Mental toughness…..Mental toughness. A characteristic highly prized by trauma surgeons. Today, however, one trauma surgeon didn’t have it. She had difficulty concentrating, and the patient before her had serious life-threatening injuries that required her full attention.
She had been a trauma surgeon now for twelve years. She was always excited about surgery and the chance to repair and restore functioning. Yet, of late, she found herself somewhat dysphoric with impaired concentration and shortness of temper. It was not like her.
She knew that police, firefighters, and paramedics could experience psychological trauma and, if left untreated, posttraumatic stress disorder (PTSD) in the course of their work. It never occurred to her that the victims that caused the first responders to be traumatized were the same injured-and-mutilated victims that they brought to her hospital for surgery.
Yet she had similar symptoms: depression, impaired concentration, unfocused anger, and, at times, grim recollections of some of the victims to whom she had provided care earlier on. She had untreated posttraumatic stress disorder.
This doctor is not alone. Trauma surgeons are at risk for developing psychological trauma and PTSD in the course of their work as well. It seems reasonable to assume that, if injured victims can traumatize first responders, then these same victims could also traumatize the receiving-trauma surgeons at the receiving hospital. In fact, the published literature has often noted the presence of PTSD in trauma surgeons. Common to these studies is the repeated request to provide more information on psychological trauma/PTSD and how to cope with it for trauma surgeons [1, 2]. A brief overview is presented in this blog. (See  for a more detailed presentation.)
Psychological trauma is a person’s physical and psychological response to having experienced, witnessed, or been confronted with (an) event(s) that involve actual or threatened death, or serious injury, or a threat to the physical integrity of the self or others .
Individuals may become victims of psychological trauma in one of three ways.
– First, one may be a victim of a direct act of violence, such as assault, rape, or a shooting.
– Second, one may be traumatized by witnessing violent, critical incidents happening to others.
– Third, persons may be traumatized by being told of violent acts. Trauma surgeons may be victims of violence and experience psychological trauma by direct violent acts, by witnessing the aftermath of violence in the patients that they receive, and/or they can be traumatized by taking a statement of the present problem or a detailed medical history.
Good physical and mental health is comprised of reasonable mastery of one’s environment, caring attachments to others, and a meaningful prosocial purpose in life. Psychological trauma may impair any or all of these domains. By definition, victims do not have control. Victims often withdraw from others and/or are abandoned by others who blame them for what has befallen them (victim-blaming). Lastly, one’s sense of order and purpose is altered by violent acts.
As with any medical condition, psychological trauma has symptoms. There are physical symptoms associated with adrenaline: hypervigilance, exaggerated startle response, and mood irritability. Second are intrusive symptoms, continuing cognitions after the event is over. Included here are conscious preoccupation, dreams, nightmares, and flashbacks (sudden intense recollections). Third are the avoidant symptoms. Here victims withdraw into themselves and become less involved with the world around them. They avoid the scene of the violent incident and avoid any reminders of it. This withdrawal continues over time and the victim becomes depressed and may develop chronic negative thoughts or feeling states.
In our case example above, the surgeon has impaired mastery (difficulty concentrating), troubled intrusive memories of earlier patient victims, and depressive feelings.
If individuals experience disruptions in any of the three domains of good health and and/or experience any of the three types of symptoms, they are experiencing psychological trauma. If any of these disruptions continue after thirty days, the individual has developed PTSD.
There are several treatment interventions that ate available to trauma surgeons. These can be utilized individually or in various combinations.
First are the various medications that have proven helpful in the short-term for anxiety and depression. Next are various counselling approaches, including psychodynamic therapy, cognitive behavior therapy (CBT), and eye movement desensitization and reprocessing (EMDR). To these may be added any system of relaxation as well as aerobic exercise programs Crisis interventions at the time of the critical incident may prove of assistance as well in resolving post-incident distress . If the surgeon has been utilizing alcohol or drugs to reduce traumatic stress, both the substance use and the untreated PTSD will need to be addressed.
Colleagues, internists, and psychological trauma counselors can assist in finding resources.
1. Kent, J., Thornton, M. M., Fong, A., et al. “Acute Provider Stress in High Stakes Medical Care: Implications for Trauma Surgeons.” Journal of Trauma and Acute Care Surgery, 88: 440-45, 2020.
2. Flannery, R. B., Jr. “Psychological Trauma and Trauma Surgeons.” Psychiatric Quarterly, 2021.
3. Flannery, R. B., Jr. Posttraumatic Stress Disorder: The Victim’s Guide to Healing and Recovery. 2nd Edition. Riverdale, NY: American Mental Health Foundation 2012.
4. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders (DMS-5). Washington, DC: American Psychiatric Association, 2013.
5. Flannery, R. B., Jr. The Assaulted Staff Action Program (ASAP): Coping with the Psychological Aftermath of Violence. Riverdale, NY: American Mental Health Foundation, 2013.
Raymond B. Flannery Jr., Ph.D., FACLP, a licensed clinical psychologist, is Associate Professor of Psychology (Part Time), Department of Psychiatry, Harvard Medical School, as well as Adjunct Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School and Adjunct Professor of Psychology (Part-Time), the Woods College of Advancing Studies, Boston College. He is an internationally recognized and award-winning scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops, for all types and sizes of groups, and may be reached at The American Mental Health Foundation.