"PTSD is not the person's refusal to let go of the past but rather the past's refusal to let go of the person." - Anonymous

June is PTSD Awareness Month, and we're focusing on what has become an extremely timely topic in healthcare — the impact of PTSD on emergency department providers.

Post-traumatic stress disorder (PTSD), most often associated with military combat, is prevalent among frontline healthcare workers — especially emergency physicians and nurses — many of whom have been severely traumatized by the effects of the COVID-19 pandemic.

We need no better evidence of the devastation that results when PTSD is left untreated than the death of prominent Manhattan emergency medicine doctor, Lorna Breen, who took her life after spending days battling this disease. We hope that if you find yourself compromised by PTSD, you will seek help immediately.

PTSD Defined

The National Institute of Mental Health defines PTSD as an illness that develops in some people who have experienced a shocking, scary, or dangerous event.

These events can have lasting effects, like intrusive thoughts that get in the way of living an otherwise healthy lifestyle, actively avoiding reminders of the event, negative or distorted thoughts and feelings, and arousal or reactive symptoms, such as angry outbursts or difficulty sleeping or concentrating.

How PTSD Differs from Burnout or Stress

While at times displaying similar symptoms, there are distinct differences between PTSD, burnout, and stress.

Burnout is categorized as physical, mental, and emotional exhaustion. While stress derives from over-engagement, burnout derives from disengagement. Burnout can lead to dulled emotions and detachment. It undermines motivation, leaving a sense of despair. 

The major difference is that while stress and burnout tend to be shorter-lived and may be eased, or even alleviated, with the lightening of one's overall workload or a change in scenery, such as a vacation or new job, symptoms of PTSD will often worsen over time and can require a much deeper dive into the psyche of the affected individual.

The Main Causes of PTSD in the ED 

For healthcare workers, especially those in the emergency department, PTSD is a growing concern, as they deal with various degrees of trauma, illness, death, and violence daily — each of which can trigger the development of PTSD. 

Those most at risk include physicians who practice emergency medicine in rural areas with limited resources, who are in residency training, involved in malpractice litigation, or indirectly exposed to trauma.

Regardless, studies have shown that 18 percent of all nurses, 15 to 17 percent of emergency physicians, and 11.9 to 21.5 percent of emergency medicine residents meet the diagnostic criteria for PTSD. 

Just last year, the Journal of Patient Safety published a report stating that more than two-thirds of providers involved in an adverse clinical event suffered from troubling memories, anxiety, anger, remorse, and distress. 

Nearly 80 percent of doctors have experienced a distressing patient event in the last year, and many go on to suffer from depression, anxiety, and PTSD. 

"It's not a matter of if clinicians are going to experience trauma while providing care, but when and how often," said Dr. Albert Wu, MD, MPH, professor of health policy and management at Johns Hopkins School of Public Health.

Why Clinicians Do Not Always Seek Help

Every year, many healthcare workers fail to seek help related to PTSD for reasons ranging from an absence of any sort of real outlet to a desire to appear stronger to a lack of recognition of their symptoms. 

During a particularly traumatic or scary event, a person's instincts might take over, instituting a "fight or flight" response. This natural reaction might make it easier to navigate the current situation but can also lead to suppressed emotions that may arise in the future when triggered.

Clinicians may refuse to open up, in regard to their mental health, for fear they will appear weak to co-workers or patients, diminishing their credibility.

Michael Myers, MD, professor of clinical psychology at SUNY-Downstate Medical Center in Brooklyn, New York, found that the stigma attached to mental illness is higher in medicine than in the general public, which means that not only are physicians more at risk for mental health conditions and suicidal ideation but also have a higher likelihood that their struggles will go unaddressed.

Dr. Myers called the situation a "conspiracy of silence" that may aggravate feelings of isolation and shame in their survivors.

"Even before [COVID-19], the whole issue of PTSD in emergency physicians has been a taboo subject for a long time," said Scott Pirkle, MD, senior vice president, group medical officer, SCP Health. 

Dr. Pirkle said that PTSD was not a focus during his tenure as an emergency physician, but that it is much more at the forefront among young EM doctors, who are mindful of the need to achieve work-life balance. 

"You were considered to be a good emergency physician if you could walk out of a critically ill patient's room—maybe even a Code Blue—and then walk into another room and see somebody with a sprained ankle or sore throat and have that same cheery disposition that you're expected to have with every patient encounter," he said. "But that suppression of those emotions overtime is the driving force behind the depression and burnout we see in physicians."

Combating PTSD in the ED

While there is still no feasible way to lessen the number of potentially traumatic events faced by healthcare workers daily, some medical institutions have begun taking steps to provide clinicians with an adequate channel to help ease the burdens of PTSD. 

Several have established peer support groups, while others have chosen to hire Chief Wellness Officers. Some academic deans have also founded learning communities, launched physician wellbeing initiatives, and incorporated resilience training into the medical school curriculum.

Dr. Pirkle advises doctors under his care to leave patient encounters at work when the shift ends.

"Before you discharge any patient, pause and replay everything you've done, every test you ordered, and every decision you made to make sure that patient is not ‘in the front seat with you’ on the way home and certainly not ‘with you’ when you are with your family," he remarked. 

He also places a high value on having a support network with whom doctors can talk, socialize, and exchange ideas to find ways to cope.

The significance of these interventions cannot be understated, but there is more to be done. The National Center for Biotechnology Information cites the importance of physicians in leadership advocating for more support programs for their colleagues with PTSD.

Other recommendations include different forms of psychotherapy, such as:

  • Cognitive-behavioral therapy - a type of talk therapy meant to aid in recognizing thought patterns that can hinder growth and recovery;
  • Exposure therapy - useful with flashbacks and nightmares, helps face frightening situations and memories, and assists in coping with them more effectively;
  • Eye movement desensitization and reprocessing - combines exposure therapy with a series of guided eye movements that help process traumatic memories and change how a person perceives them.

A 2013 KevinMD blog post — Dealing with psychological stress of being a doctor — offered these tips: 

Practice Professional Detachment

"This is an unnatural skill in which you must suppress your innate sympathy for the suffering experienced by a fellow human being," said the post. "[But it] is a necessary skill if you are to function in the medical environment."

Unpack the Experience

Doctors need to take time to "unpack" emotionally by turning the case over in their heads and exploring any unpleasant feelings so that "you can come to a resolution and move on."

Seek Professional Help

The KevinMD post concluded by recommending doctors who are "really having trouble" seek professional help.

"If you're self-medicating, or if you are bringing work home to the point it's affecting your family, be humble and realize that doctors can benefit as much as any other patient from psychological counseling and support," the post said.

Conclusion

As always, peer-to-peer communication remains vital. More healthcare workers than ever are being trained to look for symptoms of PTSD in their colleagues, as it encourages a teamwork approach to shouldering the burden of dealing with traumatic experiences. 

As PTSD among clinicians becomes a more prevalent and recognizable issue, more measures are being taken to ensure the mental wellbeing of those who face it every day.