New Orleans, Louisiana
The acutely burned patient arrives in the emergency room in a state of frightened anxiety, seeking prompt relief of the burning pain, and in a hypnoidal state that makes him highly susceptible to both good and bad suggestions. The body's response to the thermal injury is inflammation, causing progressive pathologic worsening (Hinshaw, 1963) of the injury. In sun burn, the first degree burn (redness) present on leaving the sun progresses to second degree (blister) in the ensuing 8-12 hours. The "standard" third degree (full-thickness) burn was shown by Brauer and Spira (1966) to be only second degree for the first four hours. . . . The deeper dermal layers are not immediately killed by the heat, but rather later by the body's inflammatory response.
Chapman, Goodell, and Wolff (1959a,b) showed that inflammation is mediated through the central nervous system by release of a bradykinin-like substance which is released during the first two hours after the burn stimulus, but that the release of this enzyme is held in abeyance by icing the wound. They also showed that hypnotic suggestion can produce a blister (response without a true stimulus), and can prevent blistering when an experimental burn is placed on a hypnotically anesthetized arm (true stimulus without a response). Thus, the damaging inflammatory reaction can be blocked by early hypnosis, attenuating the ultimate depth and severity of the burn (Ewin, 1978, 1979).
During the first two days after a severe burn, inflammation causes large amounts of fluid to exude into the burned tissues from the bloodstream, requiring intravenous replacement to prevent shock and kidney shut-down. Since much of this fluid is later reabsorbed and can overload the cardiovascular system, standard fluid formulas aim at giving the least amount of fluid that will maintain both blood pressure and minimal urine output of 25 cc to 50 cc per hour (600-1,200 cc per 24 hrs.). Margolis, Domangue, Ehleben, and Schrier (1983) have shown that, in every case hypnotized before ten hours, the urine output on the second day was significantly elevated, averaging 3501 cc as opposed to 1,666 cc in matched controls. With the inflammatory edema limited, the calculated fluid was too much, and the extra had to be cleared through the urine.
When a newly burned patient arrives in the emergency room, his mind is concentrated and hypnosis is usually easy to induce. Since he may be a stranger to the physician, the first communication is an introduction and suggestion.
Doctor. I'm Dr._and I'll be taking care of you (pause). Do you know how to treat this kind of burn? [This question is to bring to his immediate attention that he doesn't, and that he must put his faith in the medical team. Precise wording is important because if you ask, "Do you know anything about treating burns?" he may know something and tell you about butter, Solarcaine, or kiss-it-and-make-it-well, which is a complete avoidance of recognizing the dependence.]
Patient: No. [The standard reply. In the rare instance of a physician or nurse who actually does know about burns, you simply use that knowledge to say, "Then you already know that you need to turn your care over to us, and that we will do our best."]
Doctor. That's all right, because we know how to take care of this and you've already done the most important thing, which was to get to the hospital quickly. You are safe now, and if you will do what I say, you can have a comfortable rest in the hospital while your body is healing. Will you do what I say? [This exchange lets the patient know that he is on the team and has already done his biggest job, so he can safely lay aside his fight or flight response (he's already fled to the hospital) which mobilizes hormones that interfere with normal immunity and metabolism. It includes a prehypnotic suggestion that he is safe and can be comfortable if he makes a commitment. His affirmative answer has made a hypnotic contract that is as good as any trance.]
Patient: Yes, or, I'll try. [Frightened patients tend to constantly analyze each sensation and new symptom to report to the doctor. By turning his care over to us (the whole team), he is freed of this responsibility and worry. Next, his attention is diverted to something he hadn't thought of before.]
Doctor: The first thing I want you to do is to turn the care of this burn over to us, so you don't have to worry about it at all. The second thing is for you to realize that what you think will make a great deal of difference in your healing. Have you ever seen a person blush, or blanch white with fear?" [Even dark-skinned patients are aware of this phenomenon in light-skinned people.]
Doctor: Well, you know that nothing has happened except a thought, an idea, and all of the little blood vessels in the face have opened up and turned red, or clamped down and blanched. What you think is going to affect the blood supply to your skin, and this affects healing, and you can start right now. You should have happy, relaxing, enjoyable thoughts to free up all of your healing energy. Brer Rabbit said "everybody's got a laughing place," and when I tell you to go to your laughing place, I mean for you to imagine that you are in a safe, peaceful place, enjoying yourself, totally free of responsibility, just goofing off. What would you do for a laughing place?" [The patient needs something he perceives as useful to occupy his time. The laughing place may be the beach, TV, fishing, golfing, needlepoint, playing dolls, etc. It becomes the key word for subsequent rapid inductions for dressing changes, etc., to simply "go to your laughing place."
Doctor: Let's get you relaxed and go to your laughing place right now, while we take care of the burn. Get comfortable and roll your eyeballs up as though you are looking at the top of your forehead and take a deep, deep, deep breath and as you take it in, gradually close your eyelids and as you let the breath out, let your eyes relax and let every nerve and fiber in your body go [slow and cadenced] loose and limp and lazy-like, your limbs like lumps of lead. Then just let your mind go off to your laughing place and . . . [visual imagery of laughing place]. [This short bit of conversation does not ordinarily delay the usual emergent hospital care. Most often, when the patient arrives in the emergency room an analgesic is given, blood is drawn, I.V. drips are started, and cold water applications are applied by the time the doctor arrives. If not, these can proceed even while the conversation takes place. A towel dipped in ice water produces immediate relief of the burning pain that occurs right after a fresh burn. Since frost bite is as bad an injury as a burn, the patient should not be packed in ice, but ice water towels are very helpful. In fact, Chapman et al. (1959a,b) showed that applying ice water to a burn holds the inflammatory response in check for several hours, so there is ample time to call for the assistance of a qualified hypnotist if the primary physician is not skilled in the technique of hypnosis.]
Doctor: Now while you are off at your laughing place, I want you to also notice that all of the injured areas are cool and comfortable. Notice how cool and comfortable they actually are, and when you can really feel this, you'll let me know because this finger (touch an index finger) will slowly rise to signal that all of the injured areas are cool and comfortable."
Doctor. [After obtaining ideomotor signal:] Now let your inner mind lock in on that sensation of being cool and comfortable and you can keep it that way during your entire stay in the hospital. You can enjoy going to your laughing place as often as you like, and you'll be able to ignore all of the bothersome things we may have to do and anything negative that is said. ... Go to your laughing place.
In burns under 20%, the single initial trance generally suffices, while in larger burns, repeated suggestion helps control pain, anorexia, and uncooperativeness.
Since a thought can produce a burn (vide supra), continued feelings of guilt or anger can prevent healing and should be dealt with during emotional countershock a day or two after admission. If the patient is guilty, I stress the fact that it was unintentional and that he has been severely punished and has learned a lesson he will never forget or repeat. If he is angry, I point out that the goal is healing, and it does not interfere with his legal rights to get the best healing possible or to forgive the other person of evil intent. There is no place for anger at his laughing place, and he is instructed to postpone that feeling until healing has occurred.
It helps for the doctor to know what the laughing place is and to record it, because he may enhance it later with some visual imagery. This simple, rapid induction usually produces a profound trance almost immediately. By this time, the patient has iced towels on and the analgesic is taking effect so that he actually is cool and comfortable. It is much easier hypnotically to continue a sensation that is already present than it is to imagine its opposite. The suggestion "cool and comfortable" is antiinflammatory, and if he accepts it he cannot be hot and painful. From now on, the word injured is substituted whenever possible for the word burn, because patients use the word "burning" to describe their pain. (Do not specify a particular area, hands, neck, etc., because, while these areas will do well, some spot you forgot may do poorly.)
I just leave the patient in trance and go ahead with his initial care, get him moved to the Burn Unit, and often he will drop off to sleep. On subsequent days, "Go to your laughing place," is all the signal the patient usually needs to drop off into a hypnoidal state and tolerate bedside procedures, physical therapy, etc.
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