Wenchuan is a small city in Sichuan Province, China, that was the epicenter of a devastating earthquake on May 12, 2008. The earthquake caused significant damage to the city, and many people were buried in the rubble of collapsed buildings. One victim was rescued after being trapped for 124 hours, longer than any others we had treated, and was given immediate psychological as well as physical treatment, eventually making a good recovery.

In this study we describe the treatment of this victim, a 21-year-old man of Qiang ethnicity who was rescued after 124 hours. He was taken to the field medical station of Xijing Hospital, Fourth Military Medical University of the Chinese People’s Liberation Army. On admission, he was carried into the ward, and whilst able to hold himself up, his face was gaunt and he was suffering from severe dehydration.

A physical examination of the patient revealed the following: body temperature = 36.7°C, pulse = 147 beats per minute, respiration = 29 breaths per minute, and blood pressure = 156 / 95 mmHg. He also had multiple crush injuries, and partial skin necrosis. Laboratory tests revealed an electrolyte imbalance ([K+] = 2.7 mmol / L, [Na+] = 126 mmol / L), acute renal insufficiency, and a blood urea nitrogen (BUN) measurement of 22.3 mmol / L. Emergency surgery was carried out, during which the necrotic epidermis on the left pars iliac was removed, and the wound was wrapped. The dressings he had been wearing on admission were changed, and three injections of TAT (3000U) were administered.

An examination of the patient’s mental state was carried out on his arrival and showed that he was only mildly aware of his surroundings, yet his orientation to time appeared to be fair. However, he showed abnormal space orientation, his awareness was limited, and his concentration was impaired, although his memory appeared intact. His terrorized state of mind was expressed by tears and restlessness. While there was no overt speech and thinking disturbance, he displayed passive speech behavior: his voice was deep, trembling, intermittent, and weak, with abnormal epitomic expression. Initially, he refused medical treatment.

The patient fulfilled diagnostic criteria for acute stress disorder (ASD) according to the 3rd edition of Chinese Classification of Mental Disorders and Diagnostic Criteria (CCMD-3).

Crisis Intervention

In order to restore the patient’s mental condition to a rational state, we implemented an emergency psychological crisis intervention strategy (Miao, 2006). According to Caplan (1964), the key to successful crisis intervention is to obtain the patient’s trust so as to help him develop effective coping skills. Accordingly, we devised a three-step intervention strategy for this patient as described below.

Step 1: Obtain the patient’s trust. To reduce the patient’s feelings of extreme stress and terror, and to calm his restlessness, we spoke to him with gentle soothing words, while using low-key physical contact. Using tones and pacing of speech that resembled his own, we asked him to give us his version of the event and to describe his feelings after the earthquake. We then informed him of the circumstances of his rescue, and reconstructed his sense of safety at the cognitive level. During this communication, we held his hand and occasionally patted his shoulder or upper arm, adjusting the intensity and pace of this physical contact to harmonize with this speech. While assuring him of our support and empathizing with the feelings of tension, fear, and loneliness that had developed while he was trapped, we attempted to transfer his attention to the present by asking him to focus only on the content of our speech. Eventually, he calmed down enough to understand the circumstances, which led him to trust us to help him.

Step 2: Define the support structure. We asked the patient if he had had a spiritual pillar to hold on to that supported his will to survive during the hours he had been trapped. This information is useful for building up a picture that would stabilize him and reveal his support system. We ascertained that his main hope had been, and still was, to see his parents; accordingly, we contacted them, and within 20 minutes they were at his side.

This reunion with his parents brought the patient great comfort, which was crucial to his recovery, and rapidly restored his cognitive state. He became much calmer, and saw the rationale for accepting the clinical treatment he had initially refused. This active choice on his part for further treatment reflected an improvement in his cognitive state and a restored sense of value for his own life.

Step 3: Broaden support and reconstruct self-coping skills. Over time, the patient learned to cope with the medical treatment he received. We ensured that his parents were aware of the importance of somatotherapy and psychological counseling being continued during the latter stages of their son’s treatment.

Psychological counseling continued after the first stage of treatment. We taught him the practical approach to emotional self-management, such as “speaking, listening, and crying”. To avoid the possible transformation of his acute phase reaction to posttraumatic stress disorder (PTSD), we showed him the basic methods of desensitization and relaxation training. These methods enabled him to broaden his range of social support, learn self-coping skills, and avoid any exacerbation of his stress response. Ultimately, these methods improved his capacity for responding to support, which was a primary goal of rehabilitation.

Physical Treatment

On May 19th, while under general anesthesia, the patient received skin grafts at the same field medical station where he was first treated. The necrotic skin on his left parsiliaca was debrided, and new skin was grafted.

On May 21st, he returned to the hospital accompanied by a trained medical team. At this time, he showed a clear consciousness, good eye contact, and overall normal cognitive function. He gave relevant and coherent answers to our questions, and his emotional state appeared to be stable, although at times he seemed tense, and wept while watching television programs about the earthquake. However, he did not show any abnormal stress response, and willingly cooperated with medical personnel when required. On June 20, he had recovered sufficiently to be discharged.

Discussion

In previous studies it has been shown that about 75-80% of patients who were diagnosed with ASD would develop PTSD (Bryant, 2005). The successful treatment of this earthquake victim showed that early psychological intervention is vital for survivors of disasters, which is in accordance with the consensuses of National Voluntary Organizations Active in Disaster (NVOAD) (Everly, Hamilton, Tyiska, & Ellers, 2008), and this case may provide some insights into treating disaster survivors diagnosed with ASD.

The positive effect of social support on health was established by Durkheim (1951), who addressed the association between social aggregation and psychological well-being. The success of this intervention showed the importance of including social support in the treatment. In this case, reuniting the patient with his parents was the turning point in his recovery, which dramatically enhanced his cognitive function. This occurred because the parents were the most significant persons in his life, and he felt real safety only upon seeing them. At that point we were provided with the best opportunity to build up his cognition, and provide proper coping strategies.

Treatment may vary according to different patients and different cultures and this case illustrated the value of identifying the key support for the patient. Recognizing and providing the key support can dramatically improve the effects of treatment.

Bryant, R. A. (2005). Predicting posttraumatic stress disorder from acute reactions. Journal of Trauma and Dissociation, 6, 5–15.

Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books. Durkheim, E. (1951). Suicide: A study in sociology. Glencoe, IL: The Free Press.

Everly, G. S., Hamilton, S. E., Tyiska, C. G., & Ellers, K. (2008). Mental health response to disaster: Consensus recommendations: Early Psychological Intervention Subcommittee (EPI), National Volunteer Organizations Active in Disaster (NVOAD). Aggression and Violent Behavior, 13, 407–412.

Miao, D. M., & Wang, J. T. (2006). Military medical psychology. Chinese Medicine Technology Press, 197-206.

Appreciation is due to anonymous reviewers.