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Special Report

Special Report

PTSD, the Pandora's Box of Emergency Medicine

Shaw, Gina

doi: 10.1097/01.EEM.0000516452.68111.52

    On April 15, 2013, University of Massachusetts Memorial Medical Center emergency medicine resident Maurine Williams, MD, wasn't expecting to handle much more than some sprained ankles and a few cases of dehydration or hyponatremia. But as one of dozens of volunteers in the medical tent near the finish line of the Boston Marathon, she was close enough to feel the blast of the first homemade bomb when it went off.

    “A big wave of wind went through the tent and shook us,” said Dr. Williams, now an attending at HealthAlliance Hospital in Leominster, MA. “It sounded like a cannon had gone off. I thought maybe a transformer had blown.” But when the second explosion hit just 12 seconds later, she knew something much worse was happening.

    For a few moments, the tent was in chaos as the assembled doctors, nurses, and mid-pack runners being treated all tried to figure out what was going on. Then a voice came over the loudspeaker, calling all medical personnel to report to the finish line. Dr. Williams grabbed a box of gloves and ran outside, ultimately finding herself in front of a Marathon Sports store, where the front windows had been shattered by the explosions. “There were bodies and blood and glass everywhere, and smoke billowing out. Everyone was various shades of gray,” she said.

    A man urgently called her inside, saying that there were people who needed help. “There was one young woman on the floor, bleeding badly from a forearm injury,” Dr. Williams said. “Someone had already tied a couple of tourniquets on her upper arm. She also had a huge chunk out of her left thigh.” No sooner had she stabilized the young woman and stopped the bleeding than a police officer ran in and grabbed Dr. Williams by the shoulder. “You have to get out,” he told her. “There's another bomb.”

    They fled the store, but the third bomb turned out to be just one of those frantic rumors that so often spread at tumultuous scenes like the Boston Marathon bombings. Dr. Williams remained at the medical tent, treating an endless array of survivors. “It was two and a half hours, but it seemed like a million years.”

    The next day, she thought she would be fine to return to work in the emergency department, but her chief resident ordered her to take the day off. “I thought that seemed silly, but I did as I was told,” she said.

    When she tried to resume a normal schedule, Dr. Williams found that she wasn't fine at all. “I wasn't sleeping,” she said. “I was hypervigilant to all sounds. I tried a reduced schedule, but even that was too much. There was no way I could do my residency and work through what I had experienced at the same time.” Ultimately, with the support of her chief resident and program director, she ended up taking two full months off, going to therapy to help cope with her post-traumatic stress, and graduating from residency two months late.

    Soldiers, Police, and EPs

    Dr. Williams' experience is unusual. Most emergency physicians never find themselves on the front lines of such a major mass-casualty event. But the day-to-day traumas of the emergency department — the carload of teenagers on their way to prom brought in after a head-on collision, the angry partner of a patient who takes a swing at an attending, the abused child covered in bruises, and simply the pressure of long hours and irregular surges of adrenaline — also put emergency physicians at elevated risk from post-traumatic stress disorder (PTSD), according to two recent studies that appear to be the first to assess the condition's prevalence and risk specifically within this population.

    The National Comorbidity Survey Replication places the lifetime prevalence of PTSD in the general population at approximately 6.8 percent. (Arch Gen Psychiatry 2005;62[6]:593.) This prevalence is double or more among higher-risk groups. The prevalence of current PTSD among Iraq War veterans, for example, is approximately 13.8 percent. (Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica: RAND Corporation; 2008.) And a 2013 study found the prevalence of PTSD among police officers was 15 percent for men and 18.2 percent for women. (Int J Emerg Ment Health 2013;15[4]:241.)

    Emergency physicians have a significant rate of PTSD that is on par with war veterans and police officers, at 15.1 percent, according to a new national survey by Joseph DeLucia, DO, an associate professor of surgery and the emergency medical services liaison at St. Louis University School of Medicine in Missouri. The study, which has been presented at several recent medical meetings including the Society for Academic Emergency Medicine but is not yet published, is limited by its use of an anonymous online survey tool, which raises the potential for selection bias. Nonetheless, it surveyed 526 emergency physicians, and stands out as the first study to focus specifically on PTSD among emergency clinicians.

    “Before undertaking the survey, we looked extensively throughout the literature for another study that specifically focused on the rate of PTSD among emergency physicians, and we couldn't find anything,” Dr. DeLucia said. “This is just speculation, but I think that no one really wants to open this Pandora's box. As EPs, we're taught to be tough, to handle anything under any circumstances. We don't want to come forward and say, ‘Hey, I'm having nightmares, I'm hypervigilant with my family, I'm revisiting the deaths of my patients in my dreams.’”

    Another new study did not focus on emergency physicians exclusively, but included them in a larger survey of 546 care providers from prehospital systems (ambulance systems, air ambulance systems, fire/police) and major trauma centers in the greater San Antonio, Austin, Temple, and Dallas areas. (Injury 2017;48[2]:293.) Only about 34.7 percent of the respondents to the survey by researchers at Dell Medical School at the University of Texas-Austin, were in-hospital providers, with emergency attendings and residents representing 18 percent of the in-hospital providers and emergency nurses another 32 percent. This survey estimated risk for PTSD rather than prevalence, and found that 16 percent of ED attendings, 27 percent of ED nurses, and 29 percent of ED residents were at risk from PTSD.

    Lead author Kevin Luftman, MD, a general surgeon at Seton Medical Center Austin, said his study also might have a selection bias. “It's hard for us to get a sense of how many people saw our survey and whether those who chose to take it might have been more likely to have PTSD than those who did not,” he said. “But we did learn that there is definitely a population in our system that is at risk for this problem, and we need to do a better job of making resources available.”

    A Long Recovery Process

    The Seton Healthcare Family, a network with 11 hospitals that includes Seton Medical Center Austin, has recently taken action to support those who may be at risk from PTSD, including emergency physicians and nurses, Dr. Luftman said. The Provider/Associate Care Team (PACT), developed by the department of risk management and multiple other departments such as psychiatry and occupational health, is activated whenever someone has experienced an event that might predispose them to PTSD. PACT team members go through a full-day training course that includes small groups and role-playing. “We learn how to broach the subject, what questions to ask to get the person engaged, and how to provide them with connections to support and services that the hospital provides,” Dr. Luftman said.

    Marcia Nichols, a Seton risk management specialist who leads the PACT program, said more than 400 peer supporters like Dr. Luftman have been trained across the hospital system since the program launched in November 2015. “They deploy as soon as possible after a difficult event, ideally, before the people involved have gone home,” Ms. Nichols said. “We've found that it really helps people to just sit with someone and talk before they go home and ruminate on everything. The peer supporter then is to follow up with the person within 72 hours to see how they're doing and if they want additional assistance.” PACT peer supporters had been deployed 328 times as of mid-February, although it wasn't possible to identify how many of those encounters involved the emergency department.

    One nurse who received support from PACT after a difficult event said you never know how important a program is until you are in need of its services. “It helps us reconnect with ourselves when an unexpected turn takes place, and reconnects staff in a temporary state of disbelief,” she said. “It reminds me of a lighthouse helping a boat find its way back to shore.”

    But programs like PACT are not widespread, Dr. DeLucia said. He said he believes that emergency medicine could learn a lot from the ways in which the police and firefighters have addressed the risk of PTSD in these high-stress jobs. “These professions are very cohesive and support one another,” he said. “They have debriefing programs, screenings, and psychologists in their departments. They have really improved their response to PTSD over the last decade. We need to get to that same place in emergency medicine.”

    Dr. Williams said colleagues struggling with PTSD should avoid the compulsion to seek instant gratification, observing that even now she still experiences a moderate resurgence of her symptoms around the time of the marathon each year. “It's not as bad as before, but it's always a little different,” Dr. Williams said. “As emergency providers, we don't do long term. We want to fix everything right now. But you're standing on your own neck doing that.”

    She recommended that those who are suffering from PTSD give themselves time and be aware that the recovery process is not going to be a fast one. “The process by which everyone goes through their own trauma and tries to make sense of it is very individualized, but the overarching lesson I learned through all of it was that I had to come to terms with the fact that these are things outside of my control,” Dr. Williams said. “Trying to micromanage each element of my healing and not let flashbacks affect me was actually more harmful than helpful. I can only do the best I can on a daily basis. That's all that can really be asked of me.”

    DSM-V Criteria for PTSD

    The Diagnostic and Statistical Manual V (DSM-V) describes PTSD using these key criteria:

    • Stressor: Exposure to death, threatened death, actual or threatened serious injury or sexual violence, either directly, by witnessing the event, or through indirect exposure. Indirect exposure can involve someone close to the person, or repeated or extreme indirect experiences, as often occurs to emergency physicians.
    • One or more intrusive symptoms: Recurrent, involuntary memories, distressing dreams, flashbacks (dissociation), intense psychological distress when exposed to cues that resemble the trauma, or strong physiological reactions when exposed to those cues.
    • Avoidance: Persistent avoidance of reminders associated with the trauma, such as locations, sounds, smells, people, and feelings. This can include being unable to remember parts of the traumatic event.
    • Negative alterations in cognition or mood: Exaggerated negative feelings about the world or oneself, distorted self-blame, feeling alienated from others or unable to experience positive emotions.
    • Increased arousal and reactivity: Irritability or angry outbursts, reckless and self-destructive behavior, hypervigilance and exaggerated startle response, difficulty concentrating, sleep problems.
    • Duration and significance: To rise to the level of PTSD, symptoms must persist for at least a month and involve significant distress or functional impairment.

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