Commentary: What we can learn from bystanders who performed CPR on Itaewon victims

SINGAPORE: On the night of Oct 29, a crowd crush occurred at the Itaewon area of South Korea during Halloween festivities resulting in the deaths of 156 people and injuring another 197.

Unfortunately, emergency response was delayed and many bystanders were recruited to help tend to the injured.

Videos surfaced on the Internet of the rescue effort from members of the public, with many of them seen performing cardiopulmonary resuscitation (CPR) on those around them who had collapsed.

It was later reported that some of these bystanders had never performed CPR before and felt psychologically traumatised afterwards.

In my line of work as a psychiatrist, I once had a patient who performed CPR on a stranger who collapsed. His immediate response was that of disbelief and panic. However, he composed himself and leaped into action.

Unfortunately, the victim did not survive. My patient was left feeling unsure if he did the right thing. He ruminated about whether he had broken the victim’s ribs during CPR and had flashbacks of the sensation of the ribs cracking under his hands as he performed chest compressions. Ultimately, he was guilt-ridden that he was not able to save the victim.

SELF-DOUBT AND GUILT

In the Itaewon tragedy, the bystanders were confronted with not just one victim but a mass casualty situation. They might have just escaped from danger themselves and might have witnessed loved ones injured or perished. They were then immediately thrown into an uncoordinated rescue effort amid the chaos.

For those who were never trained in CPR, but nevertheless helped that fateful night, they might not know that breaking ribs in CPR is a common occurrence. According to a study of CPR-associated injuries published in 2017, the incidence of rib fractures after CPR is reported in more than 70 per cent of cases, with a mean number of 7.6 broken ribs per person.

These factors can certainly lead to psychological trauma in the rescuers as they struggle to make sense of the experience. They will wonder if they did enough and feel guilty especially if the victim died.

In the immediate aftermath, a mixed bag of emotions including feelings of confusion, disorientation, sadness, or anxiety is to be expected. They may struggle to sleep and have nightmares of the incident. Many may startle easily and be hypervigilant of crowds or of people coming too close to them.

LIVES CHANGED FOREVER

Fortunately for most, these symptoms will be short-lived and tend not to develop into full-blown psychiatric disorders.

However, some of those who were exposed to the trauma may develop chronic mental illnesses, like post-traumatic stress disorder (PTSD), that may be severely debilitating to their daily lives.

Patients with PTSD suffer from vivid re-experiencing of the traumatic event with symptoms such as flashbacks, nightmares, and intrusive memories.

They will try to avoid being reminded of the traumatic event which may present as phobia of crowds or avoiding ever going to Itaewon again. 

There may be persistent hyperarousal in them with symptoms like irritability, anger outbursts and insomnia. Some may also go on to develop survivor guilt, depression, and other anxiety disorders.

In the immediate aftermath, the most important aspect for helping individuals who have been exposed to such trauma would be practical support. This could be allowing them to rest from school or from work, helping them with their meals or providing them some simple sleeping aids.

While professional psychological debriefing has not been shown to be useful in preventing post-traumatic stress symptoms, allowing the individuals to speak of their experience, if they are ready to and want to, can help them to process their emotions and come to a closure.

Family and friends can help by reassuring them that the emotions they experience are to be expected. According to Austrian psychiatrist and Holocaust survivor Victor Frankl, “an abnormal reaction to an abnormal situation is normal behaviour”.

But should they experience symptoms that affect their social life or work or persist for more than one month, professional assessment and treatment will be needed.

LINK BETWEEN INTENSE EXPOSURE AND PTSD

Based on studies done on 9/11 terrorist attack, people who had a closer experience of the disaster had a higher rate of PTSD. Close to 3,000 people were killed in the 2001 attack on the World Trade Centre towers, while thousands more were injured. 

According to a study published in 2011 on the long-term effects on survivors, 15 per cent of those who were in the towers were estimated to have suffered from PTSD.

Other studies show that about 13 per cent of traditional responders and 17 per cent of non-traditional first responders, such as lay rescuers, suffered PTSD at 2.5 years.

In a separate study in 2015 on the psychological impact on lay rescuers who performed bystander CPR after receiving a text message for cardiac arrest assistance, 81 per cent reported no stress, 19 per cent reported mild stress, and none reported PTSD symptoms at eight weeks.

From the various studies, I would argue that the key factor in the triggering of emotional distress or PTSD is not the act of helping the victim, but how intensely one is exposed to the horrors of the tragic event.

Lay rescuers need to know that they were brave and heroic for overcoming their fears and taking action. Their efforts and lifesaving acts must not be discounted and are crucial in the chain of survival for victims.

We should encourage better training for the public in performing CPR and the use of equipment such as automated external defibrillators (AEDs), such that everyone can be a first responder.

Being helpless and unable to act as the victim dies must surely be much more traumatising than attempting to save a life, even if unsuccessful.

Dr Lim Boon Leng is a psychiatrist at the Gleneagles Medical Centre.