Firearm-related injuries account for more than $2.8 billion in direct emergency and inpatient care costs every year in the U.S. This does not include the indirect financial costs or emotional effects on patients and providers after incidents of mass trauma. Currently the U.S. is facing a potential shortage of physicians and mental health professionals, which would be further exacerbated in the event of mass trauma.
When a large-scale traumatic event occurs, such as the Boston Marathon bombing in 2013 or the Las Vegas shooting earlier this month, mental health professionals are part of first-responder groups. Organizations like FEMA and the National Council for Behavioral Health agree that counselors are a vital part of disaster response, allowing victims and their families to process their experiences. At Beth Israel Deaconess Medical Center in Boston, licensed social workers were accessible for patients and family members for up to five months as survivors recovered.
In 2015 alone, there were more than 750 reports of assaults by firearm according to Definitive Healthcare data (ICD-9 codes E9650-E9654). This is not an exhaustive number, as hospitals with fewer than 11 annual cases do not report them to Medicare.
Fig 1 Data from Definitive Healthcare and HealthAffairs
Mental health professionals are integrated into disaster plans on a federal, state, and local level. These counselors are available to help those affected come to terms with the trauma they have experienced, and to recount events in a place free of judgement or fear. Acute reactions to stress, such as short-term anxiety disorders, hyperawareness, dissociations, and vivid recollections of an event, are common in people who have experienced significant trauma. If left untreated, these can develop into chronic conditions such as post-traumatic stress disorder (PTSD), agoraphobia, depression, hyperarousal, and substance abuse.
In addition to aiding in the victims’ recovery, mental health providers will also be essential in supporting first responders. Emergency personnel, both at the scene of a trauma and in the hospitals where patients are treated, are subject to acute stress symptoms like flashbacks, intrusive thoughts, and insomnia. Among those most affected could be paramedics, police officers, and off-duty firefighters. In events like Las Vegas or Sandy Hook, first responders are at risk of injury and death, placing added pressure as they attempt to fulfill their roles while also protecting their own lives. Feelings of inadequacy could lead to intensified survivor’s guilt and self-criticism, which is a further detriment to their mental health.
According to Definitive Healthcare data, there were more than 14,890 inpatient diagnoses of acute reactions to stress in 2015 (ICD-9 codes beginning with 308).
Hospitals Reporting Assault with an Unspecified Firearm in 2015
|Hospital Name||Total # Reported Diagnoses|
|Barnes - Jewish Hospital South||210|
|University of Rochester - Strong Memorial Hospital||93|
|LAC & USC Medical Center||28|
|St. John Hospital and Medical Center||27|
|Timberlands Hospital (Closed)||26|
|John H Stroger Hospital||24|
|Brigham and Women's Hospital||24|
|Mississippi Methodist Rehabilitation Center||23|
Fig 2 Data from Definitive Healthcare based on most recent CMS data available
After the 1995 bombing in Oklahoma City, FEMA provided counselors to survivors for years after the event. Now, experts say the same services will be provided for survivors of the Las Vegas shooting, as well as Hurricanes Harvey, Irma, and Maria. In order to meet the increasing demand, the U.S. Health Resources & Services Administration estimates that the country will need more than 10,000 mental health providers by 2025. Emergency mental health professionals are already spread thin, particularly in times of great or overlapping tragedy.
So what can hospitals and first responder agencies do to prepare themselves for a mass trauma event?
Trauma surgeon Michael Cheatham, MD, experienced mass trauma first-hand after the 2016 shooting at Pulse nightclub in Orlando. Dr. Cheatham, chief surgical quality officer at the Orlando Regional Medical Center, directed response efforts to treat 44 victims. The primary lessons Dr. Cheatham learned didn’t have much to do with patient care—surgeons and physicians knew how to triage patients and treat the most severe injuries first. The team wasn’t as familiar with such large volumes of patients, families, and media personnel.
In order to truly prepare for an event like Orlando or Las Vegas, hospitals should hold drills and exercises to practice caring for a large influx of patients in a short period of time. Streamline and coordinate patient and provider movements to reduce wasted time, and get comfortable with an accurate, efficient method of communication.
Physicians and care providers should also be trained in how to handle dozens of families and patients’ loved ones asking questions and seeking updates. Few hospitals practice delivering updates to patients’ families or turning them away when information is not available. It is difficult to maintain a kind, compassionate demeanor with families while attempting to care for a large number of patients quickly.
Top 10 Hospitals by Volume of Acute Reactions to Stress Diagnoses
|Hospital Name||Total # Reported Diagnoses|
|Ridgeview Medical Center||299|
|Rock Prarie Behavioral Health||233|
|Millie Lacs Health System||204|
|Shirley Ryan AbilityLab||174|
|Heritage Valley Beaver||163|
|Bradford Regional Medical Center||152|
|Advocate Christ Medical Center||148|
|UMass Memorial Medical Center||139|
|Cooper University Hospital||125|
Fig 3 Data from Definitive Healthcare based on most recent CMS data available
Similarly, physicians and other hospital personnel should be trained in how to respond to media inquiries. Which team members will be fielding questions? How will the hospital provide information while maintaining patient privacy?
Establishing positive working relationships with local elected officials and police departments prior to an event can be useful for interactions with media, as they are accustomed to news conferences. It is also beneficial to form these relationships during drills and other emergency preparedness exercises, so police and providers are aware of and comfortable with each other during a mass casualty event. Understanding how the other team responds in such situations is beneficial, and leads to smoother implementations of disaster plans.
After a traumatic event, it is as important for providers and first-responders to receive emotional and psychological support as it is for patients. Departments can offer debriefings in the days and weeks following an event, including short breaks. These breaks allow for individuals to unwind, as well as make time for individual conversations and check-ins so officers don’t feel singled out in front of a group. Officers and dispatchers should be included in these meetings, as dispatchers can hear the events happening as they field emergency calls.
Psychological care in the wake of a mass casualty or traumatic event is as essential for long-term health as surgery or physical care. Professional counseling allows survivors, providers, and responders to process events and the emotions associated with them. When provided en masse, mental health provision helps to create a feeling of resilience and mutual support in communities affected by violence and loss.
Definitive Healthcare has the most up-to-date, comprehensive and integrated data on the healthcare industry. Our database tracks financial and quality metrics on over 7,500 hospitals, 1.5 million physicians, and more than 100,000 outpatient surgery centers.
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