You are working on a trauma ward and meet 16-year-old Jenna. She was admitted after being stabbed.
She had a chest drain to treat her haemopneumothorax and is recovering from a laparotomy to repair her diaphragmatic injury.
She is being managed in a surgical ward, sleeping in an open bay alongside other patients. When you meet her, you hear she has been arguing with other patients on the ward and refusing treatment.
How can you take a trauma-informed response to her care?
The role of healthcare in managing traumatic stress
The 2007 UK report ‘Trauma, who cares?’ identified serious failings in trauma care. Their findings led to the development of Major Trauma Networks and some improvements in care. Formal trauma networks 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 than 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 when managing and preventing the broader 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 understand 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.
How do patients deal with acutely stressful events?
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 ways but is likely to include emotional, physical and behavioural symptoms.
Jenna’s symptoms of acute stress include the following:
– 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
During and after a traumatic event, the fight-flight-freeze response is activated. This is a highly adaptive survival response. At the time of 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-hijack’ or fight-flight-freeze, functioning from their alarm and threat brain with a shutdown of higher-order reasoning. This is hard-wired, 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’. He promotes the hand model of the brain as a way of understanding acute distress. ‘Flipping the lid’, then, 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.
Let’s look at the flight-fight-freeze response’s impact on Jenna’s behaviour.
|Jenna’s Behaviour||How we might understand this|
|She wants her curtains closed around her bed and avoids eye contact||Jenna is antisocial, disengaged and prefers to be left alone most of the time.|
Since the incident, Jenna feels like she is in imminent danger all the time. Because of this, she is anxious and sometimes paranoid. She is jumpy when she hears normal ward noises (fight-flight-freeze).
She feels very confused about what’s happening. She doesn’t understand why she can’t stop herself from being startled when she hears a noise.
She feels ashamed about having emotional difficulties because of 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).
|She paces the ward, wants to go outside at night.||Jenna wants to go outside to buy drugs or get into trouble. |
She is not following ward rules about going outside because she doesn’t care.
Jenna has no respect for others.
Just as Jenna falls asleep, she has intrusive images of the incident and is overcome with intensely fearful feelings as if the incident or something similar might happen again. When she does fall asleep, she has nightmares.
Jenna would rather avoid sleep than have these frightening experiences. Jenna is ‘on edge’ all the time, and walking helps ease this.
Jenna feels it’s difficult to breathe properly. She feels the need to get outside for some fresh air.
Feeling uneasy and anxious, shallow breathing or hyperventilation are common symptoms of acute stress.
|She gets argumentative and threatening if staff encourage her to sleep or reminds her of ward protocol.||Jenna does not appreciate the care and treatment she is receiving. |
Jenna is rude.
Jenna is struggling to take anything on board because of acute stress symptoms. The part of her brain that supports learning and problem-solving has been hijacked by her amygdala.
Jenna had problems with her teachers and has been mistreated by people in authority both at home and in school.
Jenna often had to fend for herself.
Jenna is easily triggered when recalling her childhood traumas – particularly if conversations are rushed, complicated or feel ‘one-sided’.
How can we intervene early after traumatic events?
Evidence for early intervention after traumatic events remains somewhat limited.
Psychological First Aid (PFA) is one 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 mean talking about the traumatic event.
Whilst there is a global consensus about using of psychological first aid in disaster situations, there is little direct evidence about its efficacy.
The Red Cross integrates Hobfoll’s five principles of psychosocial support in emergencies into its approach (IFRC Reference Centre for Psychosocial Support, Copenhagen, 2018).
These include ensuring safety, promoting calm, promoting self and collective efficacy, and 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 re-traumatisation
- the development of appropriate policies and procedures.
Again, there is limited evidence about the efficacy of trauma-informed care in emergency departments or trauma wards. However, there is a growing body of literature on its applicability.
Beyond psychological first aid and trauma-informed care, there is a potential to draw on components of more targeted psychological therapies to support patients.
Birk et al.’s. (2019) systematic review focused on early interventions to prevent PTSD in survivors of life-threatening medical events. They noted that cognitive behavioural therapy showed promise, but again, evidence of efficacy was lacking.
The International Traumatic Stress Society suggests that interventions focusing on social support, skill-building, cognitive restructuring, and therapeutic exposure may be most effective.
Care models may also make a difference in outcomes. In collaborative care, a multidisciplinary team of psychologists, psychiatrists, nurses, key workers and social workers evaluate a patient’s needs and coordinate their care. This can include the provision of psychological and pharmacotherapy interventions.
Pham et al. (2019) found that collaborative care may mitigate PTSD and the severity of depression in trauma patients. Once more, the long-term outcome benefits are unknown. One key message is that single-session universal interventions have insufficient evidence for benefit and should not be used as a part of routine clinical practice.
How should we respond to acute stress?
Coordination of care – reduce re-traumatisation
Taking the opportunity to have ‘reachable moments’ or ‘teachable moments’ is a key part of what we do. We are taught the importance of safeguarding and finding out all the details. However, this comes with some issues. We risk re-traumatising the young person by questioning them about the incident on numerous occasions.
Think about what you need to know. We do not need to investigate the incident. Our role is to ensure the young person feels safe, receives excellent care, and is appropriately referred.
Use the expert teams around you to help, such as organisations like the St Giles Trust. There may be times when you need to ask for some information but do it 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:
The language you use
“Are you in a gang?” “Do you hang out with a gang?” “Do you have friends in gangs?”
These are not helpful questions, do not support treatment needs and will counteract attempts at building trusting relationships. They also imply several harmful stereotypes that may 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 about the traumatic event lots of times can re-traumatise or re-trigger the young person. Think about why you are engaging with them: if you are 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 and the team’s knowledge. The young person may perceive continuous questioning as a signal that they are in trouble. Instead, think about other interests that the young person may have that you can ask about.
Soothing the over-activated stress response and creating moments of psychological safety where possible is something we can all focus on.
Education on the normal human stress response can be helpful. It may reduce the sense of stigma and shame they feel 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 may help patients and staff and is designed to be a conversation starter towards emotion-focused conversations. Our patients get a chance to say what’s on their minds and get some help if needed.
Personal growth and reflection
Although this case is around a stabbing, it is relevant to any acute stress presentation or experience. Growing your awareness of your own tendency to a fight-flight-freeze response helps you to notice how it affects your behaviour when you’re under stress. This helps you slow down and make wiser choices about responding instead of reacting.
Be aware of labelling. Each of us has our own backstory. It influences how 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, such as supporting visiting and who she might need help contacting
– 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. Should Jenna want to speak about things, lend an 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 each other
This work is hard.
We can become tired and reactive, so looking after ourselves and our colleagues is vital.
Maintaining empathy with survivors of traumatic incidents can affect us in different ways and change how we see the world. Our response changes over time from negative, to neutral, to positive.
- A negative influence, known as vicarious trauma, is where we notice increased anxiety/anger/sadness, a cynical world view or detachment from patients/family and friends.
- A neutral impact is where we manage the distress using personal resilience, support and helpful coping strategies.
- A positive influence, known as traumatic resilience, is where we appreciate what we have or develop more profound compassion.
We need to soothe our own suffering. Take the time to gain the knowledge needed to do.
Some resources to…
…help you talk it out
Safe Connections NE London suicide support
Blindboy Podcast: Artist & comedian covers mental health, politics, culture, music, and history
Hidden Brain: explores unconscious patterns that drive human behaviour