You are working on a trauma ward and meet 16-year-old Jenna, admitted after experiencing multiple stab wounds. She has a chest drain to treat her hemopneumothorax and is recovering from a laparotomy to repair her diaphragm injury. She is being managed on a surgical ward, sleeping in an open bay alongside other patients. When you meet her, there have been instances of arguing with numerous other patients on the ward and refusing treatment.
The role of healthcare
The 2007, UK, report ‘Trauma, who cares?’ identified serious failings in trauma care nationally. These findings led to the development of Major Trauma Networks and improvements in care. The establishment of a trauma network led to a more coordinated approach to the treatment of traumatic injuries and the introduction of innovative methods of care. Patients treated within an inclusive trauma system have a 23% lower mortality rate compared to those treated in regions with few high-level trauma systems.
Despite strides made in the physical care of trauma patients, many staff feel less confident whem managing and preventing the wider impact of trauma on the individual and their families. A recent staff survey at the Royal London Hospital found that staff described:
- feeling disconnected from the world of young people and lacking in understanding.
- a wish to develop their communication skills and understanding of the factors that get in the way.
- a desire to know how best to connect a young person via referral to support networks.
- feeling frustrated that they could do little to help in brief interactions, especially when a young person is defensive or scared and their lives are so complicated.
- feeling hopeless at times when seeing the same young people return to hospital with more injuries.
We hope to address some of these needs here, focussing on how we can reduce distress for our patients.
After a traumatic event, patients may experience a range of emotional reactions. These take place on a continuum from a normal and understandable response to a severe acute stress response. Acute stress presents in many different ways but is likely to include emotional, physical and behavioural symptoms.
Jenna’s symptoms of acute stress include:
– Wanting the curtains closed around her bed and avoiding eye contact
– Pacing the ward and wanting to go outside at night
– Becoming argumentative and threatening towards staff if they tried to encourage her to sleep and remind her of ward protocol
– Having episodes of irritability and anger directed at staff when they discussed medical procedures with her
What is acute stress? During, and following, a traumatic event the fight-flight-freeze response is activated. This is a highly adaptive survival response. At the time of the danger it keeps us safe, but it becomes less helpful if it persists past the time of danger. When we meet patients like Jenna in hospital, they are likely to be still in a state of ‘amygdala-hijacking’ or fight-flight-freeze, functioning from their alarm and threat brain with a shut down for higher-order reasoning. This is a hard-wired system, designed through evolution as a way of keeping us safe; spending too much time reasoning about something when in immediate danger would not have helped us survive!
Daniel Siegal, a clinical professor of psychiatry and an expert in adolescent anxiety, refers to this as ‘flipping the lid’ and promotes the hand model of the brain as a way of understanding acute distress. According to his model, ‘flipping the lid’ is what happens when the lower, limbic parts of our brain take over and react (fight-flight-freeze) and our cortical, or thinking brain becomes disconnected. Key parts of the brain are immobilised; we cannot learn, communicate our needs, stay connected with others or problem-solve in this state.
Experiencing acute stress does not necessarily mean that the patient will go on to develop Post Traumatic Stress Disorder (PTSD); in fact, the evidence suggests that only a small proportion of people who experience traumatic events develop formally diagnosable PTSD. Acute stress reactions and the development of subsequent PTSD can be exacerbated by difficulties prior to the incident and injury such as adverse childhood events, prior trauma, substance misuse and addiction, mental health difficulties or disabilities such as ADHD and autism.
Behaviours that are very challenging for staff to manage, especially in a ward environment, can be understood in a more helpful way when we consider the fight-flight-freeze response. Let’s take a look at the impact of the flight-fight-freeze response on Jenna’s behaviour.
|Jenna’s Behaviour||How we might understand this|
|Wanting her curtains closed around her bed and avoiding eye contact||Jenna is antisocial, disengaged and prefers to be left alone most of the time.|
Since the incident, Jenna feels like danger is imminent all the time and because of this feeling, she is anxious and even paranoid about others around her. She experiences jumpiness when she hears normal ward noises (fight-flight-freeze).
She feels very confused about what’s happening to her, such as why she can’t stop herself from being startled when she hears a noise. She feels ashamed about having emotional difficulties due to messages she learned in childhood.
She is trying to hide how she is feeling from staff in case they think she is crazy – shame is a very common emotion in trauma.
Acute stress symptoms can manifest overtly as tearfulness or panic attacks (flight) but also include withdrawal, emotional numbing and depression (freeze).
|Pacing the ward, wanting to go outside at night; becoming argumentative and threatening staff if they encourage her to sleep or remind her of ward protocol.||Jenna wants to go outside to buy drugs or get into trouble. |
Jenna is deliberately not following ward guidelines about going outside at night because she doesn’t care about rules.
Jenna has no respect for others.
Just as Jenna falls asleep, she experiences intrusive images of the incident, jumpiness and intense feelings of fear as if the incident or something similar might happen again. If she does fall asleep, she experiences nightmares of the incident. These symptoms are worse at night.
Jenna would rather avoid sleep than have these frightening experiences. Jenna feels ‘on edge’ all the time and walking helps ease this. Jenna feels like it’s difficult to breathe properly and feels the need to get outside for some fresh air – feeling uneasy and anxious, shallow breathing or hyperventilation are common symptoms of acute stress.
|Episodes of irritability and anger directed at staff when they discuss medical procedures with her.||Jenna does not appreciate the care and treatment she is receiving. |
Jenna is rude.
Jenna is struggling to take information on board because of acute stress symptoms. In ‘amygdala hijacking’, the part of her brain that supports learning and problem-solving has been shut down.
Jenna had difficulties with teachers in school and was mistreated by people in authority in her life both at home and in school. Jenna has often had to fend for herself.
Jenna feels easily triggered about her childhood trauma when she is spoken to by authority figures – particularly if conversations are rushed, complicated or feel ‘one sided’ to her.
Early Intervention Following Traumatic Events
Evidence for early intervention after traumatic events remains somewhat limited. Psychological First Aid (PFA) is an approach intended for use by helpers in contact with people recently involved in distressing events. It was designed to replace debriefing models, which have been shown to increase the risk of developing PTSD under certain circumstances. In contrast to debriefing, PFA does not necessarily involve a discussion of the traumatic event. Whilst there is a worldwide consensus about the use of PFA in situations such as humanitarian crises or disasters, there is an absence of direct evidence about efficacy, although some indirect evidence is supportive. The Red Cross integrates Hobfoll’s five principles of psychosocial support in emergencies into their PFA approach (IFRC Reference Centre for Psychosocial Support, Copenhagen, 2018). These include ensuring safety, promoting calm, promoting self and collective efficacy, promoting connectedness and hope.
Beyond psychological first aid, trauma-informed care has a lot of practical applicability to supporting patients after traumatic events. This approach is based on the four pillars described by SAMHSA in 2014:
- knowledge of the impact of trauma
- understanding of the signs and symptoms of trauma
- avoidance of retraumatisation
- the development of appropriate policies and procedures.
Similarly, there is limited evidence about the efficacy of trauma-informed care in emergency departments or trauma wards but there is a growing body of literature around its applicability in this context.
Beyond PFA and trauma-informed care, there is a potential to draw on components of more targeted psychological therapies to support patients in acute stress. In a systematic review focused on early interventions to prevent PTSD in survivors of life-threatening medical events, Birk et al. (2019) noted that cognitive behavioural therapy as well as other early intervention approaches showed promise but as yet evidence of efficacy is lacking. The International Traumatic Stress Society notes that selective/indicated interventions focusing on social support, skill-building, cognitive restructuring, and therapeutic exposure may be most effective for those who are at risk for PTSD or demonstrating early symptoms but do not yet meet the criteria for a trauma-related disorder.
In addition to therapeutic approaches, care models may also make a difference to outcomes. Collaborative Care consists of a multidisciplinary team of psychologists, psychiatrists, nurses, key workers and social workers who evaluate a patients’ needs and coordinate their care so that it is tailored. This may include the provision of psychological and pharmacotherapy intervention as appropriate. Pham et al. (2019) found that collaborative care may mitigate PTSD and depression severity in trauma patients but the long-term outcome benefits are unknown. A key message from the literature is that single-session universal interventions that have been tested to date have insufficient evidence and should not be used as a part of routine clinical practice.
Supporting and Responding to Acute Stress – what you can do
Coordination of care – reduce re-traumatisation
Taking the opportunity to have ‘reachable moments’ or ‘teachable moments’ with young people when they attend as victims of violence, is ingrained in healthcare practice as the right thing to do. We are taught about the importance of safeguarding young people and ensuring that we find out all the details. However, there may be some issues with this. We risk re-traumatising the young person by questioning them about the incident on numerous occasions.
Think about what you need to know. As healthcare professionals, we do not need to investigate the incident. Our main role is to ensure the young person feels safe, is receiving excellent care, and has appropriate referrals made. Use the expert teams around you to help you with this, such as third sector organisations like St Giles Trust. There may be times when you need to ask for some information but do this in a sensitive and supportive way. Be specific about the information you need and why: “If you feel able to answer a question about the incident, I do need to ask you XY so that I can put in the referral I am doing for you to XY.”
Some things to consider when dealing with these cases:
- Language: “Are you in a gang?” “Do you hang out with a gang?” “Do you have friends in gangs?” These are not helpful questions, they do not support our medical treatment needs, and will counteract attempts at building trusting relationships. They also imply a number of harmful stereotypes which can alienate or even re-traumatise the young person. Instead, asking if they are hungry or thirsty, or need to let anyone know they are in the hospital is more helpful.
- Talking or asking about the incident multiple times can re-traumatise or re-trigger the young person’s trauma. Think about why you are engaging with this young person: if you are simply giving some oral medication, completing a tertiary survey, or on the ward round for that day, you do not need to ask the young person how this happened to them. Use the notes available to you and the team’s knowledge. The young person may perceive continuous questions as a signal that they are in trouble or not believed. Instead, think about other interests that the young person may have that you can ask about. For example, “What football teams do you support?”, “I like your trainers…”
Soothing the over-activated stress response and creating moments of psychological safety where possible is something we can all focus on.
Providing psychoeducation about the normal human stress response can be helpful because it can reduce any sense of stigma and shame the patient feels about how they are feeling and reacting in the aftermath. This video on understanding acute stress following trauma was made by the Major Trauma Psychology Team in the After Trauma team at the Royal London Hospital. It is helpful for both patients and staff and is designed to be a conversation starter and a way to open the door to emotion-focused conversations so that our patients get a chance to say what’s on their minds and get some help if needed. Feel free to share it!
Personal growth and reflection
Although this case is around a stabbing, it is relevant to any acute stress presentation or experience. Growing your awareness around the activation of your own (as well as others) fight-flight-freeze response allows you to notice how it affects your behaviour when you’re under stress. This can enable you to slow down and make wiser choices about how to respond instead of react.
Also, be aware of the trap of labels and stereotypes. Each one of us has a history and backstory that influences the way we see ourselves and the world around us. Try not to allow a person’s injury to define them.
The Social Switch Project offers training to front-line professionals to be able to openly discuss the challenges and opportunities young people face.
De-escalate and soothe
Reconnecting with Jenna:
– Encourage holistic and compassionate thinking about Jenna and her life story first
– Are all important clinical and psycho-social support actions complete (including safeguarding)?
Stay attuned to Jenna’s needs in the moment, such as supporting visiting and who she might need help to contact
– Be clear on what she can expect
– Only discuss the actual care that Jenna will get with her – not what else could have happened
– Avoid ‘theorising’
– Recognize that she is struggling and help others recognize this too, particularly at times when it feels difficult to hold this in mind due to how she is presenting
– Remain sensitive to her fight-flight-freeze response and how to help her settle it where possible
– Don’t over-promise: raising hope and not meeting it can lead to angry outbursts as trust is lost
– Avoid attempting to ‘debrief’ or ask about the incident repetitively but should Jenna express a wish to speak about the incident, provide a ‘listening ear’ and be led by her in the conversation.
– Provide psycho-education – share knowledge to reduce distress.
– Use your team appropriately; consider third sector and community organisations.
When Jenna moved to the ward – staff provided an iPad and allowed her to watch a video on soothing the stress response. A trauma nurse coordinator sat with her as she watched this and provided her with a space to talk that was led by her. In this conversation, Jenna talked about how lots of the symptoms discussed in the video were relevant to her and the nurse noticed that she seemed relieved to understand what was going on for her.
Take care of yourself and one another
This work is hard. We can become tired and reactive, so it is important to look after ourselves and our colleagues. Working with empathy with survivors of traumatic incidents can affect us in different ways and lead to a change in the way we see the world. Our response to working with trauma can fluctuate over time from negative, to neutral, to positive.
- A negative influence, known as vicarious trauma, is where we notice an increase in feelings of anxiety/anger/sadness, a cynical world view or detachment from patients/family and friends.
- A neutral impact is where we are manage the distress with the use of personal resilience, support and helpful coping strategies.
- A positive influence, known as traumatic resilience, is where we are more appreciative of what we have or develop deeper compassion.
We need to ease and soothe our own suffering. Take the time to gain the knowledge needed to do this in the most helpful way. Below are some hyper-links to resources that we hope are useful to you, your colleagues and your patients.
Talk it out:
Safe Connections NE London suicide support
Flipping the Lid – stress and the brain
Blindboy Podcast: Artist & comedian covers mental health, politics, culture, music, and history
Hidden Brain: explores unconscious patterns that drive human behavior