'I am OK.' Every time emergency physicians utter these three words, they may be putting themselves at risk for developing symptoms of an overpowering — frequently secret — disability: post-traumatic stress disorder (PTSD).
“Fine” and “OK” are common responses to any inquiry about how a member of the emergency team is faring after a traumatic event in the emergency department, which is ironic given that EDs are more prone to violence than ever before. (J Emerg Med 2012;43:736.) And violent acts are only part of a cadre of acute stressors called “personally disturbing incidents” that can lead to PTSD, which is characterized by unrelenting recollection and intrusive images that interfere with normal thinking and sleep.
There are, of course, individual variations in how such incidents are processed, but the impact of them is more predictable than past medical literature would suggest, said Mark Holland, PhD, EMT-P, who surveyed 180 first responders to learn more about PTSD among those who provide emergency care. (Prehosp Emerg Care 2011;15:331.)
A study in Denmark of more than 200 staff members in emergency care showed that the same personally disturbing incidents Dr. Holland identified also affected Danish health care providers, and those events seemed to compromise performance substantially, as measured by adverse events recently experienced by emergency personnel. (Am J Emerg Med 2013;31:504.)
Susceptibility seems highest when rescue efforts fail for victims injured by a crime, a fire, or a natural disaster. The risk is heightened when these occur in children or among those known by those providing medical care. “Consistently, these have been shown to have an impact,” noted Dr. Holland, who is the EMS division chief at Parkwood Fire/EMS in Durham, NC.
The result may be increased hostility and emotional liability, but denial or masking of mood changes is typical, as recounted by an emergency physician who serves as medical director for a large university hospital. A colleague of his from a war-torn part of the Middle East who emigrated to North America many years ago had shown no sign of duress. Yet one day, confronted with a trauma victim, tears began trailing down the physician's face while he performed the needed intervention. Afterward, he seemed to lapse into a daze, but he declined to elaborate when asked why by the medical director.
Earlier, however, this same physician had observed — almost in passing — that he had seen a similar kind of patient in his native country. This emergency physician's reaction was “triggered by something in the case he was working on,” and it could have been the type of injury or something else about the patient, such as his age or even his hair color, said Robert Stanulis, PhD, a neuropsychologist in Portland, OR, who specializes in treating PTSD and who frequently serves as an expert witness on the disorder.
Emergency physicians and nurses “can get what is called vicarious traumatization from dealing with so much trauma,” he said. “A trigger to a flashback happens more than an MD or RN on a trauma team likes to admit,” he said.
And the effects can be prolonged. A study of one emergency team that treated victims three years after a terrorist attack in Europe showed that five had symptoms of PTSD; that was a third of those who provided care. (BMJ Careers 26 Feb 2005; http://bit.ly/10x9N3P.) That same year, a U.S. study of more than 60 emergency medicine residents and interns showed that seven suffered from PTSD, and worse, the likelihood of getting the disorder increased with time spent in the ED. (J Emerg Med 2005;28:1.)
Younger emergency care providers who lack strong ties to friends or family seem particularly vulnerable. Older adults who have a network of social support seem to have more of a built-in buffer, a trend that was seen in a French study of emergency physicians. It also showed that emergency physicians accumulate significantly more stress compared with other salaried physicians. (Emerg Med J 2011;28:397.)
“When you have a job like that, there is exposure for you day after day,” said James Burks, the coordinator of emergency medical services for the ED at the Cincinnati VA Medical Center. The hospital has partnered with Cincinnati State to use space for a class in PTSD; the training sessions are being offered at the hospital as well. The aim is to help identify the disorder when it develops in the course of the jobs, not simply to improve recognition of PTSD symptoms in patients. “We think this can help lead to better outcomes,” he said.
What doesn't work? A coping style that avoids thinking about or discussing a personally disturbing incident, that denies its impact, that attempts to deal with it by “sucking it up,” said Dr. Holland.
Conversion to PTSD is associated with a sense of isolation, too. Studies on soldiers suggest it is likely to occur in a culture that values action over talk and discourages seeking emotional support. Among military personnel, the reasons for not sharing such damaging experiences with family or friends outside of work range from a desire to shield loved ones to the perception that telling others may lead to prurient fascination, which is counterproductive to feeling understood. Feelings of shame and guilt can be activated with new impunity in the absence of a sympathetic listener.
The same appears to be true for medical doctors. More than four percent of 159 physicians in rural or remote areas of Ontario, Canada, met the criteria for the PTSD, and the disorder was associated with overwork, lack of resources, and relational problems. (Fam Pract 2010;27:339.) In fact, a personally disturbing incident can happen even in a situation where there is not the remotest chance for a different outcome, such as a resuscitation attempt for a bystander already dead from a hail of bullets.
Four percent of EMS personnel in a Hawaiian survey met clinical diagnostic criteria for PTSD, and an overwhelming majority, 83 percent, reported experiencing some symptoms of it. Analysis showed that serious injury or death of a co-worker along with incidents involving children were considered very stressful; general work conditions also contributed to the overall stress levels. (Emerg Med J 2010;27:708.) Few, however, received treatment.
“In other work that I do with EDs, there is definitely a culture of discussing patients frankly and objectively, without emotion. I think this is crucial for accomplishing the work that needs to be done,” said one of the study co-authors, Deborah Goebert, DrPH, a professor and the associate director of research for the department of psychiatry at the John A. Burns School of Medicine in Honolulu. “At the same time, specific time to debrief for certain types of cases may be needed to encourage support and help-seeking. This needs to be done in a format different from morbidity and mortality sessions,” she said.
Formulation of a simple decision tree could be used to assess when an event should be an “approachable” moment for a supervisor or co-worker, as well as the possible way in which it could be addressed, Dr. Holland added.
But the fear of stigmatization has stopped many from seeking help. (Lancet 2011;377:454.) Thirty-three of 212 physicians working during terrorist attacks in Israel, for example, suffered symptoms of PTSD. Yet only three of 20 who acknowledged the syndrome received therapy for it. (Br J Psychiatry 2008;193:165.) A study of nurses with PTSD symptoms showed similar results. Only 18 percent attended critical-incident stress debriefing, and none sought any other help for their distress. (J Emerg Nurs 2003;29:23.)
Left untreated or unaddressed, detachment or over-reaction to patients can begin to occur, which can surface as “downplaying” a patient's physical complaints or proffering responses to him that clearly only provide “lip service.” Conversely, those with PTSD can over-identify with someone seeking medical attention in a way that may make the health care provider seem like a crusader, expressing self-anger at not being able to do enough for a particular patient or voicing hostility against colleagues who set ordinary and appropriate treatment boundaries. (Torture 2006;16:1.)
One South African study showed a “death connection” for PTSD, that the risk for it is higher among those witnessing death, for those involved in death notification, and for participants in emergency settings where death is likely to occur. (Emerg Med J 2006;23:226.) Generally affirming those findings, a U.S. study also showed that few of 145 emergency physicians from four academic centers had post-death debriefing to help them cope, and their most common approach to deal with the emotional after-effects was to turn to colleagues, friends, or family to discuss the sadness they felt. (Acad Emerg Med 2011;18:255.)
Dr. Holland stressed he has found success in certain coping strategies aside from empathic peer or colleague support. They include adopting a problem-solving approach in which the individual determines what he needs to do to face the lingering emotional effects, such as seeking counseling or taking time off to process the event, and reappraisal of the incident that allows the traumatic event to be reframed in a more positive light, enabling the individual to see it as an important way of shaping the future or learning a life lesson.
“We found that certain factors were associated with better coping strategies,” said Carolyn Weiniger, MD, a professor of anesthesiology and critical care medicine at Hadassah Medical Center in Jerusalem. An inference from the studies she and co-authors have conducted, one of which was done in the aftermath of suicide bombings, is that an available “outlet” may have a mitigating effect.
That outlet generally consists of one or more empathic people in whom the experience can be confided, but it's not clear whether emergency personnel who have someone to whom they can vent actually are helped by sharing their feelings or if they possess a protective advantage from already having such social support in place. “We are not able to distinguish what comes first,” Dr. Weiniger said.
This does not mean that personally disturbing incidents that lead to PTSD can be transformed into less wrenching incidents solely by supportive staff members willing to lend an ear. PTSD can occur even in the most nurturing environment as a result of the perception of the traumatic experience. Some psychological therapies have a track record for effectively treating most of those affected by PTSD, although the best evidence-based treatments — cognitive behavioral therapy is one example — have faced a battle in becoming established across the mental health community. Barriers have included cost and training. (Psychological Science in the Public Interest 2013;14:65.)
The need in emergency medicine appears great for workplace approaches and longer-term counseling or treatment. Moreover, emergency physicians are unlikely to attenuate their participation in the very events that put them at highest risk for PTSD. When the bombs went off at the Boston marathon, for instance, the physicians in the medical tent — on hand to help exhausted runners — began treating victims of the explosion amid smoke, unsure if another attack would hit nearby.
Sushrut Jangi, MD, a hospitalist at Beth Israel Deaconess Medical Center, said he thought he had seen all forms of misery. “But until that moment I had not understood how deeply a human being could suffer,” he recalled.
The doctors and nurses stayed on. One physician texted his wife: “There is bomb at the finish line, and we have to help.” Another looked at patients who were bleeding and in shock, and said, “I'm a doctor, and I'm going to take care of you.” (N Engl J Med 2013;368:1953.) And when Dr. Jangi noticed a nurse crying while she was attaching an IV bag for a patient, she brushed away her tears, telling Dr. Jangi, “I am fine.”
Stop Sucking It Up
Read Dr. Edwin Leap's column on PTSD in emergency physicians on p. 11.