Post Traumatic Stress and the Nursing Diagnosis; Part 1.

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Human Responses to Traumatic Events

If you run a Google search with the term, “post traumatic stress” (PTS) you will get 6,740,000 links taking you to all kinds of websites like those of self-help organizations, medical peer review journals, personal injury attorneys, various news media and health professionals. Notwithstanding that this medical term represents a legitimate and treatable complication for many, it may be the most overused and abused diagnosis in the history of personal injury law. In truth, every human being who experiences a traumatic event has an emotional reaction and most people wrestle with various issues for some time after the event. Additionally, most PTS sufferers resolve their issues either on their own or with professional counseling within a few months of the trauma, while a few suffer a permanent loss of the quality of life. Although the question of permanent emotional damage is most often related to whether there is any residual physical disability or whether the PTS sufferer is the victim of a personal attack or insurmountable loss. However, the bottom line is that emotional responses are all subjective. The medical expert who treats the PTS patient does not have any definitive test like a blood chemistry report that identifies a treatable or permanent adverse condition. Therefore, the objective of this paper is to provide information from which the reader can recognize the threshold for compensable pain and suffering, what constitutes a permanent condition that has a negative impact on the quality of life and how to gather and present evidence that will support or refute such claims. Thus we shall examine the nursing diagnosis, various common human responses to trauma, coping mechanisms, juror empathy and provider documentation. 

The Nursing Diagnosis and How it Works 

The nursing, as an artful and scientific body of knowledge, differs from medicine and other allied professions with one important distinction; the study of how humans respond to existing and potential health problems. As such, since trauma is defined as a life-altering event, we provide coping assistance for pain, mental anguish, phobias, acute anxiety, panic, irritability and the like. It all boils down to a change in how the traumatized person interacts with his/her environment and various communities (school, work, place of worship, home, extended family, friends, neighbors, organizations etc.). Hence, there are a number of specific manifestations of people’s responses that the nursing profession has identified in terms of diagnosis and treatment. 

The Injury phase – a Mixed Bag of Intense Emotions and Pain  

During the first instant after a traumatic event, the victim is in shock. Depending on the severity of the insult the initial shock can last from a few seconds to a few hours and can even be life-threatening. The sudden onset of physical or emotional impact produces a change that evokes a series of responses such as pain, anguish, denial, anger, guilt, anxiety, helplessness and panic. These reactions, in reality, are a desperate attempt on the part of the victim to maintain composure and regain control.

Pain – “It hurts!” 

Pain, being a human response, is a necessary part of our survival. It is usually one of the first signals that something is wrong. The problem with it is that once it has done its job it lingers and the trauma victim suffers. For that reason, we have many pain-relieving drugs and there is no doubt as to their beneficence. However, there are adverse affects; pain killers dull the senses and place the sufferer on a downward spiral toward chemical dependency. There is also the danger of overdose with self-administered narcotics through a dose-demand device that delivers a measured amount into the blood or spinal fluid. Nurse who provide coping assistance seek to work with clients to increase their thresholds for pain tolerance. However, the measurement of the quality and quantity of pain is purely subjective. The current standard is to ask the client to relate the intensity of the pain by picking a number from one to ten, with ten being the worse pain imaginable.  Also, to ascertain the quality of the pain, we normally ask the client to select from words like, “stabbing”, “crushing”, “throbbing”, etc.

Denial: “I can’t believe this happened!”

I have listened to many hundreds of trauma victims describe their ordeals – the Holocaust, automobile accidents, muggings, kidnappings, rape, explosions, falls, animal attacks and medical mistakes. The length of the injury-causing tribulation lasted anywhere from seconds, regarding accidents to years as with those who survived the Holocaust. Denial is usually the first response after the person realizes that the traumatic event is over. This initial denial is regarding the event itself. The individual is aware of what happened, but is trying to refuse to accept the new reality. Everything that the person planned to do moments before has been thwarted, so there is a natural tendency to want to continue on the intended path. Sometimes there is a loss of memory of the injurious experience due to being knocked unconscious and in some cases the victim successfully blocked his or her recollection of the event and behaves as though nothing happened. In the former case the person knows that he or she survived an accident or attack and is dealing with the injuries. The latter is more insidious because the memory of the incident has been suppressed and is still there wreaking havoc. In such instances, professional help is needed.

There was one case in which I counseled a woman who I’ll call Rachel, who had deliberately suppressed all of her responses to a four-year traumatic episode that had occurred twenty years earlier. She came to me for counseling after she had been in an automobile accident and was suffering from three herniated discs in her neck. She was double parked in front of a bakery waiting for her fourteen-year-old daughter and a drunk driver rear ended her car so hard that she found herself upside down in the back seat area. Aside from the neck pain and severe headaches, she was suffering from post traumatic stress issues. Most of her complaints were expected; she was easily startled by ordinary household noises and she was terrified of being in a car. However, there was one response that did not make any sense. She began to hate her husband with whom she had a good relationship for eighteen years. She told me that after the accident the thought of her husband touching her made her want to vomit.

Thinking that the response of revulsion toward the husband had nothing to do with the automobile accident, I asked Rachel if she had been married before. She replied that she was married to a “Mafia hit man” (murderer for hire) for four years and he was extremely abusive. Being insanely jealous, he beat her regularly and handcuffed her to the radiator in the bathroom whenever he went out. Rachel further stated that he enjoyed pointing his gun at her and threatened to kill her if she called the police to report his abusive behavior. Then one day a police officer came to Rachel’s door and she screamed when she heard the knock. The police officer kicked it in and released Rachel from her shackles. He told her that he came to inform her that her husband had been gunned down and killed. Rachel immediately threw away her husband’s clothes and personal effects. She did not attend the funeral and never spoke to anyone about her torment.

Apparently, Rachel zealously put the whole affair behind her and moved on with her life. However, rather than work through her issues, she had suppressed all of the normal responses including anger and hatred. In that way, although she did not block her memory of the first marriage, she refused to acknowledge that anything bad happened by deciding not to work through her post traumatic responses. Thus, she had made a conscious choice to suppress the memory of her four-year torture and she successfully carried it off. Twenty years later, however, the old trauma resurfaced in response to a totally unrelated accident.

Anger: “I can’t wait to get my hands on the Fool who did this to me!”

Anger is a common response to trauma. It is similar to the anger stage of the grief process and in some cases; the trauma victim experiences a deeps sense of loss culminating in grief. However, there are some important distinctions between anger arising out of loss from natural causes or from trauma. With the latter there is a reality-based target – the negligent party or perpetrator. The emotional aspect of the mind needs to seek out its mark to place blame, which on the surface seems justifiable. Sometimes, however, the object of the anger remains unidentified. In such cases, the intense negative emotion is like a heat-seeking missile flying around in search of a mark and strikes at anyone in its path. Thus we see such individuals with a high degree of irritability screaming at store clerks, restaurant servers and the like.

Additionally, anger or rage is, metaphorically, a form of fire. A fire inevitably dies out when it has consumed all the available fuel. It cannot move on in search of more fodder. Hence, to keep the flames going, one has to keep adding more fuel. In that sense, anger is the fire and obsessive thoughts of the injurious event, insult and/or the source of obstruction to one’s intentions are the fuel. Therefore, since thinking is a continuous conversation inside the head, to resolve the problem of perpetual anger one simply needs to change the dialogue.

Guilt: “If only. . .” 

One of the common responses to trauma is guilt, which takes on two forms. One is the knowledge of being the cause of someone else’s injury and the other is feeling dejected for failing to avoid an accident. Although guilt is often thought to be a deterrent from deliberate harmful acts, it is not. Standard Freudian theory refers to the “super ego” as the part of the mind that discerns right from wrong and wants to be righteous at all times; hence the “guilty conscience” generates sadness and shame upon realizing that an evil act or negligence caused pain, anguish and/or injury. Unfortunately, once the feeling of remorse is present the harmful act or failure to perform has already happened and the damage is done. Accordingly, people aren’t usually motivated to act or refrain from acting to avoid feeling guilty. They are, however, more likely to be motivated by fear of embarrassment, punishment and/or reprisals.

Alternatively, as a response to trauma, prolonged self-reproach over having failed to avoid the fateful event by commission or omission is stressful and damaging in that it often leads to depression and self-destructive behavior. Oddly, notwithstanding the resultant low self-esteem, it is actually more of an ego trip because the “if only” or the “I could have, would have, should have” conversation arises from the unrealistic notion that the person had some “divine-like power” over the events and circumstances of the day and failed to exercise it. Thus the road to resolution lies in recognizing the higher power that controls the events of this world or at least in acknowledging that the events of this world are not within any human control. Again, it’s simply a matter of changing the “conversation”.

Anxiety: “What’s going to happen to me?”

Although we go through life not knowing what will happen next, we all make plans and have expectations of a certain outcome. Sometimes things happen the way we want and occasionally we get happy or not-so-happy surprises. Most of us accept this roller coaster ride and make adjustments as needed. Humans even have an amazing capacity for remaining cool and confident in the face of danger. On the other hand, we sometimes feel uneasy about the future. As we think about our circumstances and likely outcomes there is a “comfort zone” that each person has developed over his or her lifetime based on expectations of predictability.

However, when trauma occurs the victim experiences a sudden life-altering event that came as a total shocker. Consequently, all notions of certainty are immediately stripped away. The comfort zone is suddenly gone and the person is left standing on a high wire with no safety net. Thus one way of resolving this dilemma is to re-establish those “comfort zones”. For example, most of us can get through a day without frantically worrying over what’s going to happen next because we settle into a daily routine and take most things for granted. If you’re thirsty, you go to the kitchen sink and turn the faucet. You didn’t fret over “What if the water doesn’t come out? What if it is undrinkable?” You expected to get potable water by turning the handle and didn’t even give it a second thought. However, if a person one day finds worms in the drinking glass, there is likely to be a lot of anxiety over the integrity of the water supply until he or she learns that the local authorities found and fixed the problem.

Being Vulnerable: “Help! Get me out of here!”

During some traumatic events the victim gets caught in a trap – held by extraneous forces. The more obvious scenarios (Heaven forbid) are being a hostage, kidnap victim or pinned in a car or under some debris. The less obvious circumstance of being ensnared would be seconds before an impact – seeing it coming and being unable to get out-of-the-way. These situations leave a lasting impression and can give rise to a host of undesirable responses. The moments of feeling vulnerable, no matter how fleeting, shakes the very core of our being and lessens our capacity to trust. The victim is in fear of losing his or her life. However, the aspect that results in the emotional response problems is not the actual injury-causing impact, but the loss of control or momentary feeling of helplessness and the victim becomes riddled with anxiety and mistrust.

Panic: “It’s everybody for themselves!”

Panic is a condition in which there is total loss of reasoning. It occurs in response to a perceived threat, whether real or imagined. There is usually a tremendous surge of brain wave and nerve impulse activity that manifests in either loud vocal outbursts with gross body movements or silence with the body frozen in place. When there are large crowds in one location it can spread like a brush fire and cause more harm than the perceived danger. One prime example of a massive panic response to an imaginary threat was the inauguration of the Brooklyn Bridge in 1899. The suspension bridge was a new technology then, so people were taken by surprise when they felt the swaying. One person yelled, “The Bridge is falling!” and several thousand people stampeded, trampling dozens of men, women and children to death.

Since the victim is on a rampage for survival without the ability to think of another person’s well being, panic emanates from an evil place. The stampeding human is no different from a stampeding animal. Anyone standing in the way gets crushed. There is no cure and it is both self-destructive and damaging to any one in reach. Notwithstanding the occasional success in bringing a frenzied individual back to his or her senses, the only way to deal with this total loss of self-control is to prevent it through education self-determination and practice. That is why we have fire and disaster drills in schools, hospitals and other public institutions.

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