Here’s my column in the August Emergency Medicine News.

You’ve finished the resuscitation.  She was 19 and hung herself from a tree in her family’s backyard.  You have the crumpled note that says goodbye.  When you told her mother she had died, she screamed and collapsed.  Her father wept into his hands.  A chill crept up your spine.  You hug your daughter extra close at home.

Or maybe it’s cancer.  Could that man actually be dying of cancer? He looks so young.  His kids, so young, his wife so wounded and lovely.  You try to be gracious and cheery. You call the oncologist who tells you ‘I’ve been trying to get him to accept hospice.’  You feel your lymph nodes, just in case.

Then there’s the day when the man who was arrested for car-jacking escaped from radiology  after hitting the deputy.  He was running down the hall with the officer’s service pistol in his hand.  Wait, remember that time the drunk took a swing and connected, right on your jaw? That was the guy that said, ‘I know where you live and I’ll kill you!’

What about the man whose trachea was crushed in that fight?  He died from his injury, slowly losing his life before you as you struggled with his airway.  And the burns from the high tension line that covered that teenager; the one whose arm was blown off by the electricity.

And there was that lawsuit, the one that said you basically murdered that young woman; or everything just short of it.  It was terrible the way the depositions and testimonies replayed it over and over until you could see and smell and hear the whole event so clearly.

But why would I do this?  Why remind you of all of that pain?  I’m doing it to make a point.  The things we face, the things we endure, the misery that so often visits our emergency departments, they get inside.  The stories, in some ways, are parasites; they never go away and they have the good sense not to kill us..

Perhaps they benefit us; they remind us not to make the same mistakes, with others or ourselves.  They teach us that human suffering is widespread.  They make us sensitive to the beauty and the fragility of life.  Maybe.

Or maybe they are just pain.  Maybe they are diseases themselves, or the wounds we have to suffer in the war against death and disease and misery.  I imagine they lie somewhere in between.

Fortunately, most folks in our line of work learn to disregard them.  They experience the emotions then purge them, or tuck them neatly into a cerebral box for safe-keeping.

I admit, things don’t bother me as much as they did when I was young (er).  I find myself moved but seldom paralyzed by what I see.  Besides, when I think disturbing thoughts, I just tell you, dear readers.

However, a significant number of our colleagues in emergency care don’t purge and don’t forget.  They become gravely wounded; ironically wounded, one might say, as they try to help and heal.  And they develop Post Traumatic Stress Disorder.  But we don’t talk about it much, because after all, we can handle it, right?  Maybe not.

PTSD is all the rage these days.  I suspect it’s for several reasons.  First, it has been increasingly admitted, recognized and treated.  Second, if you haven’t followed the news, there’s a war on.  Or two, or three or something.  (I lose track.)  Wars, given their tendency to produce wounded and dead people, cause enormous psychic stress and lots of PTSD.  I find it unnerving to play Air-soft or paintball, as projectiles whiz past my head.  I can’t even imagine the feeling if they were steel and lead, and intended to put me in the ground forever.  So we’re tuned in to PTSD more than normal.  We see lots of veterans who are afflicted so it’s on our ‘national radar.’

What exactly is it? I don’t want to lecture you.  Most of you know what it is.  But in a nutshell (drawn from The PTSD Alliance website), exposure to terrifying ordeals that can cause physical harm or death, leads to emotional distress.  The events can be single events, or many events over time.  That distress can cause anxiety, dysfunctional and self-destructive behaviors, withdrawal, hypervigilance, avoidance of reminders and even physical symptoms.  Victims may feel afraid or helpless.  And here’s the thing:  it can happen not only to victims of horrible events, but to those of use who care for them.  In this case, the traumatic experience is vicarious, but just as emotionally significant..

It makes sense, doesn’t it?  If you stand next to enough bleeding people, you get bloody.  If you breath the air of enough patients with the flu, you get the flu. And if you spend enough time around people who have had terrible, life-altering events happen to them, the emotions can stick to you as well. Especially when your job is to hear the story, view the wounds, fix the wounds and try to bring order and safety to the victim.

The odd thing is this; we tend to be sympathetic to those with the disorder.  And we tend to believe their stories, whether they involve mortar attacks, IEDs, child abuse or animal attacks.  But we seem unwilling to accept that it might be happening…to us.  To the White Knights of medicine (and nursing and EMS) who see the worst things on the front lines, as soon as they occur or just after.  Maybe we don’t like to embrace our humanity or our vulnerability.  Perhaps we developed the incorrect belief that a mental illness is a moral failure, or that admitting to one might adversely affect our careers.  I suppose it could be due to the fact that we get paid to expose our bodies and minds to terrible events. And some of us are paid well.  If it’s our job, and we’re paid, what right do we have to be wounded?  Shouldn’t we just ‘suck it up,’  or ‘cowboy up’ and go on?

I don’t know why we refuse to accept that many of us (more than you might expect) are suffering from PTSD. As I pondered it, I began to wonder if it’s veiled psychic wounds that sometimes leads our colleagues to eject from emergency care. It’s easier, and more acceptable, to blame burnout, frustration with policies or pay, administrative hassles or drug seekers. Everyone ‘gets’ that.  It’s much harder to admit that ‘it hurts too much to see so much hurt.’

I wonder what we can do about it?  I think a great place to start would be for individual docs just to talk to their friends, and mentors, about the terrible things they see.  Maybe we should all have a stress-relief grand rounds once a month, where no topic is off the table.  Or maybe groups should intentionally mandate short sabbaticals for recuperation.  I don’t know.  I just know that the topic is critically important.

Once upon a time, out of curiosity, I looked up the website for the French Foreign Legion.  And it turned out, enlistees could retire after 15 years and have their money sent to them anywhere in whatever was their chosen currency. And French citizenship was conferred.

Is it possible, that as our work becomes harder, our patients sicker, the demands more onerous, and our wounds ever deeper, that we need an option like this?  Is 15 years in emergency medicine enough?  Should we at least be encouraged to take some breaks in there?

I’m not sure.  But I know that a young man can go to war as a cook, see no action, but come back and perhaps quite reasonably be diagnosed with PTSD after one tour.  But a physician, nurse or medic can spend decades watching the life-blood drain out of people, giving them bad news, seeing the effects of drugs and violence, pronouncing people dead and immersing himself or herself in all of it and still consider themselves weak for feeling the pain.

Hopefully, as we accept the reality of PTSD, that can begin to change in a more humane manner for all of those who see, and treat, the sick and dying in one of the scariest settings ever concocted by man: the modern emergency department.






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