Fran Lowry

March 05, 2015

Physicians in the emergency department should be aware that they are at risk for post-traumatic stress disorder (PTSD), and should be prepared to take steps to deal with it if they find that they have symptoms.

"We don't have good numbers, but the incidence of PTSD in emergency physicians is probably around 17%," said Leslie Zun, MD, from Mount Sinai Hospital in Chicago.

The rate is "similar to that in trauma surgeons, where the incidence is 15%, and to that in emergency medicine nurses, where the incidence is 18%. We are right in the middle," he told Medscape Medical News.

"But whether or not we have it, we should be aware of it and learn to manage it," Dr Zun said here at the American Academy of Emergency Medicine 21st Annual Scientific Assembly in Austin, Texas.

"We all can be affected by what goes on in the workplace, so we need to take our own temperatures. We need to reflect on how the events we have experienced are affecting us. And if we feel we need it, we should be comfortable seeking assistance and using good coping mechanisms," he explained.

There are a lot of resources to help emergency physicians cope with PTSD, including talking with colleagues or a trusted friend or using employee-assistance programs or other psychological counseling. In addition, the National Center for PTSD, the American Medical Association, the National Institute of Mental Health, and the PTSD Alliance are good sources of information and assistance for doctors who would like help.

Help is available, but our biggest hurdle in medicine tends to be this feeling that we cannot admit our weakness.

"Help is available, but our biggest hurdle in medicine tends to be this feeling that we cannot admit our weakness. We can't admit that we have a problem, especially a mental problem. But we are just like everybody else. We get affected by events that occur around us or are directed at us, and we need to take appropriate measures to deal with those things. We are not immune," said Dr Zun.

The criteria for PTSD, as set out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, include exposure to actual or threatened death, serious injury, or sexual violence; the presence of intrusion symptoms associated with a traumatic event; the persistent avoidance of stimuli associated with the traumatic event; negative alterations in cognition and mood associated with the traumatic event; marked alteration in arousal and reactivity associated with the traumatic event; disturbance lasting longer than 1 month; and disturbance causing clinically significant distress or impairment in social, occupational, or other interactions.

Events that can precipitate PTSD include pediatric or unexpected deaths, errors, staff injury or death, a terrorist event, mass casualties, needle sticks, and even being sued for malpractice.

"The emergency department is an area where there is a lot of workplace violence, where patients are verbally and physically aggressive. Almost everybody who works in the ED has been verbally assaulted by patients — every day," Dr Zun said. "I'll never forget the guy who grabbed my tie and pulled me toward him and swore at me. It's a highly charged area."

Symptoms of PTSD include feelings of hopelessness, difficulty concentrating, hypervigilance, exaggerated or easily triggered startle response, loss of interest in normal activities, irritability, difficulty sleeping, a reliving of the event, flashbacks or nightmares, and emotional numbing or feelings of detachment.

If untreated, people with PTSD can become depressed or suicidal and have trouble at school and work. They can also develop substance abuse, alcohol problems, or physical illnesses, such as heart disease, gastrointestinal problems, headaches, obesity, sleep disorders, burnout, and cognitive impairment.

"Burnout is a big concern. Emergency physicians tend to have a high level of career satisfaction but a significant amount of burnout," Dr Zun said.

Raising awareness about PTSD could lead to self-reflection, resulting in emergency physicians asking themselves whether they could have it.

Emotional and Physical Suffering

"It's important to recognize and understand that the difficult situations we encounter in the emergency department, the stress we endure, and the emotional and physical suffering we become accustomed to dealing with can eventually affect us in adverse ways," said Robert Glatter, MD, from Lenox Hill Hospital, New York City, who is on the editorial board of Medscape Emergency Medicine.

"The sick patients and stressful situations in emergency are lessons in life, teaching us that human suffering is constant and unrelenting," he told Medscape Medical News. "The suffering also makes us more appreciative of just how fragile life can be."

"I believe that most physicians learn to deal with adversity and chronic stress, tucking away the thoughts and memories and placing them in context and perspective, as one might compartmentalize parts of life that are painful," he said.

However, "a significant number of our colleagues cannot just file the bad memories away. They are, in a sense, wounded and have difficulty healing. They develop PTSD. The problem is that as a group, physicians don't really want to talk about it," Dr Glatter explained.

"The strange thing is that we are quite understanding and sympathetic to those with PTSD. We witness and listen to the horrific stories of abuse, assaults, and confrontation on a daily basis. Yet as a group, we may be unwilling to accept the fact that we might be just as vulnerable."

This reluctance could be related to a concern that admitting to having a mental illness and needing help is akin to failure, and a fear that such an admission could lead to loss of our jobs, he said.

And the hidden psychological wounds resulting from PTSD could be contributing to physicians leaving the field of emergency medicine, he added.

We need mental and physical rest and recovery to help regenerate our souls and to regain focus.

One option that might help emergency physicians deal with PTSD is to take brief periods of time off to recover and recuperate. "We need mental and physical rest and recovery to help regenerate our souls and to regain focus," he said.

Meditation could be a healthy way to help not just emergency physicians, but all types of physicians, he added.

"Meditation has clear beneficial effects that can help reduce stress and anxiety while sharpening focus. If practiced for just 10 minutes a day, it can have powerful effects on mental well-being," Dr Glatter explained.

"It is imperative that physicians take care of themselves, not only physically but emotionally, so that they can perform at the highest possible level," he said.

Dr Zun and Dr Glatter have disclosed no relevant financial relationships.

American Academy of Emergency Medicine (AAEM) 21st Annual Scientific Assembly. Presented March 4, 2015.


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