnosis are quickly aware that the term 'relaxation techniques' equates with a hypnotic experience. It is important at this stage to assure the patient that no matter what has been going on in the vicinity, such as the animated activities of the rescue team, the patient will not be rushed during the procedure. As the technique is begun, the clinician reinforces this by repeating that the victim need not feel pressured or try too hard, but should feel free to relax at his or her own rate. The clinician should speak in a firm, quiet manner, in no way reacting to any of the activities that might be happening in the immediate vicinity. At this point, in a technique adapted from Schultz's texts on autohypnotic training [9], the victim is instructed to close his or her eyes and relax. The patient is then asked to concentrate on the distal extremities (toes), imagining/producing sensations of heaviness and pleasant warmth in the limbs as 'all of the muscles in the toes relax.' For most
24
Iserson
people, the feeling of heaviness is easier to imagine than is warmth, but this is not consistent. The clinician should continue to suggest both sensations. A significant amount of time (30-45 s) is spent on helping the victim concentrate on and relax the toes. If this can be accomplished, the remainder of the procedure is much easier. It is then suggested to the victim that the feeling flow up into the feet, then the legs, thighs, etc. A significant indication that the technique has been successful is the regularization of the victim's respiratory pattern. A suggestion to the recipient at this time should be to slow the rate of breathing and further allow the entire body to relax. It is optimal to suggest that with each exhalation, another level of relaxation will be attained. The victim is then told that he or she will feel relaxed, sleepy, and will 'travel in the mind to a very pleasant place, perhaps a beach or mountain.' A suggestion can be made that the victim will continue to feel no pain in the joint after the dislocation has been relocated. This is particularly important if there is a suspected associated fracture or additional significant injury. The victim is now ready for reduction of the joint dislocation. Although many tests have been devised to assess the depth of hypnosis in a person, these techniques are primarily for research purposes [10,11]. In a clinical setting, results are what matter, and they do not always correspond to abstract measures of hypnotic success. It is therefore unnecessary for the clinician to administer any of these tests at this point. The techniques related to emergence from a hypnotic state are not generally needed. The manipulation associated with the reduction process normally arouses the patient to a prehypnotic state. However, if a posthypnotic suggestion for pain relief has been given, this still might be in effect. Results
Hypnosis was successful in sedating/relaxing five of the six patients. Although the 'success' of hypnosis has been found hard to judge, even in a laboratory setting, it was evident that there was diminution of pain, and both visible and palpable muscle relaxation in all five patients. In one victim with a shoulder dislocation, two different rescuers had previously attempted to relocate the shoulder using the proper orthopedic method, but could not overcome muscle spasm until after hypnotic relaxation was in effect. The hypnotic trance in each case reversed immediately when the extremity 'popped' back into place. Two victims had prior experiences with hypnosis and recognized the technique being used. One person with a prior negative experience resisted all attempts at hypnosis. Gnats buzzing around her ear and other unabated noise from the surroundings also disturbed her. The person required intravenous (IV) sedation to allow humeral relocation. No victim had a new neurovascular deficit post-reduction. The victims with shoulder dislocations reduced under hypnosis walked out of the wilderness with the rescue team. Discussion
Joint dislocations are common in wilderness areas, and often cause severe disruptions of backcountry activities. While recurrent dislocations with lax ligamentous and muscular
Wilderness hypnosis
25
formations surrounding joint capsules can often be relocated with minimal assistance, first-time dislocations or fracture/dislocations usually require adequate analgesia and muscle relaxation. Intravenous sedation, commonly used in emergency department settings, is often not within a wilderness medical person's capability. Intramuscular analgesic or neuroleptic agents will often be ineffective or render the victim immobile for a long period of time. Hypnosis is ideal for the wilderness setting, as it is easy to learn and the simplest techniques can be learned from reading a text, taking a short course in hypnosis, or talking with an experienced practitioner. Practice and patience are necessary for success. Approximately 70% of the general population is considered readily susceptible to hypnosis, with those having a high attention span the most vulnerable. However, achieving hypnosis in a particular patient varies not only with the skill and experience of the practitioner, but with the interaction of personalities between the hypnotist and patient [8,12,13]. Theoretical dangers have been reported for the use of hypnosis in inappropriate circumstances or with repeated self-hypnosis. Most problems surround the use of hypnosis in the treatment of neuroses and other psychiatric illnesses, or by stage (performing) hypnotists who use the technique for entertainment [13]. Since there is no physiological or psychological danger unique to hypnosis [14], it is unlikely that circumstances surrounding the use of this technique in a wilderness setting in the face of a medical emergency would instigate any particular complication. Persons with upper extremity, patella, and toe dislocations that can be reduced can often be extricated from a wilderness setting under their own power. This is of obvious benefit to the victims, other expedition members, and potential rescuers. In a case of major lower extremity dislocation where the joint has been relocated, the subsequent extrication becomes much less of an emergency.
References 1. O'Donoghue, D.H. Treatment of Injuries to Athletes, 4th ed. Philadelphia: W.B. Saunders, 1984. 2. Iserson, K.V.; ed. Orthopedic injuries in the wilderness. In Wilderness Medical Society Position Statements, Point Reyes, CA: Wilderness Medical Society, 1989. 3. Iserson, K.V. Incidence of snakebite in wilderness rescue. JAMA 1988; 260, 1045. 4. Iserson, K. V. Incidence of injury in search and rescue volunteers - a 30 year experience. West J Med 1989; 151, 352-3. 5. Sherwood-Dunn, B. Regional Anesthesia. Philadelphia: F.A Davis, 1921. 6. Braun, H., Shields, P. Local Anesthesia - Its Scientific Basis and Practical Use. New York: Lea and Febiger, 1914. 7. Esdaile, J. Hypnosis in Medicine and Surgery. New York: Julian Press, 1957. 8. DeBetz, B. and Sunnen, G. A Primer of Clinical Hypnosis. Littleton, MA: PSG Pub, 1985. 9. Schultz, J.H. Autogenic Training. 1932 10. Cohen, S.B. Tests of susceptibility/hypnotizability. In Wester, W.e. and Smith, AH. eds. Clinical Hypnosis: A Multidisciplinary Approach. Philadelphia: J.B. Lippincott, 1983. 11. Radtke, H.L. and Spanos, N.P. The effect of rating scale descriptors on hypnotic depth reports. J Psychol1982; 111, 235-245, 1982. 12. Jacobs, D.T. Hypnosis in the wilderness. Wild Med 1987; 4, 7-8.
26
Iserson
13. Crasilneck, H.B. and Hall, J.A. Clinical Hypnosis - Principles and Applications. Orlando: Grone and Stratten, 1985. 14. Conn, J.H. Is hypnosis really dangerous? Int J Clin Exp Hypnosis 1971; 20, 61-76.
ORIGINAL ARTICLE
Relocating dislocations in a wilderness setting: use
of hypnosis KENNETH V. ISERSON Southern Arizona Rescue Association and Section of Emergency Medicine, University ofArizona College of Medicine, Tucson, Arizona 85724, USA
Joint dislocations or fracture/dislocations of extremities are disabling injuries in wilderness areas, both to the individual patient and to the patient's wilderness group. Recognizing the beneficial effect of early relocation of dislocations, wilderness practitioners are now encouraged to attempt joint relocations in the backcountry setting. To be successful, adequate sedation/relaxation must be achieved. Hypnosis was applied in six patients with shoulder or ankle dislocations. Successful relocations were accomplished in five of the patients. Those with upper extremity dislocations were immediately able to walk out with minimal assistance after relocation.
Keywords: dislocation, relocation, hypnosis, anesthesia, search and rescue
Introduction A joint dislocation or fracture/dislocation of an extremity is a common Injury in wilderness areas. It can be not only disabling to the individual patient, but also very disruptive to the patient's wilderness group. From·a medical standpoint, early relocation of a dislocation is known to have a beneficial effect on the end result [1]. It aids in maintaining neurological and vascular integrity of the extremity, reduces early and late edema within and around the joint, reduces pain, decreases the incidence of early onset of arthritis in the joint, and in some cases can improve ultimate function of the extremity post-reduction. Wilderness medicine practitioners are now encouraged to attempt joint reductions in the backcountry setting [2]. Yet, it is unclear how successful they can be without an adequate level of analgesia and relaxation. The reduction of a dislocation in a medical ~etting is usually performed with moderate to heavy sedation. In a wilderness rescue setting, it is often impractical to carry the supplies needed for such sedation, or to send in personnel with the requisite knowledge to perform the sedation. This usually requires a knowledge of pharmacology and medical procedures beyond the scope of most non-physician individuals on the 'front line'. In addition, in an adverse environmental setting, it is often necessary to be able to mobilize the patient quickly under his or her own power. Given the absence of appropriate medical supplies, necessary expertise, or luxuries of time and safe surroundings in which to sedate a patient, wilderness party members or search and rescue personnel have three alternatives in treating a joint dislocation. The first is to leave the extremity dislocated and transport the victim from the wilderness area 0953-9859/91 $03.00
+ .12 ©
1991 Chapman and Hall Ltd
Wilderness hypnosis
23
to a medical facility. This can be painful for the patient, take a great deal of time and effort, and completely disrupt an expedition. The second alternative is to attempt to reduce the dislocation without analgesia or muscle relaxation. This is often very difficult even for experienced practitioners, and unpleasant for the victim. Finally, there is the option of using an alternative form of sedation/analgesia, namely, hypnosis. This technique can be easily learned and used by nearly any wilderness Advanced Life Support provider.
Methods Over a seven-year period, six persons with major joint dislocations were encountered by the author in a wilderness setting. All victims were located during operations of the South Arizona Rescue Association (SARA), a volunteer rescue group with activities that have been documented elsewhere [3,4]. Five of the patients had shoulder dislocations (three for the first time), and one had an ankle fracture/dislocation (trimalleolar with vascular compromise of the overlying skin). The patients ranged in age from 16 to 56 years. Four were male and two were female. In the patient with the ankle fracture/dislocation, who was in extreme pain from the outset, an intra-articular injection of 8 ml 1% lidocaine without epinephrine was administered simultaneously with the preintroduction phase of hypnosis [5,6]. All reductions used a traction-countertraction technique. The reductions performed under hypnosis were completed in less than 10 minutes from the beginning of the hypnotic suggestions.
Hypnosis technique Although there are many different methods of inducing hypnosis [7], the following method has been found to be extremely easy for physicians and EMS personnel. The same method of hypnosis was attempted on all six patients. It was described to the patients as a 'relaxation technique', so as not to scare them with the word 'hypnosis'. Misconceptions about hypnosis can have a negative effect on the ability of patients to cooperate fully with the technique. It is essential that the concept of patient and clinician cooperation, frequently described as permissive hypnosis, is explained. Any feelings the patient may develop of domination, control, or coercion by the clinician should be dispelled [8]. During the 'preintroduction' phase, rapport is established with the subject, and if the subject has had prior experiences with hypnotic techniques, they are briefly discussed. Usually, persons who have undergone hypnosis are quickly aware that the term 'relaxation techniques' equates with a hypnotic experience. It is important at this stage to assure the patient that no matter what has been going on in the vicinity, such as the animated activities of the rescue team, the patient will not be rushed during the procedure. As the technique is begun, the clinician reinforces this by repeating that the victim need not feel pressured or try too hard, but should feel free to relax at his or her own rate. The clinician should speak in a firm, quiet manner, in no way reacting to any of the activities that might be happening in the immediate vicinity. At this point, in a technique adapted from Schultz's texts on autohypnotic training [9], the victim is instructed to close his or her eyes and relax. The patient is then asked to concentrate on the distal extremities (toes), imagining/producing sensations of heaviness and pleasant warmth in the limbs as 'all of the muscles in the toes relax.' For most
24
Iserson
people, the feeling of heaviness is easier to imagine than is warmth, but this is not consistent. The clinician should continue to suggest both sensations. A significant amount of time (30-45 s) is spent on helping the victim concentrate on and relax the toes. If this can be accomplished, the remainder of the procedure is much easier. It is then suggested to the victim that the feeling flow up into the feet, then the legs, thighs, etc. A significant indication that the technique has been successful is the regularization of the victim's respiratory pattern. A suggestion to the recipient at this time should be to slow the rate of breathing and further allow the entire body to relax. It is optimal to suggest that with each exhalation, another level of relaxation will be attained. The victim is then told that he or she will feel relaxed, sleepy, and will 'travel in the mind to a very pleasant place, perhaps a beach or mountain.' A suggestion can be made that the victim will continue to feel no pain in the joint after the dislocation has been relocated. This is particularly important if there is a suspected associated fracture or additional significant injury. The victim is now ready for reduction of the joint dislocation. Although many tests have been devised to assess the depth of hypnosis in a person, these techniques are primarily for research purposes [10,11]. In a clinical setting, results are what matter, and they do not always correspond to abstract measures of hypnotic success. It is therefore unnecessary for the clinician to administer any of these tests at this point. The techniques related to emergence from a hypnotic state are not generally needed. The manipulation associated with the reduction process normally arouses the patient to a prehypnotic state. However, if a posthypnotic suggestion for pain relief has been given, this still might be in effect. Results
Hypnosis was successful in sedating/relaxing five of the six patients. Although the 'success' of hypnosis has been found hard to judge, even in a laboratory setting, it was evident that there was diminution of pain, and both visible and palpable muscle relaxation in all five patients. In one victim with a shoulder dislocation, two different rescuers had previously attempted to relocate the shoulder using the proper orthopedic method, but could not overcome muscle spasm until after hypnotic relaxation was in effect. The hypnotic trance in each case reversed immediately when the extremity 'popped' back into place. Two victims had prior experiences with hypnosis and recognized the technique being used. One person with a prior negative experience resisted all attempts at hypnosis. Gnats buzzing around her ear and other unabated noise from the surroundings also disturbed her. The person required intravenous (IV) sedation to allow humeral relocation. No victim had a new neurovascular deficit post-reduction. The victims with shoulder dislocations reduced under hypnosis walked out of the wilderness with the rescue team. Discussion
Joint dislocations are common in wilderness areas, and often cause severe disruptions of backcountry activities. While recurrent dislocations with lax ligamentous and muscular
Wilderness hypnosis
25
formations surrounding joint capsules can often be relocated with minimal assistance, first-time dislocations or fracture/dislocations usually require adequate analgesia and muscle relaxation. Intravenous sedation, commonly used in emergency department settings, is often not within a wilderness medical person's capability. Intramuscular analgesic or neuroleptic agents will often be ineffective or render the victim immobile for a long period of time. Hypnosis is ideal for the wilderness setting, as it is easy to learn and the simplest techniques can be learned from reading a text, taking a short course in hypnosis, or talking with an experienced practitioner. Practice and patience are necessary for success. Approximately 70% of the general population is considered readily susceptible to hypnosis, with those having a high attention span the most vulnerable. However, achieving hypnosis in a particular patient varies not only with the skill and experience of the practitioner, but with the interaction of personalities between the hypnotist and patient [8,12,13]. Theoretical dangers have been reported for the use of hypnosis in inappropriate circumstances or with repeated self-hypnosis. Most problems surround the use of hypnosis in the treatment of neuroses and other psychiatric illnesses, or by stage (performing) hypnotists who use the technique for entertainment [13]. Since there is no physiological or psychological danger unique to hypnosis [14], it is unlikely that circumstances surrounding the use of this technique in a wilderness setting in the face of a medical emergency would instigate any particular complication. Persons with upper extremity, patella, and toe dislocations that can be reduced can often be extricated from a wilderness setting under their own power. This is of obvious benefit to the victims, other expedition members, and potential rescuers. In a case of major lower extremity dislocation where the joint has been relocated, the subsequent extrication becomes much less of an emergency.
References 1. O'Donoghue, D.H. Treatment of Injuries to Athletes, 4th ed. Philadelphia: W.B. Saunders, 1984. 2. Iserson, K.V.; ed. Orthopedic injuries in the wilderness. In Wilderness Medical Society Position Statements, Point Reyes, CA: Wilderness Medical Society, 1989. 3. Iserson, K.V. Incidence of snakebite in wilderness rescue. JAMA 1988; 260, 1045. 4. Iserson, K. V. Incidence of injury in search and rescue volunteers - a 30 year experience. West J Med 1989; 151, 352-3. 5. Sherwood-Dunn, B. Regional Anesthesia. Philadelphia: F.A Davis, 1921. 6. Braun, H., Shields, P. Local Anesthesia - Its Scientific Basis and Practical Use. New York: Lea and Febiger, 1914. 7. Esdaile, J. Hypnosis in Medicine and Surgery. New York: Julian Press, 1957. 8. DeBetz, B. and Sunnen, G. A Primer of Clinical Hypnosis. Littleton, MA: PSG Pub, 1985. 9. Schultz, J.H. Autogenic Training. 1932 10. Cohen, S.B. Tests of susceptibility/hypnotizability. In Wester, W.e. and Smith, AH. eds. Clinical Hypnosis: A Multidisciplinary Approach. Philadelphia: J.B. Lippincott, 1983. 11. Radtke, H.L. and Spanos, N.P. The effect of rating scale descriptors on hypnotic depth reports. J Psychol1982; 111, 235-245, 1982. 12. Jacobs, D.T. Hypnosis in the wilderness. Wild Med 1987; 4, 7-8.
26
Iserson
13. Crasilneck, H.B. and Hall, J.A. Clinical Hypnosis - Principles and Applications. Orlando: Grone and Stratten, 1985. 14. Conn, J.H. Is hypnosis really dangerous? Int J Clin Exp Hypnosis 1971; 20, 61-76.