The Impact of Trauma on Trauma Providers

With two recent major disasters confronting caregivers, the question remains: are caregivers prone to experience PTSD than others? 

Exhibiting a wealth of knowledge and instinct, honed and sharpened by experience, medical first responders and emergency room professionals triage and treat thousands of emergency department (ED) patients each year in America’s hospitals. But at the end of a very long day, are ED physicians likely to become susceptible to post-traumatic stress syndrome (PTSD)?

In the aftermath of two major national tragedies – the recent mass shooting of nearly 600 people in Las Vegas and the ongoing crisis in hurricane-ravaged Puerto Rico – we wonder aloud how dealing with disasters might impact caregivers. To answer some of those questions, we caught up with nationally prominent psychiatrist H. Steven Moffic, for insight:

BUCK: How likely are the ED personnel in Las Vegas to experience PTSD?

MOFFIC: First of all, Chuck, you must be thanked for your concern about emergency room professionals and personnel. Too, too often their own well-being is taken for granted by the public. We expect them to positively resolve perceived healthcare crises, and usually they do, sometimes even what seems miraculously, as if they were superheroes.

(Yet while) first responders provide first aid for mass casualties, “second” responders can provide the right stuff for recovery. They are then thanked, often profusely, then forgotten. Of course, sometimes their patients die, or don’t do as well as expected, or come in angry and leave angry.

I admire these colleagues immensely. In the large EDs, psychiatrists like myself are also present to handle the psychiatric emergencies, so we can see them work first-hand. 

Like all physicians, we are taught how to try to handle our emotions in caring for others. There is a very fine balance that works best: be enough emotionally involved to be empathetic and compassionate, but not so much as to be overwhelmed.

However, even achieving this emotional balance doesn’t provide complete immunity. Emergency room professionals are exposed to so much trauma that they inevitably absorb some secondary PTSD reactions. Decompressing with colleagues or loved ones can help with that.

That, though, is not full-blown diagnosable PTSD. Though studies are limited, it seems that the career incidence of PTSD in emergency physicians and nurses is between 15-20 percent. This is about double the rate of the general public.

Their kryptonite seems to be errors, being sued, deaths of children or staff, and mass casualties like in Las Vegas. Best would be for them to be monitored intermittently for the need for early intervention of emerging symptoms. Just in time to know how to do so well is just-released research, which suggests that “Stepped Care”, which is screening and triage to the appropriate level of care followed by ongoing systematic reevaluation, is the current best approach after disasters. I thank my beloved colleague and friend, the retired emergency physician, Randall Levin, M.D. for forwarding some of the relevant literature to answer this question.

BUCK: What is the progression? Could PTSD lead to burnout?

MOFFIC: This is a very complicated question, Chuck, so once again I need to answer in some depth. We are still trying to understand any connection(s) between PTSD and burnout. More than likely, full-blown PTSD does not lead to burnout, nor does burnout lead to diagnosable PTSD.

PTSD is mainly caused by a major trauma that seems life-threatening, though there may also be individual genetic and historical vulnerabilities. The development of resilience out of prior traumas, also called post-traumatic growth, can be protective with a future trauma. Burnout is caused more by being blocked by system bureaucracy or dysfunction in doing what you know you can to help and heal. Usually this comes in the form of thousands of everyday “micro” traumas over time. In the ED, the system has to be a well-oiled machine, where all the parts work quickly and reliably. Nowadays, it seems that is often not the case, for the burnout rate of emergency physicians is among the highest of all physicians, about 75 percent. We talk about wounded warriors in war; we also have to recognize wounded healers in healthcare. 

Where both of these problems seem to merge some is in the brain, where changes can seem similar. So, instead of a linear path of one leading to the other, we may have more like two roads leading to a final destination in the brain.

BUCK: Turning our attention to Puerto Rico: Could we be experiencing an emerging mental health crisis among citizens and caregivers?

MOFFIC: I think that there is no question that we are — and will be for a time — experiencing a mental health crisis among citizens and caregivers in Puerto Rico. Of course, at the same time, we see so many showing the best of humanity, a mental health showplace, in our often-heroic attempts to help at the same time that we have a crisis. However, the major complicating factor here is that even caregivers of all kinds, including emergency personnel, have also commonly suffered losses and trauma. Some of that has also happened in Houston and other areas of Texas after their hurricane.

With the necessary attempt to provide basic resources of food, water, shelter, and transportation, mental health challenges can be put on the backburner.

BUCK: In Puerto Rico, what mental health symptoms are most likely to surface, and when?

MOFFIC: Already we see increased anxiety and grief, but PTSD is a problem that can emerge anytime, even up to months and years later. Unresolved and complicated grief, as well as PTSD, present the challenge of maintaining mental health vigilance and appropriate help way after some degree of normality emerges.

BUCK: In the Kubler-Ross stages of grief, “depression” is just before “acceptance.” In both Las Vegas and Puerto Rico, might depression lead to other mental health symptoms?

MOFFIC: Your question, Chuck, provides an important opportunity to clarify the usefulness of the Kubler-Ross so-called stages of grief. To review, these are, in order: denial, anger, bargaining, depression, and acceptance. They were actually developed by the observations of Dr. Kubler-Ross of patients who were dying, not of loved ones or others suffering losses.

Moreover, toward the end of her life, she wrote that these were not required stages, nor stages that always developed in that order. Rather, they are common experiences, but in our attempt to master such painful times, they have come to be viewed simplistically and inaccurately. Just like our desire for a simple answer to what was wrong with the mass murderer, and what to simply do to prevent further mass murders, real life is much more messy, complicated, and uncertain.

Grief is personal and unique for everyone. Ultimately, there is never complete closure.

As to the “depression” in her stages, which you so wisely put in parentheses, it is neither everyday depression nor clinical depression. It is the depression of normal, but deep sadness, and therefore won’t tend to lead to other mental health symptoms. Therefore, the grieving should not try to stop that journey with medication or checking off the completion of stages.

Now, circling back to your earlier questions about PTSD, we have come to understand that losses can also feel traumatic, as if our life can never be the same or as good again, a perceived loss of life in its own psychological way. Therefore, we have to appreciate that in encountering significant trauma, we will also often encounter grief.

I hope that we’ve shined some light on the lives of our second responders that we all need to have available, as well as some clarity on the grief we all face in these situations and others.

Program Note: Listen to Dr. Moffic discuss PTSD on Talk Ten Tuesdays, today at 10 a.m. ET.