I cried at work the other day. It’s not that crying in reference to a sad case is new to me; it’s just new for the person who I am now.
A young woman rolled into my emergency department, trying to bleed to death; there was so much blood. Immediately my team flooded her room. Adrenaline took over, leaving no time for me to think or process or feel anything about the case. For what seemed like an eternity, I stood by her bedside, ignoring every other patient in the department. I did what any one of us would do: bark orders, call the blood bank, and run around with my team to do everything we can to resuscitate her. I stroked her hair as she cried. I stood by her husband as he was paralyzed in fear, all while watching her monitor with my heart racing.
We resuscitated her for over an hour before she was finally stable enough for the operating room. Finally, the chaplain was able to enter the room. He held hands with the patient and her husband and prayed with them while they cried.
Out of nowhere, I was suddenly triggered. I flashed back to a scenario many years ago, where a chaplain sat with me as I cried in a hospital. Every emotion from that day rushed at me in a matter of seconds. I turned on my heel, left the patient’s side abruptly, and fled the room. My nurses were startled by my quick and dramatic departure. Before I could stop it, I found myself crying, vulnerable in front of my staff. I walked quickly, trying so hard to keep my tears hidden and avoid embarrassment. After years in practice, I finally felt like a leader in my department. I couldn’t help but feel like I had shattered my reputation by giving in to my emotions in public.
I spend much of my young physician life struggling to deal with the stress and emotions surrounding our specialty. I succumbed to my emotions often during residency and my first years as an attending. Now, after years of caring for patients, I know I have become more and more disconnected, and I find difficult scenarios no longer impact me like they used to.
Table 1: Summary of Criteria for PTSD
- Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence
- Intrusion symptoms
- Negative alterations in cognitions and mood
- Alterations in arousal and reactivity
- Duration of symptoms greater than one month
- Symptoms create distress or functional impairment
- Symptoms not due to medication, substance use, or other illness
In addition to the above criteria, the patient must have one of the following specifications:
- Dissociative specification: Depersonalization and/or derealization
- Delayed specification: Full diagnostic criteria are not met until at least six months after the trauma(s), although symptom onset may occur immediately
When I think back to a few of the horrific cases I have seen over the years, I should really be in tears daily. Instead I have compartmentalized these tragedies further and further into the recesses of my mind. I ignore how they impact me until I just cannot overcome their cumulative weight. Even the smallest tasks are intolerable and impossible until I gather myself again. When I really pause to think about it, these responses are not normal—not for me or for anyone else in health care.
Recently, there has been some recognition of the fact that posttraumatic stress disorder (PTSD) is a real possibility in health care workers, particularly those who work with critically ill or injured patients. The American Psychiatric Association describes PTSD as a condition that occurs “in people who have experienced or witnessed a traumatic event.” It further explains that PTSD sufferers “may relive the event through flashbacks or nightmares; they may feel sadness, fear, or anger; and they may feel detached or estranged from other people.”1 As some of you read this, the symptoms may sound very familiar.
According to an article in the Journal of Medical Practice Management, the types of physicians most prone to developing PTSD are physicians who practice emergency medicine in rural areas with limited resources, who are in residency training, who are involved in malpractice litigation, and/or who are indirectly exposed to trauma.2 There are some of us who, unfortunately, fit into many of these categories.
Recent studies revealing the prevalence of PTSD in health care workers are disconcerting. Approximately 18 percent of all nurses, 15 to 17 percent of emergency physicians, and 11.9 to 21.5 percent of emergency medicine residents meet diagnostic criteria for PTSD.3–5 Those are frightening numbers.
Clearly, this is a real and valid concern. So what do we need to do for our colleagues with PTSD?
Developing a departmental or, better yet, institutional approach to assisting PTSD sufferers will require a change in the way we view our profession, colleagues, and the impact emergency medicine has on our lives. Recommendations need to be accepted and practiced universally. At the crux of it, recognition should be the top priority. For all levels of health care providers in our field, the evidence says our approach to address PTSD should include:5
- Cognitive behavioral therapy (CBT)
- Team debriefing after care of critical patients
- Mindfulness-based stress management (MBSR)
- Teaching effective methods to use meditation or mental cues to “self-relax”
Studies examining the efficacy of CBT have demonstrated that this treatment has been useful and effective for a wide range of psychological problems, particularly in mental health disorders in children.6 However, at present, there is minimal and low-quality evidence that CBT and mental and physical relaxation reduce occupational stress more than no intervention in health care workers.7 Many of us are not in the practice of utilizing CBT or mindfulness in our daily work and may not be aware of what these practices involve. CBT involves increasing happiness by changing the way we respond emotionally and behaviorally to certain problems. MBSR encourages a person to focus only on their immediate present, paying attention to emotions, thoughts, and somatic feelings at that given moment. It is targeted to teach an individual to calm the mind, in turn helping to cope with times of stress. With successful use of CBT and MBSR, an individual can then move on to using meditation or verbal cues to relax and regroup in times of high stress.
Team debriefing is best led by physicians or charge nurses after a critical event. This can allow the group involved to reflect on the experience. These few minutes can also be used as an opportunity to recognize team members traumatized by events and identify them for follow-up in case they require assistance.
Education of these critical methods may be accomplished by involving our psychiatry colleagues or specialists in these fields to develop learning programs geared toward emergency medicine physicians.
To those of you who have been practicing for some time, this all may sound a little “kitschy.” We trained and began our careers in an era where we view outward emotion as a sign of weakness. Perhaps we see it that way because we have become hardened, disconnected, and estranged. We are no longer in touch with the normal emotions associated with the illness, trauma, and death all around us. Perhaps we should view expression of our emotions in a different light, a sign of our own humanity.
As a group, we must have a high index of suspicion for PTSD in our colleagues (see Table 1 for a list of criteria for PTSD). We need to have our leaders advocate for effective support programs for our colleagues with PTSD. We need to develop real programs for individuals with PTSD to seek help without recourse, whether it is psychiatric therapy or time off. The road to recovery for emergency physicians who suffer from PTSD requires that we finally recognize it and ensure it is not ignored.
Dr. Shah is assistant professor of emergency medicine and associate chief medical informatics officer at Rush University Medical Center in Chicago.
- What is posttraumatic stress disorder? American Psychiatric Association website. Accessed Dec. 19, 2018.
- Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30(2):131-134.
- Mealer M, Burnham EL, Goode CJ, et al. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depress Anxiety. 2009;26(12):1118-1126.
- Lowry F. Emergency department staff not immune to traumatic stress. Medscape website. Accessed Dec. 19, 2018.
- Vanyo L, Sorge R, Chen A, et al. Posttraumatic stress disorder in emergency medicine residents. Ann Emerg Med. 2017;70(6):898-903.
- Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.
- Ruotsalainen JH, Verbeek JH, Mariné A, et al. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015;(4):CD002892.