PHOTO: ANTHONY WALLACE / AFP

CHAPTER 6: Treating physical and psychological wounds

This chapter contains basic first aid instructions that can be administered to someone who has been wounded or injured in an accident, as well as advice on how to detect and deal with psychological trauma, which may affect journalists when they work in areas of conflict or humanitarian emergency.

1. FIRST AID FOR THE WOUNDED AND INJURED

The security guidelines given in the opening chapters of this handbook are aimed at reducing the risks to which journalists are exposed. But accidents and injuries may still occur, so we describe here first aid procedures that can be used until expert medical help arrives. These can never be a substitute for proper first aid training.

What you should know before giving first aid

Providing emergency first aid can be traumatic, especially if severe injuries are present, patients are unconscious, or children, colleagues or friends are involved. In these stressful circumstances, your role when giving first aid is to determine the extent of the casualty’s injury and their chances of survival, while bearing in mind that, to be of any use as a first aider, you must avoid becoming a casualty yourself. Also, be careful that, in your haste, you don’t try and be the doctor. Some first aid procedures can be harmful if not carried out correctly. As you approach the accident, protect yourself by assessing the scene. Look out for dangers such as fire, lack of oxygen, confined spaces, and electrical, chemical or traffic hazards. Be aware that the casualty may have an infectious disease such as hepatitis or HIV. You can reduce the threat by wearing gloves and other protective clothing.

The information below is taken from the first aid guide published by the French Red Cross. It is no substitute, however, for training in practical first aid, which is highly recommended for anyone going to a high-risk area.

The four stages of first aid

  1. Secure the scene of the accident and those involved. Assess the safety conditions and make sure there is no further danger, for example from traffic, fire or electricity. Only approach the scene of the accident if there is no danger to yourself. As far as possible, ensure the casualties and others present are safe. If the situation is dangerous and you are unable take action without risk, alert the emergency services. Establish a security perimeter around the scene while awaiting help.
  2. Assess the condition of the casualty. Introduce yourself and reassure them by telling them what you are going to do. Make sure they are conscious and breathing normally. A change in their state of consciousness or breathing may be a sign their condition is life-threatening and this should be passed on to the emergency team.
  3. If you need assistance yourself, tell the emergency services.
  4. Carry out first aid calmly and unhurriedly.

Dealing with an unconscious casualty

If the casualty is unconscious and their chest is rising and falling regularly, you should free their airways and place them in the recovery position:

  1. Check the casualty’s responses.
  2. Free their airways (see below).
  3. Ensure the casualty is breathing.
  4. Place them in the recovery position (see below).
  5. If you are alone, ask someone to fetch help.
  6. Check regularly that the casualty is breathing until help arrives.

HOW TO FREE THE PATIENT’S AIRWAYS

When someone loses consciousness, the muscles relax and the tongue falls to the back of the throat, blocking the airway. This can be avoided by moving the person’s head back and raising their chin.

If necessary, undo their collar, tie or belt. Place one hand on the casualty’s forehead and gently move their head back.

At the same time, place the tips of the fingers on your other hand on the end of the casualty’s chin and raise it in order to lift the tongue away from the back of the throat and free the airway.

Do not put pressure on the soft tissue under the chin, which could restrict their breathing.

Make sure the casualty is breathing

  • Check that their chest is rising and falling regularly.
  • Put your ear close to the person’s mouth to listen for the sound of breathing.
  • Try to feel their breath by putting your cheek near their mouth for 10 seconds.

HOW TO MOVE SOMEONE INTO THE RECOVERY POSITION

  1. If the casualty is wearing glasses, take them off. Make sure their legs are straight and side-by-side. If not, move them gently together so that they are in line with the body.
  2. Move the arm closest to you so that it is at right angles to their body and bend the elbow, keeping the palm facing upwards. Kneel or assume a tripod position next to the casualty.
  3. Take the other arm in one hand and place the back of their hand against the ear on your side of their head. Keep their hand pressed against their ear with the palm of your hand on the casualty’s palm.
  4. With your other hand, grab the leg further away from you behind the knee and raise it, keeping the foot on the ground. Move to a position further away from the casualty, at the level of their thorax, so that you can turn their body towards you on to its side, without moving backwards.
  5. Roll them by pulling on their leg until their knee touches the ground. Gently move your hand from under their head while holding their elbow to prevent their hand from moving and thus making sure their head stays still.
  6. Adjust the position of the upper leg to ensure that the hip and knee are at right angles.
  7. Open the casualty’s mouth with the finger and thumb of one hand without moving the head, so that fluids can drain out.

Ask someone to call the emergency services or fetch help yourself if you are alone. Check regularly that their breathing is normal.

RECOVERY POSITION

IMAGE © Drawing by Jean-Pierre Danard, courtesy of the Fédération des Secouristes Français Croix Blanche

External bleeding

When blood spurts or pours continuously from a wound, direct pressure should be applied to stop the bleeding:

  1. If possible, avoid contact with the casualty’s blood. Ask them to put pressure on the wound themselves.
  2. Otherwise, press directly on the wound with your hands protected by gloves, a plastic bag or cloth.
  3. Make the casualty lie down in a horizontal position.
  4. Ask someone nearby to alert the emergency services or do so yourself.
  5. If the bleeding continues, press more firmly. If this is not sufficient and there is massive life-threatening bleeding from a limb, consider applying a tourniquet (instructions below).
  6. Maintain pressure on the wound until assistance arrives.
  7. If you have to leave the scene, for example to raise the alarm, use a compression bandage in place of manual pressure.
  8. Wash or disinfect your hands afterwards.

HOW TO APPLY A COMPRESSION BANDAGE

The bandage used instead of manual pressure must be clean and should completely cover the bleeding wound. The compression bandage should be applied as quickly as possible after manual pressure is removed. The binding must be wide enough to entirely cover the wadding and long enough for at least two turns around the affected limb. The binding should be tight enough to prevent the bleeding from starting again. If the compression bandage does not stop the bleeding completely, apply a second wad on top of the first to increase the pressure. If this fails, resume manual compression.

SEVERE BLEEDING AND APPLICATION OF A TOURNIQUET

This advice comes from Christophe Talmet, in charge of training at the French Red Cross.

Your first response when faced with major external bleeding should be to apply a haemostatic dressing. This acts as a cushion, compressing the wound, and is held in place tightly by closure strips.

If there is major bleeding from a limb which you are unable to staunch with a compression dressing, and if the injury is life-threatening and the emergency services are some distance away, in these circumstances only, you should apply a tourniquet to stop the flow of blood to the wound.

The tourniquet should be a wide binding made of strong cloth that will not break the skin but will stop the flow of blood. It should be placed just above the wound so that the area of skin deprived of blood is a small as possible.

To tie the tourniquet, form a loop in the cloth. If the wound is mid-calf, place the loop under the knee of the casualty with the two protruding ends on one side. Hold one of the strands of the loop in place, by pressing on it with your knee, for example, and pass the other strand over the injured leg and through the loop. Pull on this strand tight to stop the bleeding. Take the other end of the binding, which you have kept in place with your knee, and tie a knot.

There is also a purpose-made tourniquet, where you just have to slip on a strap and turn the baton to tighten it.

NB:

  • Once the tourniquet has been applied and the bleeding has stopped, don’t undo it or loosen it for any reason until the injured person is under the charge of a doctor.
  • Note down the time the tourniquet was applied and display it prominently on the casualty, for example on their forehead. This is vital information for the surgeon who treats the injured person. The usual practice is to write “T” (for tourniquet) and the local time. For example if you applied the tourniquet at 2:30 pm, write T14:30.
  • Don’t place clothing or a blanket over the tourniquet, which could prevent it from being noticed and thus cause it to be removed too late.
  • The casualty may exhibit symptoms of circulatory distress such as low blood pressure, pallor or cold sweat. Make them lie down and reassure them.
  • Do not give the casualty anything to drink since they will have to undergo surgery. Moisten their lips if necessary.

Fractures

In the event of a fracture when there is no assistance nearby, the main thing is to immobilise the joints above and below the break to prevent pain and further complications.

For example:

  • For a fracture of the forearm, immobilise the elbow and wrist
  • For a fracture of the leg, immobilise the knee and ankle

Temporary immobilisation of the limbs is necessary whenever the casualty has to be moved and other more appropriate means are not available. This can be done using:

  • Clothing: if there is no equipment available, use a piece of clothing such as a shirt, sweater or jacket turned inside out pinned in place or, better still, tied with a necktie or headscarf.
  • One or more blankets.
  • One or more triangular bandages, made of stiff cotton, canvas or non-woven paper. It should measure at least 1.2 metres (4 feet) on its longest side.

In the event of a fracture of a lower limb:

  • Make the casualty lie down.
  • Immobilise them with care, using bandages and a splint.
  • Alert the emergency services and arrange for them to be stretchered out.

10. PSYCHOLOGICAL TRAUMA: MANAGING TRAUMATIC STRESS

This introductory guide has been prepared by the Dart Center (dartcenter.org), which supports journalists who are coping with traumatic stress.

Journalists in high-risk areas work on stories that involve bereavement, violation and profound personal loss. Reporters may themselves witness death or be subject to attack. Awareness of the potential psychological impact of trauma is crucial to effective and free reporting. Unrecognised traumatic stress may compromise safety awareness or erode professional judgment – in extreme cases derailing careers. Some basic knowledge can both boost resilience as well as provide valuable insight into the experience of traumatised subjects and sources.

What is trauma?

Mental health professionals classify an incident as traumatic when someone experiences or witnesses an event involving actual or threatened death, serious injury, or other threat to their physical integrity, giving rise to intense fear, helplessness or horror. Bombings, violent assaults, rape, torture, the aftermath of natural disasters or serious accidents – all familiar subjects to reporters – are common scenarios.

Geographical proximity is not essential: repeated exposure to images of death and injury, or discovering that a close associate or family member has met serious harm may in some cases evoke the same responses.

Trauma reactions are rooted in the biology of survival. Faced with perceived threat, the brain triggers the release of hormones, such as adrenalin. Individual responses vary, but may include:

  • Increased alertness or sense of presence
  • Fight and flight responses (elevated heart-rate, dry mouth, loss of bowel control, sweating, etc.)
  • Numbing and disassociation (feeling psychologically separated from the event or out of one’s body)
  • Heightened emotionality
  • These are normal responses to abnormal situations, and at times may help survival. It is useful to be in alert mode in a dangerous environment. Such reactions normally subside in a few days or weeks after the danger has passed.

But sometimes distress persists for longer and individuals may feel changed by harrowing events in specific ways, experiencing:

  • Intrusive memories, ranging from nightmares and flashbacks to more subtle unwanted reminders of a horrifying event
  • Arousal (elevated heart-rate, night sweats, etc.)
  • Overreaction to everyday events, difficulty concentrating, irritability, unusual anger or rage
  • Emotional numbing, social withdrawal, avoidance of any reminders of a distressing event or a sense of growing distance from loved ones.

When such reactions persist a month after a journalist has returned to safety, that may indicate a psychological injury. Clinicians define “post-traumatic stress disorder” as a combination of intrusion, arousal and numbing, but other changes such as depression or substance abuse may also appear. Predicting whom this will happen to, or when, is not possible. Even journalists who have coped well during many years in the field, and who colleagues regard as emotionally robust, may experience overload at some stage. (Note that for local journalists living in situations of on-going threat, it can be hard to determine what would qualify as a month-long period of safety, in which trauma reactions might no longer be part of a survival response appropriate to that environment.)

Trauma and journalists

Most media workers show remarkable resilience in the face of horror.

Journalists usually exercise a choice when they pursue violent stories – the choice of whether to take an assignment or turn it down, the many choices involved in framing an account. This element of control – something normally denied other survivors and victims – may give a sense of mission and be in part protective, but it doesn’t bestow immunity.

Indeed, recent studies show that journalists are just as vulnerable to emotional injury as soldiers, firefighters or other frontline participants in tragedy. Traumatic stress can have a particularly insidious effect upon journalists. Studies show that repeated exposure to horror – rather than being protective – may actually increase the likelihood of distress. Intrusive memories, an inability to concentrate, sleep difficulties, explosive anger, numbing and social isolation all take a toll on journalists’ news judgment, capacities and relationships. The good news is that PTSD responds well to treatment, and studies show that resilience may be boosted by a range of self-care measures. But the impact of trauma should command journalists’ attention and respect.

Self-care

Traumatic stress derives from an intense emotional engagement with violence. Although different from general stress, it shares some of the same neurochemistry. This is why everyday pressures – deadlines, personal conflict, culture shock, financial uncertainty, etc. – may exacerbate trauma. There are practical measures journalists can take to safeguard their wellbeing before, during and after assignments.

BEFORE AN ASSIGNMENT

  • Training and preparation: evidence shows that people who are mentally prepared for challenging situations have greater emotional control during them. Preparation of all kinds – hostile environment training, craft skills development, research into the history and culture of an area – as well as trauma awareness can boost selfefficacy, reduce general stress and promote resilience.
  • Locate allies: Make prior contact with others in the area so that you have a network in place. Journalists, humanitarian workers, UN staff in the region, and others can provide valuable social as well as logistical support. This may be particularly important for isolated freelancers or journalists embedded with the military.
  • Work on fitness: Exercise builds resistance to stress.
  • Don’t forget domestic matters: Set time aside for family, friends or loved ones. Sort out your finances and make sure that your next of kin have access to your insurance details, will, etc. Worrying on assignment about having left such things undone can significantly add to stress. Also consider tidying your accommodation before leaving. Returning to a place that feels ordered and safe may help the transition back.
  • Be sure you are ready to go: Evidence suggests that repeat exposure to danger and trauma without sufficient downtime greatly increases vulnerability to PTSD. If you are feeling pressured to go, and it simply doesn’t feel like emotionally the right time, then consider turning down that assignment.

DURING AN ASSIGNMENT

  • Look after your body:
    • Eat and sleep well. (Even special-forces soldiers prioritise these.)
    • Take exercise. Just stretching or walking for thirty minutes can elevate mood.
    • Drink water. Dehydration impairs brain function.
    • Watch your alcohol consumption. Too much can increase nightmares and flashbacks.
    • Be careful with stimulants. Caffeine boosts adrenalin levels.
  • Pay heed to your emotional needs:
    • Develop simple, daily rituals that take you out of the story. Reading, doing exercise or a craft hobby, for instance, can provide respite from toxic subject material.
    • Acknowledge feelings. Talk to people you trust or try writing a journal.
    • Never underestimate the importance of laughter.
    • Try deep breathing, especially if distressed. (Breathe slowly into your diaphragm, pause, then breathe out on a count longer than the in-breath.)
    • Try to form the habit of reframing negative situations: acknowledge what’s happened, but then list any positives that still apply. Focus on future steps that you can control. Thinking obsessively about what went wrong may increase vulnerability.
  • Support others:
    • Social connection is one of the most protective factors in the face of trauma – but that means the ability to give as well as receive support.
    • People recover better from trauma when their co-workers are positive and supportive. Be careful with attributing blame.
    • Be available to listen, but don’t dig for feelings, or make assumptions about what others might be experiencing or what you think they should be feeling.
    • Be a leader. Allow yourself and your co-workers proper recovery time.
    • If somebody is finding it hard to cope, consider suggesting they concentrate on lighter practical tasks, rather than ceasing work altogether. Activity is often protective.
    • Different cultures may have different ways of handling grief and trauma. Respect this.
    • Understand your sources: Understanding how trauma affects people may also help you avoid making journalistic mistakes. Some victims may be affected to an extent that there are factual errors in their accounts that they are not conscious of, while others may have near photographic recall.

AFTER AN ASSIGNMENT

Sometimes leaving a story behind is the hardest part. Subsequent assignments may feel pointless in comparison, and some may feel there is guilt for leaving people behind to face danger or deprivation. Relating to others outside of the story can pose its own challenges. People have widely different capacities to listen to descriptions of trauma and may close down discussion or minimise what is being said; and journalists themselves may shy away from discussing topics that could cause friends and family to worry about their safety. Here are some suggestions for managing the transition in and out of a story:

  1. Some journalists suggest taking a day or two of “decompression time” out for themselves before returning home. (Remember to explain to your partner or family first your reasons.)
  2. Thinking about life at home can be a powerful motivator when on the road, but try and keep your expectations of return in proportion. If you have been away for a while, others may be in a different place in their lives: you may not be able to pick up from where you left.
  3. Develop connections with others who have had similar experiences. Being able to talk – or just hang out – without the pressure to explain yourself may make all the difference.
  4. Take stock of your mental wellbeing. It is never too late to seek help.

Working with traumatic imagery

Imagery from war zones, crimes scenes and natural disasters is often gruesome and distressing. The proliferation of high-definition cameras over the last decade has significantly increased the volume and graphic nature of material streaming into newsrooms, from traditional journalistic sources and social media alike. Even when the events depicted are far away, journalists and forensic analysts, deeply immersed in a flood of explicit, violent and disturbing photos and video, may feel that it is seeping into their own personal headspace. Reactions such as disgust, anxiety and helplessness are not unusual; and the content may re-surface outside of work in the form of intrusive thoughts and disrupted sleep.

Here are six practical things media workers can do to reduce the trauma load:

  1. Understand what you are dealing with. Think of traumatic imagery as if it is radiation, a toxic substance that has a dosedependent effect. Journalists and humanitarian workers, like nuclear workers, have a job to do; at the same time, they should take sensible steps to minimise unnecessary exposure. Frequency of viewing may be more of an issue than overall volume, so think about pacing your trauma-image load and ensuring down time.
  2. Eliminate needless repeat exposure. Review your sorting and tagging procedures, and how you organise digital files and folders, among other procedures, to reduce unnecessary viewing. When verifying footage by cross-referencing images from a wide variety of sources, taking written notes of distinctive features may help to minimise how often you need to recheck against an original image. (And never pass the material onto a co-worker without some warning as to what the files contain.)
  3. Experiment with different ways of building some distance into how you view images. Some people find concentrating on certain details, for instance clothes, and avoiding others (such as faces) helps. Consider applying a temporary matte/mask to distressing areas of the image. Film editors should avoid using the loop play function when trimming footage of violent attacks and point of death imagery; or use it very sparingly. Develop your own workarounds.
  4. Try adjusting the viewing environment. Reducing the size of the window or adjusting the screen’s brightness or resolution can lessen the perceived impact. Try turning the sound off when you can – it is often the most affecting part.
  5. Take frequent screen breaks. Look at something pleasing, walk around, stretch or seek out contact with nature (such as greenery and fresh air, etc.). All of these can all help dampen the body’s distress responses. In particular, avoid working with distressing images just before going to sleep. It is more likely to populate your mental space. (And be careful with alcohol – it disrupts sleep and makes nightmares worse.)
  6. Craft your own self-care plan. It can be tempting to work twice, three times, four times as hard when working on a story with big implications. But it’s important to preserve a breathing space for you outside of work.

A NOTE FOR MANAGERS AND EDITORS

According to the American Psychological Association, studies show that women are twice as likely as men to develop a posttraumatic syndrome. Women also suffer from such syndromes for longer and are more sensitive to being reminded of the trauma by a stimulus. The Association says: “Although women are at greater risk for negative consequences following traumatic events, many often hesitate to seek mental health treatment. Survivors often wait years to receive help, while others never receive treatment at all.” This is clearly also true for women journalists, who are particularly exposed to the possibility of traumatic situations when out reporting. These include being the direct victim of sexual violence or witnessing it. Like other women, they are reluctant to talk about this kind of experience, either out of discretion (especially in cases of sexual violence) or to avoid giving the impression of not being “up” to the job. Women are more likely than men to feel under constant pressure to prove that they are good at their work. For resources and information contact the Dart Center at www.dartcenter.org