PTSD in ED Nursing/ Critical Care Nursing

[likemike, BSN, RN]

I was recently assaulted (again) at my Level 1 knife and gun club. We have more behavioural emergencies than traumas some nights.

I practice in an urban ED, which city is known for it's tolerance of drugs/alcohol and social liberalism.

I am also a former Paramedic who spent most of my street time in the ghetto. (No offense, but ghetto Medics know what I speak of)

I am also a former Navy Hosptial Corpsman who spent the majority of my two tours with the operating forces on a small combat ship wo a physician and with the Fleet Marine Force. One of my tours was a combat tour during the First Gulf War.

I came back from that experience with PTSD and have not had a military flashback for a number of years.

In the last bit of my training I was primary for a 3 yo female who had been accidentally run over by her daddy. I had an out of body experience, saw her face in my dreams.

Sought help, but not a good fit. Then just sucked it up and soldiered on, relapsed with cigarettes...yech. (thank goodness for nicorette)

State ENA president has criticized at a meeting my specific ED for the lack of Critical Incident Debriefings. For instance, he also is an EMS leader and after a 12 yo girl was sqaushed on the freeway, immediately got a Critical Incident Debriefing for PD, CHP, FD, and EMS, when he asked my hospital to send the ED Nurses he was told "...they are too busy and can't come"

So I was set up to fail to a degree, part of which is my own lack of self care, part of it instiutional culture.

In a period of 3 weeks, I had three "stable and tucked" patients (our population has a long problem list, Axis one and two, with multiple co morbidities).

All three of these folks suddenly went south in a matter of seconds, with A, B and C problems. I was alone as they tried to die, and did the appropriate interventions, ie getting help, resusitating them etc. This is not unusual in our setting. Despite ratios, we "must be ready to code a patient on a second's notice, as our patients are so sick, so my kids must be ready to jump in right away" says our Nurse Manager.

Then I witnessed a new Nurse get sucker punched in the jaw by a drunken female.

All of this within weeks.

A female patient was intoxicated at a local sporting event, fought with her girlfriend and assaulted two Police Officers in trying to subdue her.

Both Officers were taken out, one with a kick to the knee and ACL tear, one with multiple heel vs testicles and human bite.

She went to jail, was refused and ended up in the ED on a BB, c collar, spit mask and four point soft ties. The look on the Paramedics faces was one of abject fear. (I know that feeling all too well)

Seriously the worst behavioural emergency in 29 years. She was banging her occiput to the back board with that sickening watermelon like sound and it required the Attending, one resident and four RN's to prevent her from hurting herself. We HAC'd her and were waiting for it to take effect.

She spit on the Attending's face shield. Then somehow managed to spit under my face shield and glasses directly into my eye and attempted to sink her fangs into my wrist. I had gloves on and the spit mask prevented a human bite. (Four of us were physically holding her down, no choice)

But I then had a flashback to my colleague getting sucker punched and then had like an out of body vision of my dominant hand becoming infected with a rapidly spreading cellulitis. There goes my career..I envisioned.

I arrested her and had to leave work as I was unable to safely care for my other patients.

Had three days off, did all the right self care things and as soon as I hit the campus had a huge panic attack and again went home.

Was off for 5 weeks, saw EAP, and essentially the root cause analysis of my PTSD was RT the little 3 yo girl. No critical incident debriefing in our culture remember, no closure.

Started on prozac and a little metop. Also started working out again, huge help.

Now I am back to full duty, and am doing quite well thank you.

I did some online research and found that up to 10 percent of Critical Care Nurses (ED, ICU, CCU) at some point suffer from PTSD, a higher rate for noc shift.

I am thinking of writing my story up in a journal. I would really like to share my story with others so that they can learn just how important self care is.

Despite the barriers my house has..

If anyone knows of any good articles on PTSD re Critical Care Nurses and/or wishes to share story, I would be greatful.

This is not about me, but rather about us.

Our own unique "Band of brothers and sisters"

Respectfully,

Mike

[waterlily777]

woah dude... that was intense...

hope you continue to take care of yourself and remain in the nurses' ranks for many years to come!

Peace

Lily

[nerdtonurse?, BSN, RN]

I haven't been a nurse that long, but my dad's a vet, so I've seen PTSD. I sometimes get a little twinge of a panic attack, especially if I've had a run of really bad nights, but no true PTSD yet.

Only 2 things so far have given me nightmares and panicky twinges....keep in mind, rural hospital, ICU stepdown unit, not a urban Level one, but we still do have a "gun and knife club"....

Had a knife pulled on me, guy was going thru the DTs but wasn't at the 4 pt place yet in our matrix. We'd searched him, and later the family admitted that he was "scared of being in the hospital" so they gave him a 4.5 inch knife. He'd ripped IV line in half, I went in to do a restart, and he starts telling me he's going to cut me if I come near him. I tried to reorient him, and he swiped at me with the knife. I have never been so angry in my life. I told him to drop the f**** knife or I was going to make him eat it. I was ticked off like you would NOT believe, and I guess between me being too mad to have the sense to run and the shakes, he did drop it. Security made the scene, got the knife out from under the other bed where I'd kicked it, and I four pointed the guy. All the time he's screaming he's going to kill me, he's going to have his brother waiting for me in the parking lot, etc. My extent of "after incident response" was my manager asking what I'd done to provoke the guy. Uh...nothing. I guess I should have let him stab me to avoid damaging his self esteem:banghead:

The other was a young woman dying from untreated breast CA. She lost her job when the local plant got moved offshore, so no healthcare. Found a lump, couldn't afford to do anything about it, so when she finally came in for SOB, it had mets'd into both lungs, brain, liver, bones, etc. They tried radiation and chemo at that point, but it was too late. Woman was in such denial, she remained a full code. When she did code (thank god I was off that day) I don't think anyone exactly ran with the code cart. I think just seeing what was essentially untreated breast CA (orange peel skin, tumors that had ruptured and were leaking stuff that looked and smelled hideous, both nipples gone) was enough to give most of us nightmares, and there were two nurses who just couldn't take her as a patient.

Our "support staff" is each other, and of course, if anyone even THINKS you may want to call employee health, you're going to be eased out the door since you "can't take it." I saw that after a MVA came in with 3 kids, none of which made it out of the ER. One nurse who identified with the kids (hers were about the same ages) called to talk to someone "anonymously" and word got back to her supervisor, and out the door she went.

[traumaRUs, MSN, APRN]

I did 10 years at a level one trauma center and then when I got my APN, went into nephrology. I'm now headed back (part time for now) to a small community hospital ER.

You guys are the best! This is not an easy job: we must always be ready to take whatever rolls thru the door, many times we are thrust into the thick of a horrible situation where someone or more than one someones die and rarely is it as peaceful as it is on TV.

Critical Incident Stress debriefing is mandatory in order to keep the unit functioning. You have got to have a way to deal with the stress. In no other nursing specialty do you not have a clue what is coming in, how you will deal with it and what the outcome will be.

Here is a resource that I got from the ENA:

http://www.giftfromwithin.org/index.html

Here is the gateway to PTSD info:

http://www.ptsdinfo.org/

Violent Death Bereavement Society:

http://www.vdbs.org/

Hope these help...they all came off the ENA website.

[Altra, BSN, RN]

{{{{likemike}}}}

We are indeed a different breed.

A police officer friend of mine once opined that critical incident debriefings should be mandatory in his field and in ours, so that there is no stigma in "asking" for one. I wholeheartedly agree. We can be "tough" and "ready for anything" and still recognize the value of alleviating the psychological impact of what we see & do.

I once had that "out of body" feeling you describe after coming about 8 inches from a gun held by the angry & intoxicated boyfriend of my patient. (no metal detectors) I "watched" myself continue to work, reassure my coworkers that I was fine, and "heard" myself laughing and saying I must be crazy to keep doing this. I "saw" and "heard" myself like that each night for that continued long stretch of 7p - 7a shifts.

[Miss Mab]

Likemike,

Thank you for sharing and for what you're attempting to do w/your proposed project.

Our workplaces(though mine thankfully is now a former) sound reaaalllllly similar if ya know what I'm saying, though I won't pretend to have had close to your exact experiences.

The topic of PTSD in critical care is one I know wholeheartedly exists and is all too often ignored, or worse, maligned, within many facilities today. This stuff does have an impact, there's only so much water that can flow off yer back, y'know? We are not weak or 'not up to it' if we realize something is very wrong in this picture.

It needs to be addressed and I thank you for your contribution and your post.

Stay well,

Mab

[wonderbee, BSN, RN]

This has been the subject de jour as of late these past few days on my psych unit. Staff assaults are all too common.

I've been punched, kicked, bitten, thrown down, slapped and spit on. I also had to cut someone loose who was in the midst of a self-hanging. I've seen walls punched out, doors splintered and destroyed and rages so fierce you'd think the incredible hulk was our patient. We deal with this day after day with no forum for debriefing. I'm numb. It feels like going to war. Other staff members have said the same thing. My response was to go casual. Not everyone has that option. There needs to be a forum for dealing with this stuff.

I hear you loud and clear. Some mighty intense stuff.

[lupin]

There are nights I come home from work and feel like calling in for good before my next shift. I have had bad nights run through my head over and over again (Tyleonol PM is a great thing). When I very casually asked a long time RN who I trusted in my ER about debreifing he told me to never talk to anyone in Admin because they would track me down and ease me into another area or out the door. His advice was when it became too much, transfer to another unit or specialty where ER experience was important, like ICU or L&D or OR and then after I was over being shellshocked then I should look into ER again.

Not promising. But I do feel that if someone told me I'd still be where I am today when I retired, I might just scream and run off into the mountains.

[gonzo1, ASN, RN]

I work in the local knife and gun club too. So many psyches I think I am becoming one by osmosis.

There is no such thing as debriefing in my ER. One minute you are holding what's left of the brains of the latest gunshot in your hands and the next you are in the next room giving a tetorifice shot to the guy that has a paper cut.

If you can't go with the flow you are considered less than a "man".

So far I haven't really had any assaults on my person but the violence is getting to me.

How much can you see and not go crazy.

Unfortunately ER is all I know and I can't stand floor nursing.

[TraumaNurseRN]

Humor helps me...and the ability to vent when I need to.

[Roy Fokker, BSN, RN]

Wow Mike!

I don't even know where to begin!

Thank you for sharing such an intimate, personal glimpse of your rials and tribulations.

If anyone knows of any good articles on PTSD re Critical Care Nurses and/or wishes to share story, I would be greatful.

Not too long ago, we had a rather bad trauma [we aren't a designated trauma center]. From the time we heard the panicked voice over the radio informing us of the incident... to the actual time the patient rolled in, I felt a sense of dread like I'd never felt before.

And soon enough, my fears were confirmed. The patient was a health care professional - someone we all knew. We fought like alley cats to keep the pt. alive, but it was futile (pt. was probably long gone way before EMS reached the site) - but it was a cluster**** to say the least. Way too much blood, impossible to intubate, two crikes that failed along with the three suction cans we set up. It was infuriating, maddening and saddening to say the least.

Here was a person I saw living and breathing not barely 16 hours ago, shared a joke or two. And now the pt. is dead - leaving behind a spouse and two young children...

It was horrid and horrible.

Management stepped in and did some counselling - and some of us who needed professional help got it ASAP.

I am thinking of writing my story up in a journal. I would really like to share my story with others so that they can learn just how important self care is.

(emphasis mine) Oh absolutely!!

I'm so sorry I have no links or words of comfort to help you

- Roy

[traumaRUs, MSN, APRN]

You do learn some tricks of self-preservation too - you have to! Seeking help isn't a sign of weakness. Rather, its a sign that you want to continue to do the job as well as you can and for that you might occasionally need some help.