Through the Looking Glass

Suchismita Datta, MD, MHPE, FACEP
New Hyde Park, New York
Member of ACEP Medical Humanities Section
Neil Dasgupta, MD, FACEP, FAAEM
New Hyde Park, New York

The air in the trauma room smelled like a summer afternoon barbeque in the backyard. In front of me was an intubated little girl with dark hair and a face that reminded me of my own daughter, except it was burnt to a crisp. Her whole body was 98% burned, to be exact. At least that’s what the trauma surgeon told me when he looked over at me. Both of us knew what that meant.

Outside the room was the mother of this child, sitting in a chair, with a veil of catatonia covering her face. There were no tears in her eyes or cries from her mouth. She just stared at her child, moving only to breathe. She told me that she left her house early that morning to get to work, only to get a phone call a couple of hours later telling her that her house had burned down due to unknown reasons. Both of her elderly parents had died on scene, and her two children aged 10 and 17 had been transported to the hospital in critical condition.

I came home that evening feeling broken. After putting our kids to sleep, I told my husband about the little girl. He is also an emergency physician [EP] at the county hospital nearby, and it turns out that his trauma bay had received her brother after the fire. My husband told me that the boy had kept asking “did she make it out?” repeatedly, and how now it made sense who “she” was. We sat in silence for a little while, soaking in the story of this poor family who looked just like us. Then we went around the house, making sure everything was ok, protecting our family as much as we could. Eventually, we went to sleep, our hearts heavy with anxiety about how fragile life was, and guilt that we still had everything while the family from our trauma bays had lost everything.

As EPs, we carry a whole spectrum of such stories. It can feel heavy at times, but it is an incredibly humbling privilege to bear witness to someone else’s story, albeit costly to our own well-being. Secondary trauma is described as the emotional stress that one experiences by being exposed to someone else’s firsthand trauma. Figley calls secondary trauma “[t]he natural, consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other — the stress resulting from helping or wanting to help a traumatized or suffering person (Figley, 1995).”

Zhang et al performed a meta-analysis in 2020 of published articles that used the Maslach Burnout Inventory to assess the prevalence of burnout found that approximately 40% of EPs globally reported high levels of emotional exhaustion and depersonalization. Another study performed a systematic search of articles between 2011 and 2022 using search keys for ‘burnout & stress’ and ‘burnout & post-traumatic stress disorder,’ and their analysis showed that EPs scored significantly higher for all dimensions of burnout when compared to other healthcare professions (Somville et al., 2023).

While it may seem obvious to many that EPs are particularly vulnerable to secondary traumatic stress (STS) and the associated burnout,  there is also an abundance of evidence to support that these lived experiences are very real. In 2013 the American Psychiatric Association (APA) recognized STS as being a diagnostic criterion for post-traumatic stress disorder (a DSM-5 Criterion A stressor). A study published in 2017 enrolled 118 emergency medicine clinicians, of which 72.9% were physicians, and found that 12.7% screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptoms, and 33.9% had at least one symptom at clinical levels (Roden-Foreman et al., 2017).

So what can we do? How do we ration our empathy? How do we remain professionally engaged? How can we remain effective in our clinical roles and continue to preserve our humanity? Although the answer may be a little different for all of us, deliberation is key. I invite you to consider taking up writing as a way to facilitate reflection and process your stories.

Sandars (2009) talks about reflective writing as a process where one deliberately thinks about and analyzes experiences to gain insights, make meaning, and inform future actions. Rita Charon (2001), the founder of modern-day narrative medicine, speaks about how reflective writing can be a model to nurture empathy as a physician. A recent systematic scoping review published in 2023 on the use of reflective writing in medical education showed that it can nurture a physician’s identity formation (Lim, J., 2023).

Although one can take a more structured approach to writing (such as using a prompt), creating a regular writing practice can in itself be healing. I recently got some excellent and practical advice from one of my mentors and role models, Dr. Jay Baruch, on how to re-engage with my writing practice. I am going to mash up his advice with some other writing life lessons I have stumbled across/stolen from other mentors and give you these tips to get you started on your own writing journey:

• Treat writing like a muscle: work it out every day!
• Assign yourself at least 5 minutes to write daily. Use a timer if needed.
• Use a pen instead of a keyboard - there is something about the physicality of a pen and paper, and the fact there is no “backspace”
• Do not edit, just write.
• Use a cheap notebook. The point is to write, not for it to be pretty.
• Your writing is for yourself, no one else has to read it. It does not have to be “good” by any standard.
• Use prompts if you need to. These can be written prompts, (what did you bring home from shift today that you wish you hadn’t?) or visual ones, such as a picture or a photograph.
• Have fun with it! Get down into the weeds of your emotions. Do not be afraid. Cry if you need to. Laugh when you can.

Another way to help process our experiences on the frontline can be sharing stories with other colleagues during defined “storytelling” sessions. We are piloting such an experience in our department in October, 2025. This effort is in part being championed by one of our second-year residents, which I take as a sign that the future of emergency medicine is brighter and will focus more on wellness than in the past. We are excited to share our experience here after the pilot, so stay tuned!

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Charon, R. (2001). Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA, 286(15), 1897–1902. https://doi.org/10.1001/jama.286.15.1897
3. Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (1st ed.). Routledge. https://doi.org/10.4324/9780203777381
4. Lim, J. Y., Ong, S. Y. K., Ng, C. Y. H., Chan, K. L. E., Wu, S. Y. E. A., So, W. Z., Tey, G. J. C., Lam, Y. X., … & Radha Krishna, L. K. R. (2023). A systematic scoping review of reflective writing in medical education. BMC Medical Education, 23, Article 12. https://doi.org/10.1186/s12909-022-03924-4
5. Roden-Foreman, J. W., Bennett, M. M., Rainey, E. E., Garrett, J. S., Powers, M. B., & Warren, A. M. (2017). Secondary traumatic stress in emergency medicine clinicians. Cognitive Behaviour Therapy, 46(6), 522–532. https://doi.org/10.1080/16506073.2017.1315612
6. Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685–695. https://doi.org/10.1080/01421590903050374
7. Somville, F., Van Bogaert, P., Wellens, B., De Cauwer, H., & Franck, E. (2023). Work stress and burnout among emergency physicians: A systematic review of the last 10 years of research. Acta Clinica Belgica, 78(1), 52–61. https://doi.org/10.1080/17843286.2023.2273611
8. Zhang, Q., Mu, M., He, Y., Cai, Z., & Li, Z. (2020). Burnout in emergency medicine physicians: A meta-analysis and systematic review. Medicine, 99(32), e21462. https://doi.org/10.1097/MD.0000000000021462