She was 19 and hung herself from a tree in her backyard. You have the crumpled note that says goodbye. Her mother collapsed when you told her she had died. Her father wept into his hands. A chill crept up your spine. You hug your daughter extra close at home.
Could that man be dying of cancer? He looks so young. His kids are so young, his wife so wounded and lovely. You call the oncologist who tells you, “I've been trying to get him to accept hospice.” You feel your lymph nodes.
Then there's the man arrested for carjacking who escapes from radiology after hitting the deputy. He runs down the hall with the officer's pistol in his hand.
Remember the drunk who took a swing and connected on your jaw? That guy said, “I know where you live, and I'll kill you!”
What about the man whose trachea was crushed in that fight? He died from his injury, slowly, right in front of you as you struggled with his airway. And the burns from the high tension line that covered that teenager, the one whose arm was blown off by the electricity.
What about that lawsuit that said you basically murdered a young woman? It was terrible the way the testimony played it over and over until you could see and smell and hear the whole event so clearly.
But why would I remind you of all of this pain? My point: the things we face, the things we endure, the misery that so often visits our emergency departments get inside us. The stories are parasites; they never go away, and they have the good sense not to kill us.
Perhaps they benefit us; they remind us not to make the same mistakes twice. They teach us that human suffering is widespread. They make us sensitive to the beauty and the fragility of life.
Or maybe they are just pain. Maybe they are diseases themselves or the wounds we have to suffer in the war against death and disease and misery. I imagine they lie somewhere in between.
Fortunately, most folks in our line of work learn to disregard them. They experience the emotions, then purge them, or they tuck them neatly into a cerebral box for safekeeping.
I admit, things don't bother me as much as they did when I was younger. I find myself moved but seldom paralyzed by what I see. Besides, when I think disturbing thoughts, I just tell you, dear readers.
A significant number of our colleagues in emergency care, however, don't purge and don't forget. They become gravely wounded, ironically wounded, one might say, as they try to help and heal. They develop post-traumatic stress disorder. But we don't talk about it much because we can handle it, right?
PTSD is all the rage these days, I suspect because it has been increasingly admitted, recognized, and treated. And there's a war on. Or two or three. (I lose track.) Wars, given their tendency to produce wounded and dead people, cause enormous psychic stress and lots of PTSD. I find it unnerving to play Airsoft or paintball as projectiles whiz past my head. I can't even imagine the feeling if they were steel and lead meant to put me in the ground forever. So we're tuned into PTSD more than normal. We see lots of veterans who are afflicted so it's on our national radar.
Most of you know what it is, but in a nutshell, it is exposure to terrifying ordeals that can cause physical harm or death and that lead to emotional distress (drawn from the PTSD Alliance website; see FastLinks). The events can be single events or many events over time. That distress can cause anxiety, dysfunctional, and self-destructive behaviors, withdrawal, hypervigilance, avoiding reminders, and even physical symptoms. Victims may feel afraid or helpless. And it can happen not only to victims of horrible events but to those who care for them. The traumatic experience in that case is vicarious but just as emotionally significant.
It makes sense, doesn't it? If you stand next to enough bleeding people, you get bloody. If you breathe the air of patients with the flu, you get the flu. If you spend enough time around people who have experienced terrible, life-altering events, the emotions can stick to you, especially when your job is to hear the story, view the wounds, fix the wounds, and try to bring order and safety to the victim.
The odd thing is, we tend to be sympathetic to those with the disorder. We believe their stories whether they involve mortar attacks, IEDs, child abuse, or animal attacks. But we seem unwilling to accept that it might be happening to us, the White Knights of medicine (and nursing and EMS) who see the worst things on the front lines.
Maybe we don't like to embrace our humanity or our vulnerability. Perhaps we developed the incorrect belief that a mental illness is a moral failure or that admitting to one might adversely affect our careers. I suppose it could be because we get paid to expose our bodies and minds to terrible events. If it's our job and we're paid, what right do we have to be wounded? Shouldn't we just suck it up?
I don't know why we refuse to accept that many of us (more than you might expect) are suffering from PTSD. As I pondered it, I began to wonder if veiled psychic wounds sometimes lead our colleagues to eject from emergency care. It's easier and more acceptable to blame burnout, frustration with policies or pay, administrative hassles, or drug seekers. Everyone gets that. It's much more difficult to admit that it hurts too much to see so much hurt.
What we can do about it? A great place to start would be for doctors to talk to their friends and mentors about the terrible things they see. Maybe we should have a stress-relief grand rounds once a month, where no topic is off the table. Or maybe groups should intentionally mandate short sabbaticals for recuperation. I don't know; I just know that the topic is critically important.
I once looked up the website for the French Foreign Legion, and it turned out that enlistees could retire after 15 years and have their money sent to them anywhere in any currency. And French citizenship was conferred.
Is it possible that as our work becomes more difficult, our patients sicker, the demands more onerous, and our wounds ever deeper that we need an option like this? Is 15 years in emergency medicine enough? Should we at least be encouraged to take some breaks?
I'm not sure. But I know that a young man can go to war as a cook and see no action but be diagnosed (perhaps quite reasonably) with PTSD after one tour. But a physician, nurse, or medic who spends decades watching the life-blood drain out of people, giving them bad news, seeing the effects of drugs and violence, and pronouncing people dead is still considered weak for feeling the pain.
Hopefully, that can change for all of those who see and treat the sick and dying in one of the scariest settings ever concocted by humans: the modern emergency department.
Treating PTSD — in EPs
Read our Special Report on PTSD in emergency physicians on p. 18.
- Visit the PTSD Alliance website at http://www.ptsdalliance.org/.
- Visit Dr. Leap's blog at www.edwinleap.com/blog and follow him on Twitter.com/edwinleap.