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
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
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,
● 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.
Beta agonists: Associated primarily with elevated levels of norepinephrine , causing increased
cardiac output and increased respiratory function.
• 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.
• 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
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.
15. 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.
9. High rates of suicidality: (Parker) An observed rate of over 50 % among adult survivors
Three great myths (cont’d)
MYTH NUMBER TWO: THE PATIENT YOU SEE IS THE PATIENT YOU ARE
TREATING
MYTH NUMBER THREE: THE PATIENT PERCEIVES THE HOSPITAL AND STAFF AS
BENIGN
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)
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)
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.
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.)
A PATIENT MAY HAVE SUFFERED HORRIFIC TRAUMAS OF WHICH YOU ARE UNAWARE,
THAT MAY EXPLAIN THEIR BEHAVIOR.
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
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
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.
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.)
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.
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.
ALWAYS KEEP YOUR EYE ON THE PERSON IN THE BED, NOT JUST THE BODY IN THE BED.
CASE STUDIES
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
• ADVOCATE FOR YOUR PATIENTS. OUTSIDERS CAN SUGGEST CHANGES, BUT ONLY
INSIDERS CAN IMPLEMENT THEM.
• 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.