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THE ROLE OF NURSING & CLINICAL PRACTICE IN THE AMELIORATION OF POST TRAUMATIC IMPACT OF BURN INJURY
Rev. Dr. Chrys L. Parker, J.D.
ACPE, CBF, CFT, D-APA, EMT Diplomate, American Psychotherapy Association Pastoral Care Specialist, American Association of Pastoral Counselors Professional Medical Chaplain / Certified Field Traumatologist Executive & Clinical Director, Texas Burn Survivor Society Administrator, Janey Briscoe Children’s Burn Project ( University Hospital, San Antonio, Texas ) Director of Holistic Clinical Services, Wesley Primary Care Clinic Tramatology Consultation to the Medical & Surgical Professions (210) 383 – 2598 Email: firstname.lastname@example.org
Copyright 2006, duplication prohibited without permission
Hour 1: ● Foundational trauma theory ● Neuro-endocrine basis of post traumatic stress disorder and medical implications ● Helplessness: Special considerations in burn injury ● “User’s Guide to the Brain”: How it all comes together ● Significance of PTSD in long term medical outcome - why you should care Hour 2: ● Three Great Myths regarding burn treatment; associated psycho-medical risks ● “Seven Deadly Sins”: Errors & risks in clinical practice through patients’ eyes Hour 3: ● Case studies: (l) The Abandoned Patient; (2) The Misunderstood Patient; (3) The Retraumatized patient Summary: What you can do to improve the standards of care for your patients and in your facility ● Questions from attendees are welcomed. ● There will be a ten minute break following each segment. Your assistance in returning to the program on time is greatly appreciated, so that the course may stay on schedule. ● Please sign in with your contact information; Rev. Dr. Parker will be pleased to furnish you with updates to your Complimentary bibliography by mail or email.
FOUNDATIONAL THEORy OF TRAUMA AND POST-TRAUMATIC STRESS DISORDER
• Trauma, in its psychological/ psychiatric context, is the mind’s response to stimuli that present an overwhelming threat of serious bodily injury, death or destruction of : - oneself - significant others and loved ones - persons for whom we feel physically responsible (i.e., patients) - a core belief system essential to one’s life (i.e., that one’s body is safe from unwanted invasion) ● It is associated with situations in which the sufferer is helpless to escape or control the event ● Further associated with the overwhelming of normal coping mechanisms, and engagement of the fear / survival response, also referred to as “alarm” or “fight/flight/freeze” response.
“the mind is what the brain does”
Being the sum of the combined processes and perceptions of the brain, “mind” is not separate from the body. Processes that begin in perceptions wind up as neuro- endocrinological expressions. They are not imaginary, but physical and objectively measureable. Mental responses and mental illness, especially responses to trauma, are therefore not separate from the body’s experience of burn injury. Rather, they are a constituent part of that physical injury. Identification and intervention with mental injury is therefore vital to achievement of long tern recovery and avoidance of post-discharge morbidity and mortality.
Roots and expressions of post traumatic stress
• PTS IS, IN ORDER: PERCEPTUAL (FEAR), NEUROCHEMICAL RESPONSE (ALARM), THEN BEHAVIORAL ADAPTATION TO FEAR. PTSD OCCURS WHEN BRAIN’S NEUROCHEMICAL RESPONSES TO FEAR, ARISING OUT OF THE ALARM RESPONSE OF THE LIMBIC STRUCTURES OF THE BRAIN, BECOME HABITUATED, OR REFLEXIVE. THEY CONTINUE TO OCCUR BECAUSE THE BRAIN CONTINUES TO PERCEIVE DANGER/TERROR. THIS MAY OCCUR MONTHS, YEARS OR EVEN DECADES AFTER DANGER HAS (OBJECTIVELY SPEAKING) PASSED. WHAT BEGINS AS A SURVIVAL MECHANISM RUNS AMUK, AND OUTLIVES ITS USEFULNESS, BECOMING DANGEROUSLY STRESSFUL TO BODY AND SOCIALLY MALADAPTIVE TO THE PERSON PTS IS NEUROCHEMICAL . SYMPTOMS ARE SEEN PHYSIOLOGICALLY LONG BEFORE THEY MANIFEST AS OUTWARD BEHAVIOR, IN RESTRAINED AND SEDATED PATIENTS WHO CANNOT ENGAGE IN TYPICAL “BEHAVIOR”, PER SE. IT MUST BE DETECTED, INITIALLY, THROUGH CAREFUL MONITORING OF PATIENT PHYSIOLOGY, ESP. H/R, B/P, STARTLE RESPONSE, SLEEP DISORDER, ALTERED MENTAL STATUS (ESP. DISSOCIATION), DISORIENTATION, AND ELEVATED LEVELS OF CIRCULATING CATECHOLAMINES (NOREPINEPHRINE, SERATONIN, DOPAMINE)) AND CORTISOL.
MISCONCEPTIONS ABOUT PTS AND PTSD
IT IS NOT DEPRESSION; IT IS THE NEURO- CHEMICAL OPPOSITE OF DEPRESSION Depressive appearing features are often the result of sedation, muscle catabolism, fatigue, flat facial affect, & adrenal exhaustion following hyperadrenalism. IT IS POSSIBLE TO DEVELOP PTSD (ACUTE) IMMEDIATELY AFTER A TRAUMATIC INCIDENT; IT IS NOT NECESS. TO WAIT 3 MONTHS BEFORE DIAGNOSING ITS ONSET Post traumatic stress disorder can be prophylactically treated by the surgeon, consistent with burn protocols. WAITING 3 MONTHS BEFORE INITIATING INTERVENTION VIRTUALLY GUARANTEES THAT THE PT. WILL DEVELOP THE FULL BLOWN DISORDER. Delay guarantees the response will become neurally imprinted and difficult to treat later. VIRTUALLY 100% OF critical BURN PATIENTS are observed to DEVELOP PTSD (ACUTE). ALMOST ALL SHIFT INTO THE SEVERE, CHRONIC FORM unless immediately and prophylactically treated. (parker)
Simplified algorythyms for understanding pts/ ptsd: UPSTAIRS/ DOWNSTAIRS: the brain as “office building”
UPSTAIRS: COL. POTTER’S OFFICE. NEO CORTEX OR “HUMAN” BRAIN, I.E., RATIONAL DECISION MAKING,PLANNING, JUDGMENT, INSIGHT, WORKING MEMORY. PREFERS TO CONDUCT LEISURELY STRATEGIC PLANNING SESSIONS; PERFORMS POORLY AS COMBAT INFANTRY . NEVER GOES IN COUNTRY. DOWNSTAIRS: RADAR O’REILLY’S OFFICE, IN COUNTRY. KEEPER OF ALL THE DATA. LIMBIC OR “MAMMALIAN” BRAIN, I.E., SEAT OF LONG TERM AND EMOTIONALLY CHARGED MEMORIES, AND SURVIVAL RESPONSES. ALWAYS SCANNING THE DATA. ACTS TWICE AS FAST AS THE COL. TO INSURE SURVIVAL OF THE UNIT WHEN UNDER ATTACK. (HIPPOCAMPUS, AMYGDALAE, HYPOTHALAMUS) BASEMENT: BASAL STRUCTURES, BRAINSTEM. “REPTILIAN BRAIN”. PLUMBING, A/C & HEATING, VENTILATION, ETC. HYPER-ACTIVATED WHEN RADAR SOUNDS ALARM. THE CEO (COL. POTTER) DOESN’T HAVE MOST OF THE INFORMATION. THE CORPORAL DOES AND WANTS TO SAVE THE UNIT AND BE A HERO. INFORMATION FLOWS UPWARD FROM THE CORORAL TO THE COL. IN TIMES OF CRISIS, BUT NOT DOWNWARD. RADAR SOUNDS THE ALARM, HIJACKS THE RESPONSE TO ENEMY ASSAULT, (HYPOTHALAMIC-PITUITARY-ADRENAL AXIS) AND RUNS THE SHOW, PUSHING THE COL. OUT OF THE PICTURE . RADAR SAVES THE UNIT AND WINS THE PURPLE HEART,
CLINICIANS: PLEASE NOTE THATTHE CRITICAL BURN PATIENT OPERATES “DOWNSTAIRS” MOST OF THE TIME. HIGHER THINKING, COGNITIVE PROCESSES ARE HIGHLY IMPAIRED, BROCA’S AREA MAY SHRINK AND VERBAL EXPRESSIVITY ABOUT TRAUMA IS LIMITED OR ABSENT. THE COL. DOESN’T RECEIVE RECON REPORTS FROM RADAR DUE TO THE COMMUNICATION LINES BEING CUT OR STATIC INTERFERENCE. EXPECT IRRATIONAL-APPEARING BEHAVIOR . DO NOT BE JUDGMENTAL, AS LIMBIC BEHAVIOR IS ESSENTIALLY INVOLUNTARY.
SIMPLified ALGORYTHYMS: ALPHA/ BETA
● The amygdala scans the environment like Radar, and alerts the hippocampus that enemy is near. ● The hippocampus sounds the alarm (the H-P-A Axis) to mobilize response to attack. ● The HPA axis sends neurotransmissions via the sympathetic (invountary) central nervous system to ensure that infantry is equipped with adequate fluids, hydraulic pressure and oxygen and nutrition to sustain the infantry in combat with the enemy. ● These transmissions travel in the alpha and beta systems, which generate alpha 1 and 2 , and beta 1 and 2 adrenergic agonists. ALPHA AGONISTS: Associated primarily with elevated levels of epinephrine, causing vasoconstriction and peripheral vascular resistance, and stimulation of the central nervous system Beta agonists: Associated primarily with elevated levels of norepinephrine , causing increased cardiac output and increased respiratory function. In addition, dopamine serves as a dominant neurotransmitter between adrenergic effectors and receptors. Low levels in the dopaminergic system are associated with synthesis of epinephrine and vasoconstriction, while high levels of dopamine are associated with increased cardiac output and blood flow.
Simplified algorythyms; adrenergic / cholinergic
• Post traumatic stress response is marked by significant elevations in circulating catecholamines, provoking increase in CNS tone and elevations in metabolic activity and response (See collected writings of Bruce D. Perry, M.D., provided in bibliography) Adrenergic and noradrenergic responses to traumatic stress include increased circulation, peripheral resistance and vasoconstriction, increased cardiac contraction and output, increased bronchodilation and respiratory output, increased muscular contraction, increased glucose production, and decreased protein synthesis. Cholinergic response to traumatic stress is prompted by seratonin, which initiates secretion of glucocorticoid hormones, especially cortisol. The effects of hypercortisolism in post traumatic injury includes inflamation, the diminished peripheral uptake and utilization of glucose, increased plasma levels of proteins and muscle catabolism, and decreased bone formation. Hyperelevation of cortisol can also lead to increased vascular resistance. CLINICIANS: IF THE PHYSIOLOGICAL MARKERS OF POST TRAUMATIC STRESS RESPONSE LOOK TO YOU LIKE THE MARKERS OF HYPERMETABOLIC SYNDROME IN BURN INJURY, THEY SHOULD… THEY ARE ESSENTIALLY THE SAME. SUFFERERS OF POST TRAUMATIC STRESS DISORDER ARE OBSERVED TO CONTINUE SUFFERING HYPERMETABOLISM, EITHER CONTINUOUSLY OR EPISODICALLY, UNLESS OR UNTIL EFFECTIVELY MEDICINALLY TREATED.
Helplessness: special considerations in burn injury and treatment
• THE MOST SIGNIFICANT AGGRAVATING FACTOR IN PTSD IS HELPLESSNESS TO ESCAPE THE SOURCE OF FEAR, PAIN OR TERROR. UNLIKE OTHER SINGLE-EPISODE TRAUMAS, BURN TRAUMA DOES NOT END. IT REOCCURS WITH EACH DEBRIDEMENT, DRESSING CHANGE OR OTHER PROCEDURE. ALTHOUGH LIFE SAVING AND BENIGNLY INTENDED, THE BODY ONLY PERCEIVES TREATMENT AS INTENSELY PAINFUL AND THREATENING. MERE ANTICIPATION OF TREATMENT PROCEDURES CAN TRIGGER FULL BLOWN POST TRAUMATIC STRESS RESPONSE. LATER, MERE RECOLLECTION CAN DO LIKEWISE. BURN TREATMENT IS SIMILAR IN PROFILE TO THE TRAUMATIC EXPERIENCES OF PRISONERS WHO UNDERGO ONGOING, SYSTEMATIC TORTURE BY THE CAPTORS. ALTHOUGH THE NEO-CORTICAL PROCESSES OF THE BRAIN MAY EVENTUALLY ALLOW THE PATIENT TO DEVELOP INSIGHT INTO THE BENIGN NATURE OF TREATMENT, THIS AREA OF THE BRAIN DOES NOT EXERCISE GOVERNANCE DURING TRAUMA. THE GOVERNING AREA, I.E., THE LIMBIC SYSTEM, RECOGNIZES CAREGIVERS AS PERPETRATORS, CREATING EXTREME STRESS FOR BOTH PATIENT AND CLINICIANS.
SIGNIFICANCE OF PTSD IN BURN INJURY: WHY SHOULD YOU CARE?
• DUE TO MASKING BY OPIATE AND SEDATIVE MEDICATIONS, PTSD BEHAVIORS DO NOT FULLY EMERGE UNTIL AFTER DISCHARGE, WHEN PHYSICIANS AND NURSES ARE NO LONGER PROVIDING COMPREHENSIVE CARE, AND THE BURDEN FALLS ON PATIENTS AND FAMILIES TO DEAL WITH INTOLERABLE SYMPTOMS SUCH AS DISSOCIATION, FLASHBACKS (RE-EXPERIENCE OF TRAUMA), DISORIENTATION, AGITATION, AKATHESIA, RAGE, NIGHTMARES, HYPERAROUSAL , HYPERVIGILANCE AND CHRONIC TACHYCARDIA. BEHAVIORAL SYMPTOMS CAN BE PARALYZING, AND VERY DESTRUCTIVE OF FAMILY STRUCTURES AND RELATIONSHIPS THAT ARE NECESSARY TO CONTINUED MEDICAL CAREGIVING AT HOME. THIS IS A MAJOR CAUSE OF BOTH SOCIAL AND MEDICAL MORBIDITY, AND IS A LEADING CAUSE OF SUICIDALITY. CONTINUED HYPERMETABOLISM DUE TO PTSD IS AS SERIOUS A CONCERN POST-DISCHARGE AS IT IS IN THE IN-PATIENT PHASE, AND CAN PRECLUDE RECOVERY OF NORMAL FUNCTION DUE TO PERMANENT CNS DYSREGULATION. HABITUATED NEED FOR DOPAMINE ELEVATION TO ACHIEVE SELF-SOOTHING CAN LEAD TO PATIENT BEHAVIORS WHICH ARE POTENTIALLY LETHAL. IN SUMMARY, PTSD CAN UNDO THE LIFESAVING AND REHABILITATIVE WORK WHICH CLINICIANS HAVE DONE. THE PATIENT IS “SPARED”, ONLY TO LIVE A LIFE THAT SOON BECOMES UNLIVABLE. (BREAK )
POST TRAUMATIC STRESS IN THE ACUTE HOSPITAL PHASE: WHAT CLINICIANS CAN DO
• • TREAT EVERY PATIENT AS THOUGH THEY ARE NEURO-PSYCHOLOGICALLY IMPACTED BE ALERT TO PHYSIOLOGICAL SIGNS OF TRAUMATIC STRESS, ESP. WHEN PATIENT IS HIGHLY SEDATED, RESTRAINED OR VENTILATED. TRAUMATOLOGIST WOULD NOTE: A. ELEVATED CATECHOLAMINE LEVELS: MAY BE TRENDED THROUGH USE OF 24 HOUR FRACTIONATED URINE CATECHOLAMINE SCREENS. B. TRENDING VITALS Q HOUR: BE ALERT TO PATTERNS OF ELEVATED PULSE, AS THIS MAY INDICATE FLASHBACKS DURING SLEEP. MAY ALSO COINCIDE WITH TIMING OF ASPECTS OF BURN INJURY. C. BE ALERT TO CHRONIC SINUS TACH CONCURRENT WITH A NORMAL TO LOW B/P. D. BE ALERT TO REFLEX TACH OCCASIONED BY MEDICATION THAT DROPS PRESSURES, PROMPTING INCREASE IN CARDIAC OUTPUT.
WHAT CLINICIANS CAN DO, CONT’D.
TAKE TIME TO WATCH THE PATIENT SLEEP TO NOTE PATTERNS OF THRASHING OR AKATHESIA, GRIMMACING, EYE ACTIVITY. BE ALERT TO SIGNS OF DISSOCIATION, SUCH AS A GLAZING LOOK IN THE EYE, SOMETIMES PRECEEDED BY FLUTTERING; ALSO LAYING OF THE HEAD OVER TO ONE SIDE (USUALLY THE NON-DOMINANT, BUT NOT ALWAYS). BE VERY ALERT TO SITATIONS IN WHICH DISSOCIATION (MENTAL “CHECK OUT”) APPEARS TO BE FOLLOWED BY “CHECK IN” TO ANOTHER DISCRETE PERSONALITY WHO DOES NOT KNOW YOU OR THE ENVIRONMENT. REMEMBER THAT ANY RESTRAINT, ESPECIALLY PROLONGED RESTRAINT, WHETHER CHEMICAL OR PHYSICAL, EXACCERBATESS HELPLESSNES AND P.T. STRESS REMEMBER THAT THE MASKING OF EARLY SYMPTOMS DOES NOT ALLEVIATE THEM, BUT ONLY MAKES THEM LESS OBSERVABLE TO TREATING CLINICIANS
THREE GREAT MYTHS AND THE RISKS THEY MASK
MYTH NUMBER ONE: PATIENTS ARE “HEALED” ON THE BURN UNIT REALITY: While it is true that patients cannot heal without the burn unit, it is also true that they cannot truly heal on the burn unit. Healing is more than treatment. It implies a restoration of wellness, not merely the completion of treatment or the remission of symptoms. Completion of burn surgical treatment does not necessarily imply that wellness is restored. Wellness is also very much dependent upon psychosocial and economic factors not addressed in the hospital phase. Unseen risks contributing to post-discharge morbidity/ mortality: 8. 9. 10. 11. 12. Failure or inability of system to track patients following discharge from clinic. Drop out of medical care by patient or parents of patient Culture of itineracy among many patients; displaced, often migratory Culture of poverty: burn injury & fire can destroy entire infrastructure for life and care. Shockingly high levels of psychiatric injury among not only patients, but caregivers and other family members, i.e., siblings. Family models of dysfunction.
THREE GREAT MYTHS, (CONT’D)
1. Substance and Chemical Abuse Impacting Burn Patients a. Self medication against pain of untreated physical and emotional symptoms of PTSD b. Self medication against pain of narcotic withdrawal, or in continuation of narcotic addiction Domestic and Criminal Violence Impacting Burn Patients: a. Patients as perpetrators: Domestic or criminal violence arising out of untreated PTSD Males particularly pre-disposed toward acting out, to raise dopamine levels b. Patients as victims: Females are particularly predisposed toward “acting in”, ie, self mutilation or self abuse in a drive to feel, or repeatedly placing oneself in a situation of vulnerability to violence or sexual assault as a result of the drive to raise levels of endogenous opiates to which the PTSD sufferer becomes habituated. “Burned out” dopamine receptors require ever higher levels of chaos, violence or hypersexualized behavior to elicit a soothing dopamine rush. High levels of undiagnosed co-morbid mental illness among patients and family members, esp. bipolar disorder. a. Acute mania often fueled by inapproprite medication during or after hospitalization, which jeopardizes medical compliance. b. Aggravated by treatment that does not account for the medical effect of the burn injury and the post-burn elevated catecholamine levels of the patient, in conjuction with electrical instability in the brain resulting in dangerous overstimulation. High rates of suicidality: (Parker) An observed rate of over 50 % among adult survivors
Three great myths (cont’d)
MYTH NUMBER TWO: TREATING 3.
THE PATIENT YOU SEE IS THE PATIENT YOU ARE
DIFFERENTIATION IN FUNCTION BETWEEN THE COGNITIVE AND LIMBIC SPHERES OF BRAIN FUNCTION CAUSE THE PATIENT TO BEHAVE LIKE TWO DIFFERENT PEOPLE. YOU (CLINICIANS) ARE TREATING THE “ LIMBIC PATIENT” MORE OFTEN THAN THE COGNITIVE PATIENT. THE FAMILY MEMBER AS UNSEEN PATIENT – MENTALLY ILL ADULTS CREATE CHAOTIC ENVIRONMENTS IN WHICH CHILDREN ARE MORE EASILY BURNED. THE PREVIOUSLY TRAUMATIZED INDIVIDUAL AS “UNSEEN PATIENT.” IF
PREVIOUSLY TRAUMATIZED, THE PATIENT ENTERS THE BURN INJURY WITH PTSD OR NEUROLOGICALLY DISPOSED TO IT. A PREVIOUSLY TRAUMATIZED PATIENT WILL USUALLY ADOPT A POST-TRAUMATIC COPING STYLE CONSISTENT WITH THAT WHICH WAS EMPLOYED IN THE EARLIEST TRAUMA, PARTICULARLY IF THE EARLIEST TRAUMA WAS PRE-VERBAL. TRAUMA SUSTAINED PRIOR TO THE AGE OF THREE BECOMES VERY STRONGLY IMPRINTED, DUE TO THE HYPERSENSITIVITY OF THE LIMBIC SYSTEM IN INFANTS AND TODDLERS.
Three great myths, (cont’d)
THE “WELL SUPPORTED PATIENT” MAY BE AN ILLUSION; WHAT YOU SEE IS NOT NECESSARILY WHAT YOU GET A. SUPPORT MAY BE ABSENT AND PT. MAY BE TOO ASHAMED TO DISCLOSE B. ONE OR MORE CAREGIVERS OR FAMILY MEMBERS MAY BE AN ABUSER OR PREDATOR C. OVER-ENMESHMENT BETWEEN CAREGIVER AND PATIENT AS A SET UP FOR CO-DEPENDENCY DISORDER
THREE GREAT MYTHS (CONT’D)
MYTH NUMBER THREE: THE PATIENT PERCEIVES THE HOSPITAL AND STAFF AS BENIGN 3. PTS. OVERWHELMINGLY DESCRIBE TREATMENT AS MORE TRAUMATIC THAN THE BURN PTS. LIMBIC SYSTEMS PERCEIVE THE HOSPITAL AND STAFF AS INFLICTORS OF PAIN. EVEN IF THE ALERT PT. IS VERBALIZING TO THE CONTRARY, LIMBIC, FEAR BASED RESPONSES ARE ONGOING. PTS. OVERWHELMINGLY DESCRIBE HOSP. AS INSPIRING FEAR, HELPLESSNESS AND DREAD PTS. DREAD JUDGEMENTALISM BY STAFF AS MUCH AS PAIN. 14. COMBAT VETERANS ARE TRAINED TO SHUT DOWN AND NOT DIVULGE
WHEN THEIR BODIES ARE UNDER THE CONTROL OF ANOTHER. “PSEUDO P.O.W.”
Great myths (cont’d)
HOSPITALIZATION CAN BREED EXTREME LOSS OF HUMAN AGENCY (ABILITY TO ACT UPON FREE CHOICE) CAN RESULT, IN RARE CASES, IN CAPTIVITY SYNDROME, A DISCRETE FORM OF MENTAL ILLNESS (JOYCE BRAAK, M.D.) THIS SYNDROME HAS ASPECTS OF STOCKHOLM SYNDROME (I.E., RAPID IDENTIFICATION OF “PRISONER/ PT.” WITH “CAPTOR/NURSE” WITHIN 48 HRS.; TRANSCENDS STOCKHOLM SYNDROME: RAPID DEGENERATION OF SENSE OF SELF. PRISONER BECOMES AT ONE WITH THE CAPTOR, UPON WHOM THE PRISONER BECOMES COMPLETELY DEPENDANT. INDEPENDENT DECISION MAKING VIRTUALLY CEASES. THE PRISONER SEES HIMSELF/HERSELF AS AN EMPTY BODY THERE TO DO THE CAPTOR’S WILL. ULTIMATELY, THE PRISONER (PT.) CANNOT SURVIVE WITHOUT A CAPTOR, AND WILL NOT TOLERATE “LIBERATION”. WILL ACTUALLY LASH OUT AGAINST OR REJECT THE HELP OF “LIBERATORS” AND SEEK OUT THE CAPTOR. HAS VERY SERIOUS IMPLICATIONS FOR PATIENT SURVIVAL.
“ seven deadly sins”…. Through patients’ eyes
Taking control of my body: invasion as a progressive concept In which control of the body is the ultimate assault, esp. when accompanied by pain. Analagous responses between burn survivors and rape survivors. what you can do: A. never touch without verbally asking permission, even if the patient is sedated or unconscious. Remember that the unconscious patient can hear you, so be very careful what you say in their presence.. Inappropriate remarks, references to poor prognosis or comments about “circling the drain”, etc. can alter patient response. B. TELL THE PATIENT – ESP. IF UNCONSCIOUS OR SEDATED – WHERE YOU ARE GOING TO PUT YOUR HANDS, INSTRUMENT, NEEDLE, ETC. BEFORE YOU DO SO. C. NEVER EVER SAY “I HAVE TO HURT YOU TO HELP YOU.” DO NOT IDENTIFY YOURSELF AS THE PERPETRATOR OF THE PROCEDURE. SAY “ I THINK THIS PROCEDURE WILL PROBABLY HURT; I’M SORRY THAT IT IS NEEDED. MAY I HAVE PERMISSION TO GO ON? “ WAIT (IF POSSIBLE) UNTIL PT. INDICATES READINESS.
SEVEN DEADLY SINS (CONT’D)
1. IGNORING OR DISCOUNTING MY FEAR
DO NOT SAY “DON’T BE AFRAID”….. I AM AFRAID WHETHER YOU WANT ME TO BE OR NOT. DO NOT SAY “SHH. IT’S OKAY”…. THINGS ARE OKAY IN YOUR BODY, NOT IN MINE. DO NOT SAY “DON’T CRY”…. CRYING IS DESIGNED TO RESTABILIZE MY B/P, H/R AND RESP. IT’S MY PARTY AND I’LL CRY IF I WANT TO. DO NOT RESPOND TO MY FEAR WITH THE OFFER OF AN ELECTRONIC DEVICE (I.E., “DO YOU WANT ME TO TURN ON THE T.V?” OFFER TO SIT BY MY BEDSIDE WITH ME FOR A FEW MINUTES. WHEN YOU SEE A RESPONSE INDICATING FEAR, VERBALLY ACKNOWLEDGE IT. SAY “I FEEL AS THOUGH YOU ARE AFRAID… WHAT MAY I DO TO MAKE YOU FEEL SAFER? -OR- (AS APPROPRIATE) HAS ANYTHING EVER SCARED YOU THIS WAY BEFORE. GIVE ME PLENTY OF TIME TO THINK; I PROBABLY CAN’T RESPOND RAPIDLY IF I AM UNCONSCIOUSLY RESPONDING TO A PRIOR TRAUMA.
SEVEN DEADLY SINS (CONT’D)
DO NOT TAKE AWAY MY AGENCY. IT IS HELPFUL TO GENTLY AND PLEASANTLY, BUT FIRMLY, INSIST THAT THE PT. EXERCISE THE POWER OF FREE CHOICE AT LEAST EVERY 30 MINUTES TO AN HOUR. AT LEAST ONCE EVERY TIME YOU ARE IN THE ROOM. CAN BE ABOUT ANYTHING , AS LONG AS EITHER A YES OR NO IS ACCEPTABLE. IT CAN BE ABOUT THE MOST MINOR THINGS, AS LONG AS IT IS A CHOICE ABOUT SOMETHING. REMEMBER THAT THE PT. HAS THE RIGHT TO REFUSE ANYTHING YOU DO. SO ALWAYS ASK PERMISSION TO ADMINISTER MEDICATIONS. DON’T EVER ASSUME THAT ANYTHING IS OKAY WITH THE PATIENT, EVEN IF YOU KNOW OR FEEL IT’S MEDICALLY NECESSARY YOU STILL REQUIRE CONSENT.
SEVEN DEADLY SINS (CONT’D.)
DON’T ASSUME YOU KNOW ME OR MY HISTORY.
A PATIENT MAY HAVE SUFFERED HORRIFIC TRAUMAS OF WHICH YOU ARE UNAWARE, THAT MAY EXPLAIN THEIR BEHAVIOR. NEVER JUDGE A PATIENT… YOU ARE VERY LIKELY TO BE DOING SO INCORRECTLY. JUDGMENTALISM IS NOT AN APPROPRIATE CLINICAL FUNCTION. JUDGMENTALISM CAN “POISON” PREVAILING OPINION ABOUT A PATIENT AND COMMUNICATE MESSAGES THAT IMPOSE FEELINGS OF REJECTION AND SHAME WHICH DEFEAT THE PATIENT’S DESIRE TO BE MEDICALLY COOPERATIVE. DON’T JUDGE WHO THE PATIENT IS… ASK THE PATIENT ABOUT WHO HE IS. SAY “ I KNOW YOU HAVE A REAL LIFE OUTSIDE THIS HOSPITAL…. WOULD YOU TELL ME ABOUT IT?” ASK ABOUT FAMILY, FRIENDS, INTERESTS, FAVORITE BOOKS, MOVIES, FOOD, ANYTHING THAT ALLOWS THE PATIENT TO VERBAIZE SOMETHING ABOUT WHAT AND HOW HE CHOOSES TO BE OUTSIDE THE HOSPITAL.
SEVEN DEADLY SINS (CONT’D.)
1. DON’T DEPRIVE ME OF ACCESS TO MY SUPPORT SYSTEM
UNFORTUNATELY, THIS IS OFTEN A MATTER OF HOSPITAL OR UNIT POLICY. ROUND THE CLOCK FAMILY SUPPORT IS ESSENTIAL FOR MANY PATIENTS. ALSO, CHILDREN AND YOUNG SIBLINGS OF PATIENTS ARE USUALLY EXCLUDED FROM VISITATION. DEPENDING ON THE CASE, THIS CAN HAVE VERY HARMFUL CONSEQUENCES 5. EXCLUSION OF A YOUNG CHILD WILL CAUSE THE CHILD TO FANTASIZE ABOUT WHAT IS TRANSPIRING, AND THE FANTASY WILL USUALLY BE MORE FRIGHTENING THAN THE REALITY. EXCLUDING CHILDREN CAN CAUSE SIGNIFICANT FEELINGS OF DESPERATION IN THE PARENT, AND INSPIRE FEAR, TERROR AND ABANDONMENT IN THE CHILD. ADJUSTMENT TO APPEARANCE NEEDS TO BEGIN EARLY. IT IS BETTER TO ALLOW THE CHILD TO SEE THE PATIENT EARLY ON, AND REPEATEDLY, SO THAT CONTINUAL CHANGES IN APPEARANCE CAN BE SEEN BY THE CHILD. IT IS HELPFUL TO TAKE “FAMILY PHOTOS” SO THAT THIS CHANGE CAN BE DOCUMENTED AND MEMORY CAN BE REFRESHED CHILDREN CAN DEAL WITH WHAT THEY ARE PREPARED FOR BY ADULTS, IN A VERY NON ANXIOUS MANNER. WHAT THEY CAN’T DEAL WITH IS THE UNKNOWN.
SEVEN DEADLY SINS (CONT’D.)
1. DON’T TAKE MY DIGNITY AND AUTONOMY
KNOCK AND ANNOUNCE BEFORE ENTERING, UNLESS PATIENT IS CONSCIOUS BUT ASLEEP. IF PATIENT IS UNCONSCIOUS, KNOCK AND ANNOUNCE ANYWAY. THE UNCONSCIOUS PATIENT IS STILL EXERCISING HYPERVIGILANCE AND MUST BE PUT AT EASE. DON’T OVERSTIMULATE: PATIENTS WITH P.T. STRESS ARE MANY TIMES MORE SENSITIVE TO STIMULI THAN FAMILY OR CLINICIAN CAREGIVERS. MAKE SURE THAT PATIENT HAS SOME CLEAR SPACE AND DOWNTIME, FREE FROM NOISE. ALWAYS KEEP T.V AND RADIO AT LOW LEVEL. DO NOT ALLOW FAMILY MEMBERS TO “COMMANDEER” THE TV. MAKE SURE THE PATIENT IS OFTEN OFFERED A CHOICE. DO NOT SUBJECT AN UNCONSCIOUS PATIENT TO MUSIC OR TV OF YOUR PREFERENCE. MAKE INQUIRES AND ENSURE THAT IT IS HIS/HER PREFERENCE. RESPECT MODESTY ALWAYS. ALWAYS ASK THE PATIENT WHAT HE/SHE WANTS COVERED. UNCOVER ONLY WHAT IS NECESSARY, OR IN ACCORDANCE WITH THE PAIN LEVELS OF THE PATIENT.
SEVEN DEADLY SINS (CONT.)
DO NOT TAKE AWAY BELIEF IN MY FUTURE
PLEASE REFRAIN FROM EVER TELLING PATIENTS THAT THEY AREN’T GOING TO HAVE A NORMAL LIFE. THIS CAUSES THE INTERNALIZATION OF MESSAGES THAT HAVE SERIOUS ADVERSE CONSEQUENCES AND CAN INITIATE SUICIDALITY. 5. THIS IS NOT A STATEMENT OF FACT, BUT A PERSONAL JUDGMENT, & INAPPROPRIATE. IMPOSES THE CLINICIAN’S STANDARD OF NORMAL 6. ESTABLISHES A “NEGATIVE EXPLANATORY STYLE”, WHICH CLINICALLY CORRELATES WITH INCREASED ILLNESS AND DISEASE . 7. ESTABLISHES AN ARTIFICIALLY IMPAIRED LEVEL OF PATIENT EXPECTATION, WHICH IS EXACTLY WHAT THE PATIENT WILL DESCEND TO 9. IS A HYPOCRISY… WHY DEMAND MEDICAL COMPLIANCE AND EFFORT FROM PT.? 10. CAN EASILY ROB PT. OF ALL HOPE, THE ONE TRUE ESSENTIAL COMPONENT FOR SURVIVAL. WITHOUT IT, A HIGH RISK OF ATTEMPTED SUICIDE IS CREATED. 6. IF ASKED, SAY “ THE WAY YOUR LIFE TURNS OUT IS MOSTLY UP TO YOU. IT WILL BE AS NORMAL AS YOU WANT TO MAKE IT BE.”
SEVEN DEADLY SINS (CONT’D)
NURSES AND THERAPISTS HAVE THE ABILITY WIELD ENORMOUS POSITIVE INFLUENCE ON THE PATIENT’S MENTAL STATUS. PRIMARY REQUIREMENT IS EMPATHY, AND THE WILLINGNESS TO MENTALLY ENTER THE BODY THE PATIENT AND ROLE REVERSE. SOME CLINICIANS, HOWEVER, ARE SO CONTROL ORIENTED THAT THEY CANNOT “GO THERE.” DO NOT REACH FOR PLATITUDES SUCH AS “GOD WON’T PUT ANY BURDEN ON YOU THAT YOU DON’T HAVE THE STRENGTH TO BEAR.” THIS TURNS GOD INTO A PERPETRATOR OF BURN INJURY. DO NOT FORCE RELIGION AS A SOURCE OF SUPPORT ON A PATIENT – MANY PATIENTS ARE VERY ANGRY AT GOD AT THIS POINT . IF A PATIENT HAS ALREADY OFFERED INDICATIONS THAT THEIR FAITH IS A SOURCE OF SUPPORT, IT IS APPROPRIATE TO SAY “WOULD YOU LIKE TO BE PRAYED FOR, OR WOULD YOU LIKE TO PRAY TOGETHER?” ALWAYS KEEP YOUR EYE ON THE PERSON IN THE BED, NOT JUST THE BODY IN THE BED.
CASE ONE: “ THE ABANDONED PATIENT” Two year old pediatric patient with approximate 80% initial TBSA, full thickness. CASE TWO: “THE MISUNDERSTOOD (MISJUDGED) PATIENT” Forty two year old male with approximate 80% initial TBSA, mostly full thickness CASE THREE: “THE RE-TRAUMATIZED PATIENT” Approximately 40 year old female with 35-37% initial TBSA, 2nd and 3rd degree frontal burns on upper / lower extremities, torso and face. Note: Case vignettes are presented with the permission of the patients, who have been treated in a variety of facilities. No connection between the care of any given patient presented and clinicians of this facility should be presumed, nor should errors in care be ascribed to this facility or its clinicians. It is, however, that clinicians may be informed and enlightened by examples of practices that were not helpful to patients, as many facilities share common practices. Names are withheld, however outcomes are actual.
Summary: what you can do to positively impact standards of care
• BE WILLING TO ‘ROLE REVERSE’ WITH YOUR PATIENT; ENTER EMPATHICALLY INTO THEIR MINDSET WITHOUT TAKING ON THEIR PATHOLOGY. STAY HEALTHY AND NONANXIOUS YOURSELF TO THE GREATEST EXTENT POSSIBLE. OBSERVE THE LINK BETWEEN MIND, BRAIN AND BODY. PSYCHOLOGICAL MORBIDITIES ABSOLUTELY CAN AND DO INFLUENCE MEDICAL OUTCOME AND VICE VERSA. EXPRESS AND PRACTICE A WILLINGNESS TO WORK INTERDISCIPLINARILY WITH PROFESSIONALS WHO ARE SPECIFICALLY TRAINED TO SUPPORT YOUR CLINICAL FUNCTIONS BY PROVIDING NECESSARY PSYCHOLOGICAL THERAPEUTIC SUPPORT TO THE PATIENT. ADVOCATE FOR YOUR PATIENTS. OUTSIDERS CAN SUGGEST CHANGES, BUT ONLY INSIDERS CAN IMPLEMENT THEM. CONTINUE TO ACQUIRE EDUCATION ABOUT THE PSYCHOLOGICAL REALM. ACKNOWLEDGE THE VITAL ROLE YOU CAN AND DO PLAY, AND THE EXTENT TO WHICH PATIENTS RECALL WITH DEEP GRATITUDE THOSE CLINICIANS WHO TREATED THEM WITH COMPASSION, EMPATHY AND RESPECT.
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