Psychological Effect of a Mass Casualty Event on General Surgery Residents

Anxiety and depression in surgeons: A systematic review

INTRODUCTION

The unique pressures of a surgical career put surgeons at particular risk of mental health conditions, including anxiety and depression. Surgeons have previously been shown to have a high prevalence of psychological distress. This study aimed to systematically review the prevalence of anxiety and depression amongst surgeons, and to identify factors that can modify the risk of anxiety and depression in surgeons.

METHODS

A 10-year systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines to identify citations related to the keywords "anxiety" OR "depression" AND "surgeon" in PubMed/Medline and ScienceDirect databases. Inclusion and exclusion criteria were applied to produce a final list of citations.

RESULTS

Thirty-one citations were included with a total of 11,399 participants. The median percentage of anxiety in surgeons was 20 with a range of 54.6%. While the median percentage of depression was 24 with a range of 59%. Risk factors associated with a higher risk of anxiety and depression include female gender, younger age, concurrent burnout, and occupational concerns regarding the COVID-19 pandemic. Protective factors include institutional support and a sense of social belonging.

CONCLUSIONS

There was a high prevalence of anxiety and depression amongst surgeons over the past decade. It is imperative to develop strategies to mitigate the effect of anxiety and depression in surgeons.

"The Wild West:" Nurse Experiences of Responding to the 2017 Las Vegas Mass Shooting

OBJECTIVE

The purpose of this study was to explore the experiences of nurses who responded to a public mass shooting in 2017.

METHODS

This qualitative study was conducted with a sample of nurses who responded to a mass shooting, recruited purposively from a hospital in Las Vegas, Nevada. Intensive interviews were conducted with a total of 7 nurses, audio-recorded and transcribed for thematic analysis.

RESULTS

Six themes were developed from interview data: (1) "The worst night of my life": Overrun and overwhelmed; (2) Unexpected altruism and benevolence of patients and staff; (3) "The Wild West": Giving victim care by improvising beyond rules; (4) Experiencing a range of reactions in the immediate aftermath and in the long term; (5) Shifts in nursing practice and evolving team dynamics; and (6) Defining realistic approaches to support staff mental health and mass casualty preparation.

CONCLUSION

Nurses who were involved in responding to the public mass shooting described the event as life-altering. Given the critical role of nurses in responding to mass shootings, it is essential to consider how nurses can be supported in the aftermath of these events and how mass disaster preparation can include attention to the needs of nurses.

"It Haunts Me": Impact of COVID-19 Deaths on Frontline Clinicians In Acute Care Settings-A Qualitative Study

BACKGROUND

The COVID-19 pandemic created unprecedented conditions for clinicians providing end-of-life care in acute care settings, yet almost 2 years since the start of the pandemic, little is known about its impact on clinicians.

OBJECTIVES

To qualitatively explore how clinicians experienced their role as they cared for dying patients with COVID-19 during the pandemic and the impact of these experiences on their lives as health care professionals.

METHODS

In-depth, hour-long interviews were conducted by phone in the spring of 2022 at a single time point with 23 physicians and nurses in critical care and emergency department settings from 2 health systems in California. The goal was to elicit perspectives on experiences with end-of-life care and the long-term impact of these experiences. Clinicians were asked to reflect on the different stages of the pandemic, and interviews were analyzed using a thematic analysis.

RESULTS

The interviews highlighted 2 primary themes around provision of end-of-life care during the COVID-19 pandemic. First, clinicians described challenges around their clinical duties of providing care to dying patients, which included decision-making dilemmas and professionalism challenges. Second, clinicians described the emotional aspects around end-of-life care situations they experienced, including communication with family members, "being patients' family members" at the end of life, and various degrees of meaning-making and remembrance of these experiences.

CONCLUSIONS

The findings highlight the sustained and cumulative emotional challenges and burden clinicians are still shouldering more than 2 years after the start of the pandemic.

Stress Disorders: the Trauma Surgeon as the Second Victim

Purpose of Review

We review the vocabulary and studies regarding stress disorders, as it relates to trauma care providers, specifically trauma surgeons. In addition, we make recommendations regarding strategies to address the needs identified and future areas of research to assess the adequacy of these strategies.

Recent Findings

Stress disorders in trauma are common and constant, identified at levels similar to those seen among first-responders to mass-casualty events. These disorders are identified at every level-from trainee to the most experienced. Trauma surgeons experience the trauma firsthand, as well as through forced re-traumatization as a part of routine care. High levels of cumulative stress result due to the volume of patients that can be difficult to process due to the frequency of shifts and disrupted sleep patterns. This level of chronic stress can lead to a cycle of burnout and increased stress, which is harmful to surgeons and patients.

Summary

Stress disorders are common and poorly understood. Treatment options are infrequently encountered. In order to more adequately respond to this, systematic change is necessary.

Psychological Trauma and the Trauma Surgeon

Research has demonstrated that first responders may develop psychological trauma/ posttraumatic stress disorder (PTSD) in the performance of their duties. Often overlooked in these studies of police, firefighters, and paramedics is an additional group of providers in this health care delivery system: the trauma surgeons, who receive the victims transported by the first responders. Although limited in scope, the research literature does identify the presence of PTSD in trauma surgeons. These studies have repeatedly cited the need for further information about psychological trauma for trauma surgeons. This paper addresses that need with a brief overview of psychological trauma, where surgeons may encounter victims, and how to cope with its aftermath.

"You Remember Those Days"-A Qualitative Study of Resident Surgeon Responses to Complications and Deaths

OBJECTIVE

Postoperative complications and deaths are unavoidable aspects of a surgical career, but little is known about the impacts of these unwanted outcomes on resident surgeons. The goal of this study was to characterize the impact of complications and deaths on surgery residents in order to facilitate development of improved support systems.

DESIGN

This qualitative study was designed to explore resident surgeons' experiences with unwanted outcomes, including postoperative complications and death. Semi-structured interviews explored a range of topics related to personal experiences with unwanted outcomes. Analyses of interview transcripts were performed iteratively and informed by thematic analysis.

SETTING

An anthropologist at the University of Michigan conducted interviews with general surgery residents from academic, community, and hybrid training programs across the country.

PARTICIPANTS

Twenty-eight mid-level and senior residents (PGY3 and above) were recruited for participation from 14 different training programs across the United States.

RESULTS

Resident surgeons described an initial period of emotional response, characterized by feelings of sadness, frustration, or grief. Simultaneously or soon afterward, interviewees described a period of intellectual response aimed at understanding how and why an outcome occurred, with the expressed goal of learning from it. Many residents described impacts to their personal lives. Several factors that influenced the duration and intensity of these responses were identified, including a sense of ownership, which was a powerful driver for improvement.

CONCLUSIONS

This qualitative study provides a nuanced description of resident surgeons' responses to unwanted outcomes. While emotional responses were characterized by strong feelings, such as sadness and grief, intellectual responses were focused on learning from the events. These data may help inform the development of structured support systems by residency programs.

STRUCTURED ABSTRACT

Facing post-operative complications and deaths is an unavoidable aspect of surgical training, but the impacts on surgery residents has not been well characterized. Through semi-structured interviews with general surgery residents from programs across the United States, this qualitative study explored the ways that residents respond to unwanted outcomes. Residents described an initial period of emotional response, characterized by strong feelings, often of sadness or grief. There was a subsequent or concomitant period of intellectual response, in which residents examined how and why this outcome occurred, with the goal of learning from it. A feeling of ownership was strengthened by involvement in patient care and length of rotation. In light of this detailed description of resident experiences, residency programs can foster the development of improved support for trainees as they navigate these profoundly impactful events.

Rebuilding Graduate Medical Education After a Crisis: Perspectives of Medical Residents in the United Arab Emirates

Pandemics create unprecedented public health challenges that require comprehensive and coordinated responses from health care systems and can, thereby, cause substantial and prolonged disruption to residency training. The coronavirus 2019 (COVID-19) pandemic has impacted medical education worldwide. Currently, there is a gap in the literature from the trainee's perspective, and little advice on resuming post-pandemic operations. As internal medicine residents serving on the frontlines of a COVID-19 designated government hospital in the United Arab Emirates, we also faced significant challenges and uncertainties during the pandemic. We are fortunate to have overcome the initial surges and have spent the past 6 months navigating a new reality. We believe that the COVID-19 crisis provides an opportunity for graduate medical education programs worldwide to implement targeted changes that can lead to sustainable improvements in the system. In supporting learning during these times, our residency program has adopted flexible scheduling, focused on frequent and transparent communication, incorporated different strategies to build community and promote psychological wellbeing, and advanced virtual teaching modalities. The aim of this article is to share the strategies that have helped us to move forward in the aftermath of the first phases of the pandemic, whilst we prepare for the uncertainty of the future. We hope that the lessons we have learned can help inform other programs as they react and adapt to the global after-effects of this crisis.

Emotional intelligence, cortisol and α-amylase response to highly stressful hyper-realistic surgical simulation of a mass casualty event scenario

Lifetime exposure to stress leads to risk of suffering from cumulative detrimental physiological and psychological ailments. Due to the nature of healthcare and exposure to trauma, medical professionals are particularly susceptible to the negative impacts of high stress environments. emotional intelligence plays a role in ameliorating the risk of being negatively impacted by these stressors. As such, there is special interest to develop and implement training interventions for medical personnel that would allow them to improve emotional intelligence potential with the goal of enabling them to handle stress better and mitigate burnout. A hyper-realistic surgical simulation training session, replicating the intensity of a Mass-Casualty Event scenario, was implemented to allow medical professionals to experience this in real time. Overall, the training led to increased emotional intelligence, correlating with decreased hypothalamus-pituitary-adrenal axis and sympathetic nervous system stress biomarkers, cortisol and α-amylase. This novel training provides, at least, short-term improvements in emotional intelligence that is reflected with a physiological response. These results guide the ongoing effort to develop therapeutic tools to improve long term stress management, mitigate burnout and reduce post-traumatic stress risk after an exposure to a Mass-Casualty event scenario.

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This study examines the relationship between emotional intelligence and stress response.

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Higher values in self-perception and stress management correlate with lower cortisol and α-amylase values.

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Alpha-amylase is more predictive of pre-event emotional intelligence while cortisol levels are better for post-event.

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Training improves short-term emotional intelligence, that may be useful to enhance stress management and mitigate burnout.

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Monitoring α-amylase and cortisol levels may help identify individuals at risk or with lower resilience potential.

Physicians on the Frontlines: Understanding the Lived Experience of Physicians Working in Communities That Experienced a Mass Casualty Shooting

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: "I wonder if I'm broken"; (2) the importance of and need for mass casualty shooting preparedness: "[We need to] recognize this as a public health concern and train physicians to manage it"; (3) massive media attention: "The media onslaught was unbelievable"; and (4) commitment to advocacy for a public health approach to firearm violence: "I want to do whatever I can to prevent some of these terrible events."

Knowing Your Team: Rapid Assessment of Residents and Fellows for Effective Horizontal Care Delivery in Emergency Events

BACKGROUND

Horizontal care, in which clinicians assume roles outside of their usual responsibilities, is an important health care systems response to emergency situations. Allocating residents and fellows into skill-concordant clinical roles, however, is challenging. The most efficient method to accomplish graduate medical education (GME) assessment and deployment for horizontal care is not known.

OBJECTIVE

We designed a categorization schema that can efficiently facilitate clinical and educational horizontal care delivery for trainees within a given institution.

METHODS

In September 2019, as part of a general emergency response preparation, a 4-tiered system of trainee categorization was developed at one academic medical center. All residents and fellows were mapped to this system. This single institution model was disseminated to other institutions in 2020 as the COVID-19 pandemic began to affect hospitals nationally. In March 2020, a multi-institution collaborative launched the Trainee Pandemic Role Allocation Tool (TPRAT), which allows institutions to map institutional programs to COVID-19 roles within minutes. This was disseminated to other GME programs for use and refinement.

RESULTS

The emergency response preparation plan was disseminated and selectively implemented with a positive response from the emergency preparedness team, program directors, and trainees. The TPRAT website was visited more than 100 times in the 2 weeks after its launch. Institutions suggested rapid refinements via webinars and e-mails, and we developed an online user's manual.

CONCLUSIONS

This tool to assess and deploy trainees horizontally during emergency situations appears feasible and scalable to other GME institutions.

Mass casualty events: what to do as the dust settles?

Care during mass casualty events (MCE) has improved during the last 15 years. Military and civilian collaboration has led to partnerships which augment the response to MCE. Much has been written about strategies to deliver care during an MCE, but there is little about how to transition back to normal operations after an event. A panel discussion entitled The Day(s) After: Lessons Learned from Trauma Team Management in the Aftermath of an Unexpected Mass Casualty Event at the 76th Annual American Association for the Surgery of Trauma meeting on September 13, 2017 brought together a cadre of military and civilian surgeons with experience in MCEs. The events described were the First Battle of Mogadishu (1993), the Second Battle of Fallujah (2004), the Bagram Detention Center Rocket Attack (2014), the Boston Marathon Bombing (2013), the Asiana Flight 214 Plane Crash (2013), the Baltimore Riots (2015), and the Orlando Pulse Night Club Shooting (2016). This article focuses on the lessons learned from military and civilian surgeons in the days after MCEs.

Mental Health During Environmental Crisis and Mass Incident Disasters

Veterinarians responding to animal health-related incidents are in the same class as first responders and should be aware of similar mental health concerns. Cultivating resiliency, identifying symptoms, and linking individuals to support systems are practical strategies to provide positive outcomes for veterinarians facing difficult experiences. This article explores veterinarians as first responders and farm stress; an overview of mental health responses to trauma; strategies and interventions for individuals, families, communities, and veterinarians; a discussion of boundaries and threshold for managing crisis; barriers and considerations for service provision; and a summary and discussion of future research and curriculum opportunities.