Let's do some introspection: PTSD among emergency providers

There’s no ‘normal’ day in the Emergency Department. It’s a matter of pride that as a group, we’re all highly adaptable and energetic enough to handle anything that comes through the door at any moment. It’s never boring.

It’s an honor and a privilege that we’re exposed to some of the most intense moments in the lives of others. How many of us have seen a young child get seriously injured or even die? Diagnosed a terminal illness? Told someone her (or his) significant other passed away in an unexpected manner? Participated in the care of someone who has been the victim of a horrific violent crime or rape? How many of these have happened in the last few months or even weeks? bummedmd

We all like to think that we’re the type of person that is strong enough to handle these situations. While I think for the most part that it’s true, I’d still like to do a bit of introspection – is this completely healthy for us, as providers, to work in this environment?

As it turns out, it’s predictably unhealthy for a subset of providers. Some of us working in the ED will develop symptoms resembling post-traumatic stress disorder. It’s thought that this is due to the frequency of exposure to death, dying, and victims of trauma. There have been two small studies on ED doctors specifically. The first investigated symptoms using a voluntary survey in 181 attending and resident physicians from Belgium that attended a national emergency medicine conference. It found a prevalence of clinically significant symptoms in 15 percent of providers^[1]. The second looked at PTSD within emergency medicine residents specifically. It surveyed the residents of an inner-city residency program, noting symptoms in 7 of 63 residents^[2]. These are small studies with imperfect methods, but to me, these numbers are still big enough to take note. It’s important, not only from a pure mental health perspective, but because symptoms have been linked to level of burnout among employees^[3]. Given the notoriety of burnout within EM physicians, it’s worth an attempt to address the issue.

Delving deeper, the studies both suggest that the more a population is exposed to traumatic experiences at work, the more prevalent the symptoms become. In the study of residents, authors point out that symptoms became more severe and prevalent with increasing years of residency^[2]. The study of ED physicians did not specify level of training, and it found that the frequency and length of exposure was related to the severity of symptoms^[1]. This is consistent with literature that examines other professions that work with trauma victims. Similar studies on firefighters and paramedics found a comparable prevalence of symptoms, and noted that symptoms increased with the total number of ‘fatal incidents’ witnessed^[4], total number and severity of exposure to traumatic events^[5], and years of on-the-job experience^[6]. In a meta-analysis of papers on PTSD symptoms among a variety of healthcare professions, authors concluded that the raw number of ‘incidents’ witnessed was predictive of symptoms, which became more pronounced as a person’s career progressed^[7]. This is important for two reasons. First, this implies that to become symptomatic, you don’t need to be exposed to one sentinel, extremely traumatic event, but that instead the day-to-day grind outside the realm of normalcy can produce the same result. This also highlights that it’s not something one can just “get used to” or tends to just “go away” on its own. In fact, in a study on Irish doctors exposed to a mass casualty, investigators found that doctors for whom it was the second exposure actually fared more poorly than those who were novel to catastrophic violence^[8]. This suggests that repeated exposures may worsen one’s ability to cope and not aid adaptation.

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So, this is pretty depressing, right? The good news is that there are some things you can do to help prevent the progression of symptoms. The best thing one can do as an individual is to develop a support system for oneself. This is the strongest negative predictor of developing symptoms^[1],[5]. Likewise, the best thing an employer can do is facilitate support among the staff. According to the Office of Veterans Affairs^[10] and psychiatrist Matthew Tull^[9],it may help to educate yourself about symptoms that are common after repeated exposure to traumatic experiences and understand that having some stress reaction is normal. If you’re feeling particularly bothered, find a healthy distraction that works for you – examples include reading, cooking, or exercising. As always, stay away from excessive use of alcohol or other mind-altering substances. Some psychiatrists recommend writing about your thoughts. So, take care of yourself – have a low threshold for talking to someone, asking for help, or offering a hand to a colleague.

^[1] The impact of occupational hazards and traumatic events among Belgian emergency physicians. Francis J. Somville, Véronique De Gucht and Stan Maes. International Journal of Behavioral Nutrition and Physical Activity (2016) 24:59 DOI 10.1186/s13049-016-0249-9

^[2] Symptoms of post-traumatic stress disorder among emergency medicine residents. Mills LD, Mills TJ.J Emerg Med. 2005 Jan;28(1):1-4.

^[3] Impact of post-traumatic stress disorder and job-related stress on burnout: a study of fire service workers. Mitani S, Fujita M, Nakata K, Shirakawa T. J Emerg Med. 2006 Jul;31(1):7-11.

^[4] The mental health of fire-fighters: An examination of the impact of repeated trauma exposure. Harvey SB, Milligan-Saville JS, Paterson HM, Harkness EL, Marsh AM, Dobson M, Kemp R, Bryant RA. Aust N Z J Psychiatry. 2016 Jul;50(7):649-58. doi: 10.1177/0004867415615217. Epub 2015 Nov 24.

^[5] Trauma exposure, posttraumatic stress disorder and the effect of explanatory variables in paramedic trainees.Fjeldheim CB, Nöthling J, Pretorius K, Basson M, Ganasen K, Heneke R, Cloete KJ, Seedat S. BMC Emerg Med. 2014 Apr 23;14:11. doi: 10.1186/1471-227X-14-11.

^[6] Post-traumatic stress among Swedish ambulance personnel. Jonsson A, Segesten K, Mattsson B. Emerg Med J. 2003 Jan;20(1):79-84.

^[7] Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis. de Boer J, Lok A, Van’t Verlaat E, Duivenvoorden HJ, Bakker AB, Smit BJ. Soc Sci Med. 2011 Jul;73(2):316-26. doi: 10.1016/j.socscimed.2011.05.009. Epub 2011 May 30.

^[8] Questionnaire survey of post-traumatic stress disorder in doctors involved in the Omagh bombing.

Firth-Cozens J1, Midgley SJ, Burges C. BMJ. 1999 Dec 18-25;319(7225):1609.

^[9] Tull, Matthew. Coping with PTSD: Healthy Ways to Deal with Post-Traumatic Stress Disorder. Verywell.com. Aug 11 2016.

^[10] Coping with traumatic stress reactions. Retrieved from http://www.ptsd.va.gov/public/treatment/cope/coping-traumatic-stress.asp (Aug 22 2016)