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Tips for recognizing, managing secondary traumatic stress in yourself :

May 21, 2020

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Lucy, an intensive care unit physician, walked in and plopped down in a chair. She was silent for a moment and then began crying. “I think I’m burning out,” she said. Lucy began to describe her workweek, filled with seemingly insurmountable challenges, including exhausting shifts, being pulled into adult care, limited personal protective equipment and patient deaths. 

She then shared her experience of delivering bad news to the wife and children of her 45-year-old COVID-19 patient. “I can’t get this family’s story and their emotional reactions out of my head. The mom and kids all started sobbing hysterically as I told them their dad likely would not survive this disease. The kids couldn’t understand why they couldn’t hug their dad. This is going to be an awful death. I find myself wanting to avoid this family because I can’t take their pain away.” 

Secondary traumatic stress (STS) can hit any medical provider at any time. Unlike burnout, which is due to the overarching stress of a job, STS presents with actual trauma symptoms. The National Child Traumatic Stress Network defines STS as “the emotional duress that results when an individual hears about the firsthand trauma experiences of another.” Symptoms of STS are similar to those of posttraumatic stress disorder (PTSD).

The difference between STS and PTSD is that STS occurs after indirect exposure to threatening events (e.g., hearing patients’ stories, delivering bad news to patients, observing intense emotions in others), while PTSD occurs due to a perceived direct threat to an individual. Like PTSD, STS can be challenging to recognize and manage without help.

Symptoms of STS include hypervigilance, avoidance, re-experiencing and change in mood. STS also can include guilt, anger, problems sleeping, challenges with concentration, exhaustion and an impaired immune system.

After training thousands of medical providers on the impact of trauma, we found that the most common symptoms shared are sleep problems, including difficulty falling asleep, having a patient’s story or face pop in their mind when they lay down to sleep, or waking up with nightmares about a particular patient.

We carry our patients’ stories with us. The longer we are in practice, the more stories we have — the good, the bad and the traumatizing. Our patients should affect us. If we feel nothing, then we can’t connect as strongly and may not be able to optimize patient care.

During this pandemic, our usual ability to connect with patients might be different and may feel suboptimal. Recognize that you are doing the best that you can under these strained circumstances.

Following are ways to remain connected to patients while preventing STS or dealing with STS if it happens.

  • Know what STS is and how to recognize symptoms in yourself.
  • Pay attention to your body and mind. What are the signs that you are beginning to struggle with a patient or a patient’s story?
  • Avoid avoidance. Shoving your feelings/symptoms away only works in the short term (and is necessary sometimes). If you need to put your feelings away to get through the day, do it. But make sure to create space for yourself to revisit your reactions and to deal with them.
  • Plan ahead. Take control of your emotional health by setting aside time for yourself, even if it is a few minutes at a time.
  • Learn what strategies work for you. Here are a few ideas:
    • Take time away from work.
    • Debrief/share your experiences.
    • Engage in physical activities.
    • Connect with friends or family, even if only virtually.
    • Connect spiritually.
    • Spend time outside.
    • Learn relaxation techniques such as meditation, guided imagery, yoga.
    • Engage in creativity such as art or writing.
    • Reflect on the meaning in your work.

How do we know if we need more help?

  • As a rule of thumb, if work gets in the way of life or life gets in the way of work, consider seeking mental health support.
  • If your emotional reactions affect your patient care, seek help.
  • Evidence-based treatments such as cognitive-behavioral therapy or trauma-focused cognitive-behavioral therapy can help medical providers work through the challenges of the job (or of home life) and get back on track to achieving their goals. Telehealth is becoming widely available for mental health support during this pandemic.

Lucy continued to process her feelings and realized that many nights she was losing sleep because she was worried about her patient and his family. She was repetitively checking the medical record to see if her patient had shown signs of decline. She started dreaming that her partner had COVID-19 and that she did not recognize it in time. We processed these signs of STS together realizing she needed more mental health support. She made a telehealth appointment with a therapist to start the process.

Dr. Marsac is an associate professor at the University of Kentucky. Dr. Ragsdale is an associate professor at University of Kentucky and a member of the AAP Section on Hospice and Palliative Medicine.

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