Handling the Fallout of Community Violence and Mass Shootings

Scant attention has been paid to the psychological effects on health care workers forced onto the front lines of such horrific events.

At some point, you just become numb to the numbers.

In Orlando, Florida, 49 dead; 14 dead in San Bernardino, California; 26 dead in Newtown, Connecticut; 58 dead in Las Vegas, Nevada; 17 dead in Parkland, Florida. The steady drumbeat of mass-casualty incidents goes on, seemingly without end, not just in the United States but around the world.

Much has been written about how citizens are trying to process these horrors, but scant attention has been paid to the psychological impacts such events have on health care workers who suddenly find themselves on the front lines of a battlefield.

Physician and nurse burnout, the result of long-term exposure to stressful events, time pressure and problematic workplaces, has become a major area of concern in medicine. Witness the vote in June 2016 by the American Medical Association to push the Centers for Medicare & Medicaid Services to add physician satisfaction and well-being to its measures for accountable care organizations and other practices.

Those efforts, while overdue and welcome, addressed the cumulative effects of work-related stress. Mass casualty incidents spike emotions in ways caregivers may not be equipped to handle.

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Researchers have looked at compassion fatigue and its related disorders: vicarious trauma, secondary traumatic stress, secondary stress disorder or insidious trauma. But the medical community is catching up to the impacts of these random, horrific events.

“It’s a very important question. I wish I had more surveys and information,’’ said Mark Linzer, MD, divisional director of general internal medicine at the Hennepin County Medical Center in Minneapolis, Minnesota.

Linzer, who has written extensively on physician stress and burnout, said many of the same coping techniques can apply.

“For an acute, intense event, a formal psychological debriefing with a psychologist should occur,’’ he said. “That’s what we train here.’’

Linzer noted that his facility has an infrastructure in place to help caregivers struggling with stress. “We have a wellness committee and an annual wellness survey and stress predictors, a reset room and professional work-life office,’’ he said.

Hennepin MC had its own recent brush with a major traumatic event: Philandro Castile died at the center after being shot by a police officer on July 6, 2016, during a traffic stop. The incident gained international attention after Castile’s girlfriend posted a video on Facebook of the shooting’s aftermath, leading to protests around the country.

Linzer declined to discuss the incident or its impacts on the Hennepin staff.

Jessica Lloyd, MD, a pediatrician at Mattel Children’s Hospital UCLA in Los Angeles, California, helped start a training program there to help residents manage stress. She spoke with the American Association for Physician Leadership about the innovative program on June 2, 2016, a day after murder-suicide on her campus.

“It was just a building away,’’ Lloyd said of the shooting at the UCLA engineering building. “We were all on lockdown. There were 200 police vehicles and helicopters and sirens ― a lot of sensory overload.’’

Such experiences certainly can have an impact.

“At what point does it go from a normal stress reaction to a traumatic event that you are a part of, to a time when you actually do need help?’’ she posed. “Most people can handle a good amount of that, but if you add a traumatic event, it can just put you over the edge.’’

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There is a resource available for those seeking to prepare themselves and their teams, to the extent possible, for facing catastrophe. It’s a guide published by the Community Oriented Policing Services of the U.S. Department of Justice and the National Alliance on Mental Illness.

The title is apt: “Preparing for the Unimaginable; How Chiefs Can Safeguard Officer Mental Health Before and After Mass Casualty Events.”

The primary audience is police supervisors, but the lessons are not limited to cops and other first-responders. During a mass casualty event, all responders and caregivers are on the front lines.

Community Oriented Policing Services director Ronald L. Davis captures the challenge in the guide’s opening comments:

“Though most agencies have trained and equipped their officers for immediate response to mass casualties, few have prepared their personnel for the psychological fallout. Tragic events can have a profound effect on first-responders, who may suffer emotional distress that lingers long afterward, leading to personal problems, alcoholism, post-traumatic stress disorder and even suicide.’’

Throughout the guide, a reader could substitute the words physicians or nurses for police ― the message is the same.

“Resilience can be a matter of degree, and not all traumatic events are created equal. … Most police officers may be able to tolerate a more vivid exposure to death or violence than the general public, but there are situations, such as mass casualty events, where the traumatic stress simply exceeds an officer’s ability to cope without support.’’

The guide helps users understand the dynamics of resiliency and get past the notion that people, especially those in high-stress professions, are immune from trauma.

It gives suggestions on how to prepare for a mass casualty event, such as locating not just mental health counselors to support your team but the right ones.

It gives specifics on how to get through the immediate ordeal while not losing sight of the long-term effects. It breaks down strategies for the first weeks ― from chaos to a new normal ― then the first few months.

One striking suggestion: Connect survivors and caregivers. Spending time with others who have been through the same traumatic event builds community and resilience, it says.

Individuals have their own timelines for healing from a traumatic incident. If someone is struggling, it may seem to come out of the blue, or it may be hard to tie new behavior to the long-ago traumatic event, the guide notes. Many people who experience problems like excessive drinking or changes in mood will be able to conceal that from colleagues for a long time.

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The most powerful and relatable parts of the guide, however, are the personal testimonies. One holds particular relevance for health care professionals:

“A year after the shooting, I was mentally and emotionally not functioning, almost to the point of not getting out of bed. And even though I’m a nurse, I didn’t know about trauma — I didn’t know what trauma could do to a person or that there was such a thing as PTSD by association. I was so angry. I was mad at everyone and everything. I was depressed beyond belief, alone, and isolated.

“Many family and friends were supportive, but a lot of people couldn’t deal with the trauma. They would break down crying on the phone. Or people were afraid to call because they didn’t want to intrude. And the last thing you want to do when something dramatic like this happens is dump it all on someone who can’t handle it. I relied on the people who called me to be my support system, because I didn’t dare reach out. I was isolated but, at the same time, saturated with the media.

“You need to know that when a trauma occurs, alcohol abuse, depression and chaotic behaviors can be symptoms of PTSD. Whether it is the officer or the family member displaying symptoms, you need to know what it looks like and that it is a physical injury. There is treatment. You can and must do something about it.’’

Those excerpts are from the story of Lori Kehoe, RN, a former hospice nurse and the wife of Michael Kehoe. Now retired, he was the Newtown police chief on Dec. 14, 2012, the day a gunman went to the Sandy Hook Elementary School and shot and killed 26 people, including 20 young children.

This article was originally published by the American Association for Physician Leadership in August 2016 and updated in July 2018.