Hospital Trauma Care And Management Of Trauma-Related Psychological Problems
By Josef I. Ruzek, Ph.D. and Kate Garay, R.N., M.S.N., C.F.N.P.
NCP Clinical Quarterly 6(4): Fall 1996
Hospital trauma care involves the coordinated efforts of a highly specialized surgical team which has the fundamental intention of saving life and limb. Primary care, on the other hand, involves intervention by a generalist who assists an individual to maximize current health and well-being, and prevent illness. These two intentions do not appear to coexist in traditional health care. Furthermore, primary care is typically administered in an outpatient medical setting. Trauma surgery specialists refer to primary care providers when the crisis is over and the wounds are healed.
But what about the emotional wounds brought about by severe injury? What is the incidence of post-traumatic stress disorder and other psychological problems in the acutely injured population? Would early or preventive interventions from a primary care perspective serve to reduce the incidence of complicated psychological reactions after injury? Do psychological factors play a role in the individual’s functional recovery, i.e., return to work/school after injury? In this article we will explore how the objectives of primary health care might be better integrated with the acute care of the physically injured, serving the intention of preventing chronic PTSD, other psychological morbidity, loss of productivity, and increased health care services utilization.
Hospital Trauma Care
Medical centers which specialize in the acute treatment of severe injuries are called "Trauma Centers." "Trauma," according to the definition used here, is the same term used by Trauma Centers worldwide. It refers to sudden, life-threatening physical injury, requiring rapid intervention by a well-trained surgical team. The foremost Trauma Centers in the United States provide immediate access for the severely injured patient to teams of surgical specialists, who provide diagnostic and surgical services, and extended intensive and post-acute care. Such Trauma Centers have evolved in the last twenty years to have significant impact on the number of lives saved after devastating injuries due to vehicular accidents, violent assault, falls, and burns (1).
It is interesting to note that the current state of the art for care of injured civilians has been enhanced by the relative success of surgical resuscitation of soldiers in Vietnam. This improvement in wartime care of the injured was due largely to the rapid transportation from site of injury to definitive surgical treatment. Since the Vietnam War, the American College of Surgeons Committee on Trauma has developed standards for the implementation of a regionalized system of Trauma Centers in the U.S., permitting the rapid transport of injured persons to definitive care centers (2). Although the most studied population in the field of PTSD is arguably that of the Vietnam combat veteran, systematic investigation and treatment of PTSD in the injured civilian population has been slow to evolve. While the best possible medical technological interventions have been developed, post-traumatic emotional sequelae remain relatively unaddressed in this system. Now, as trauma treatment systems are maturing, and the resuscitation and intensive care technology is being refined, the question is being asked: "What is the quality of life after severe injury?"
Medical Trauma Services, Post-Traumatic Stress Responses, And Functional Recovery
Individuals receiving medical trauma care may be at high-risk for post-traumatic stress disorder. Research across trauma populations has produced evidence indicating that receipt of physical injury (3) and perception of life threat (4, 5) by the victim are associated with later development of PTSD; life threat may also predict long-term stress reactions in emergency room patients (6). Clearly, Trauma Centers select for patients with these characteristics. Feinstein (7) reported that 60% of patients hospitalized for bone fractures rated their accident as life threatening. The growing research on survivors of accidental injury indicates high rates of PTSD in this population (8, 9), and accident victims comprise the majority of users of hospital Trauma Centers in the United States: 60% of injuries are the result of vehicle accidents, 20% are due to falls, 15% to violent assaults, and the remainder are the result of poisonings, burns, accidents of nature, drowning, suffocation, self-inflicted injuries, and suicide attempts (10).
Most significantly, the few recent prospective studies of the psychological effects of physical trauma conducted out of medical settings suggest considerable rates of PTSD. For example, Shalev, Peri, Canetti, and Shreiber (11) studied patients admitted to a hospital emergency room and then to surgical or orthopedic wards. They identified 51 patients who sustained mild or moderate (not severe) physical injuries due to a traumatic event and assessed them at one week and six months after the trauma. 1-week levels of peritraumatic dissociation, depression, anxiety, and intrusive symptoms were associated with later development of PTSD, findings which are broadly consistent with studies conducted in other settings. At six month follow-up, 25.5% of patients met criteria for PTSD. It should be noted that this figure may be an underestimate of the true incidence of PTSD in this setting, since victims of severe injury (e.g., burns, head injury) were excluded from the study. Feinstein (7) followed forty-eight patients admitted to an orthopedic ward for surgical correction of bone fractures. He found a PTSD rate of 14.6% at six months post-accident. However, this study was limited to patients who suffered fractures; individuals who, during their accident, lost a limb, suffered additional physical trauma, or were exposed to fatalities were excluded. Given these limitations, it seems likely that a higher rate of PTSD may be observed in more general hospital trauma samples.
In addition to coping with PTSD and other trauma-related emotional problems (e.g., depression: 12, 13), the survivor of severe injury may also be facing a range of other stressors, including job loss, financial worries (due to loss of occupation or medical bills), physical pain and disability, and problems of everyday life management (e.g., transportation). Current data suggest that functional recovery may be largely unrelated, in moderately injured patients, to severity of injury or degree of physical disability (2, 14, 15), and that psychological factors may be more important (1). In a recent study, both PTSD and depression were found to significantly affect return to regular productive activity - work, homemaking, or school (12).
Toward A New Model Of Hospital Trauma Care
We believe that it is time to rethink delivery of hospital trauma care to address the psychosocial outcomes of injury, and that a comprehensive model of care should include the following elements: provision of early and/or preventive psychological and pharmacological interventions; routine post-discharge outreach to trauma patients; screening for risk for negative emotional and socioeconomic outcomes; provision of support services for families; attention to the emotional needs of Trauma Center staff; and attention to the emotional effects of medical care and the hospital environment itself.
First, it seems likely that a range of psychological interventions may be appropriately applied with this population, including psychoeducation about medical procedures and trauma and stress reactions, training in stress-management, medication, and exposure treatments. Early interventions may help prevent development of PTSD among some trauma survivors (13, 16). Foa, Hearst-Ikeda, and Perry (13) for example, delivered 4 sessions of cognitive-behavioral therapy - education, breathing/relaxation, imaginal and in vivo exposure, and cognitive restructuring - to recent female victims of sexual and nonsexual assault. Referral sources in this study included hospital emergency room personnel. Subjects were assessed within 3 weeks of the assault and treatment was started immediately following assessment. Five months post-assault, individuals who received this early post-trauma care were significantly less depressed and experienced fewer reexperiencing symptoms than a matched control group. None of the treated group showed depression or more than six PTSD symptoms; 56% of the control group reported moderate-to-severe depression and 33% had more than six PTSD symptoms. This study provided evidence that a brief cognitive-behavioral program administered shortly after an assault can accelerate rate of improvement of trauma-related psychological problems.
Second, routine outreach activities can help address post-trauma problems experienced after hospital discharge, by helping identify patients with problems, providing referral information, and connecting survivors with hospital- and community-based services. Many of these patients have preexisting and untreated psychiatric problems (e.g., alcoholism) which require referral for treatment; others will continue experiencing distressing traumatic stress reactions.
Third, screening methods like those advocated in the primary care setting may be helpful in the context of medical trauma care as well. It has become common to intervene with sexual assault victims in medical settings, and measures have been developed for application in the emergency room itself (17). Similar measures can be used to identify general trauma care patients at risk for problems and in need of greater support services.
Fourth, it is important to address the needs of the families of trauma survivors, who are secondary victims (18). The trauma experience is often stressful for them as well, and post-trauma problems of the survivor may create problems in the family. The families of individuals who die in hospital, often experience unexpected and sudden loss(es) and bereavement issues. These families may develop a range of psychological problems and can benefit from support and counseling.
Fifth, it is essential to consider the needs of the helpers themselves, the emergency room and intensive care staff whose work makes them witnesses to mass death, deaths of children, grotesque injury, and severe human-caused injury. Such exposure may exact a powerful emotional toll which is too often accepted as "just part of the job" and ignored by program administrators and Trauma Center staff themselves.
A more comprehensive conceptualization of trauma and PTSD in the hospital setting encourages attention in other directions as well. In addition to the event producing the injury, the emergency room process in particular and hospital experience in general may also serve as stressor events. The experience of threat to one's own life may take place in hospital, as may panic, dissociation, suicidal ideation, and so on. Patients may react irrationally to physical restraint and experience the pain associated with trauma care itself as threatening and traumatic (19). It is also possible that awareness during anesthesia is associated with later development of PTSD (20). The unpredictability and uncontrollability of medical treatment, and the witnessing of traumatic events which may occur in the emergency room, are features of the hospital treatment design which may require new ideas and experimentation.
Primary Care Goals In The Hospital Trauma Care Setting
In current practice, people who survive severe trauma make their way from the scene of the accident to emergency transport and on to an emergency room. Usually, a person has one or more operations there, goes to an Intensive Care Unit (ICU), then to a post-ICU surgical floor, and then is discharged to a rehabilitation facility or home, with clinic follow-ups.
This "treatment pathway" is designed to save lives. However, its design can be expanded to include the intention of restoring emotional well-being and minimizing socioeconomic complications which may emerge after the acute treatment phase. Well-placed interventions by trained staff could serve to educate about, prevent, and treat problems of psychological and socioeconomic recovery (in concert with the surgical issues addressed by physicians). Trauma Centers do provide the necessary trained staff -- physiatrists, psychologist or psychiatrist consultants, social workers, nurse specialists, physical and occupational therapists, nutritionists. Many of these professionals are aware of a need for post-trauma psychological help for their patients (21). But the key word is integration. A model service, tailored to the needs of trauma patients and placed in the post-ICU area, could serve as a hub for patient, family, and professional counseling and education about trauma recovery issues. It could also be an area for introducing a range of preventive and stress-reducing services, like relaxation training, acupuncture, massage, meditation, stress-management, and group support. The treatment philosophy and related services would easily expand to the ICU and clinic from the post-ICU unit.
Primary health care is designed, from a clinical perspective, to pursue goals related to health maintenance, illness prevention, and maximization of well-being (22). We believe that the objectives of primary health care may be pursued over the well-developed pathway from resuscitation to community reintegration faced by the injured person. Can a more collaborative, aggressive approach to the prevention of post-trauma stress reactions have an impact on the health and psychological and socioeconomic well-being of persons recovering from injury?
Conclusions And Recommendations
Physical trauma is a significant problem in our society, one that remains largely unrecognized by the public. It particularly affects our youth: of the two and a half million people hospitalized yearly in the U.S. due to trauma, the average person is between the ages of 15 and 35 (8, 23). Billions of dollars are lost each year in productive work, and tragically, lives are saved while much is lost in the misery of physical, emotional, and socioeconomic disability. The majority of trauma victims, even those who might benefit from help, will not eventually seek mental health treatment. However, unlike treatment for PTSD which takes place in traditional mental health settings, the hospital environment permits a proactive early identification of those at high-risk for development of PTSD and other trauma-related psychological problems, and implementation of screening procedures and active follow-up may enable more effective and earlier outreach to survivors. Potential positive outcomes include reduced PTSD symptomatology; shorter duration of trauma-related distress; greater patient satisfaction; reduced post-trauma physical health care utilization; and reduced societal cost. Emotional functioning is likely to affect utilization of health services; for example, Saravay, Pollack, Steinberg, Weinschel, and Habert (24) found that emotional distress during the first few days of a medical/surgical hospital stay predicted hospital utilization across four years following discharge. We believe that both human distress and medical costs may be reduced by early post-trauma mental health interventions.
In line with such goals, we believe that, PTSD specialists and the staff of Trauma Centers must increasingly take steps to (a) educate patients, families, professionals, and the public at large about the problems of trauma care, (b) support the development of model integrated treatment systems which include a more comprehensive attention to the post-discharge recovery process and to the various groups - survivors, families, and medical staff - affected by physical trauma, and (c) support conceptual and research developments in the field of trauma care.
A majority of injured persons will make it back out to society on their own, with expectations that they "get back to normal." But "normal" is not a place that exists for many of these people. Their lives are changed forever, and the grieving, rebuilding, and emotional renewal that must be done in order to create a more positive future must be encouraged by the trauma system that committed to saving their lives.
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