Shortly after a gunman wounded nine people and killed 10, including himself, at Umpqua Community College in Roseburg, Ore., Lesa Beth Titus, BSN, RN, trauma coordinator for the hospital where many of the shooting patients were taken, introduced herself on a conference call, saying she was from Mercy Medical Center in Roseburg. Dead silence. Her small Oregon timber town had been known for, if anything, its proximity to spectacular fishing, hunting and rafting. “Roseburg is now seen as the scene of a mass shooting,” Titus said. “This has been a big mind-shift for people here.”
It takes a long time for a community to recover from the shock of a mass casualty shooting, say nurses and mental health specialists, and not everyone heals the same way or at the same pace. Nurses and other hospital staff are part of a grieving community. They may also have been directly involved in preparing for or treating people with multiple gunshot wounds, putting their emotional reactions aside as they rushed to save lives.
Emergency nurses often consider themselves immune to the tragedies they see every day, Titus said, an attitude that extends to everyone in the department. “A mass casualty is a mass casualty,” she said. “You can’t minimize it. But it’s also in many regards a bigger part of what we do every day.”
Numerous studies have shown a correlation between repeated exposure to traumatic events and post-traumatic stress disorder. A 2012 study published in the International Journal of Nursing Studies of emergency nurses in Belgium showed nearly one-third had noticeable anxiety, depression and sleep disorders. Almost one in 10 met clinical levels of PTSD. Dealing with sudden death or serious injury, particularly of a child or adolescent, was the most traumatizing event, nurses in the study reported.
A senseless and deliberate act such as a mass casualty shooting adds another layer of complexity, said David Tetrault, PhD, MDiv, chaplain and critical incident stress management team leader at Banner-University Medical Center in Tucson, Ariz. Banner-UMC treated patients, including Rep. Gabrielle Giffords, wounded in a highly publicized mass shooting in 2012. “Your sense of right and wrong, your personal values, all of that gets violated and makes it harder to deal with,” Tetrault said.
Returning to baseline
The public attention following a mass casualty shooting, both welcome and unwelcome, keeps it constantly in peoples’ minds and makes it hard to get back to daily living, said nurses who have experienced such an event in their communities.
In Roseburg, national media and protesters on both sides of gun law issues swarmed the town, overwhelming and angering many residents, Titus said. In Newton, Conn., after a gunman shot 20 children and six adults at an elementary school in the Sandy Hook neighborhood in December 2012, the streets were so clogged with traffic, it took Anka Roberto, MSN, RN, MPH, DNP(c), more than an hour to make what was usually a 15-minute drive home after comforting a friend.
Many people came because they wanted to help, but the crowds got in the way of community members connecting to each other, said Roberto, director of the learning resource center and simulation coordinator at Fairfield University School of Nursing in Connecticut and the mother of a Sandy Hook Elementary School student who was uninjured in the shooting.
In Tucson, Banner-UMC experienced an outpouring of national and international attention that lasted weeks and included a hospital visit by President Barack Obama. Secret Service, local police and campus security were a constant presence. ED nurses and other trauma staff were bewildered by their designation as national heroes for simply doing their jobs, Tetrault said. Meanwhile, some workers in other departments felt left out of the loop.
After the shooting, the hospital used critical incident stress management to help workers deal with shock, anger, fear and other emotions some were experiencing, and in the initial days to meet basic needs for food, comfort and information. CISM, an intervention protocol created for dealing with traumatic events, originally was developed for firefighters, police officers and other first responders. It offers people exposed to a traumatic event a voluntary way to share experiences, release emotions, learn about the symptoms of secondary stress, and get referral for more help, if needed.
Banner-UMC’s CISM team met with people individually and in groups, and held large meetings to provide information. Hospital staff reported sleeplessness, anger, upset stomachs, headaches, sadness and guilt because some people had not been saved, Tetrault said. “The part that surprised me was how strong the response was for those who were not on the front line,” including administrative staff from other hospital campuses.
Dealing with secondary trauma
After a traumatic event, everyone reacts differently and all feelings are normal, say mental health experts. Some people want to talk about it all the time. Others don’t want to talk at all. It’s important to respect both reactions, said Joy A. Lauerer, DNP, RN, PMHCNS-BC, assistant professor in the College of Nursing at Medical University of South Carolina in Charleston and a child and adolescent psychiatric mental health clinical nurse specialist. “We know that trauma is long-lasting and that it affects the brain and neurological systems,” Lauerer said. Some people process trauma more readily than others, she said. Those dealing with difficult events in their personal lives, such as divorce or the death of a parent, are more at risk for secondary trauma. Some may struggle for years, she said. Others may do well until something retriggers the trauma.
Lauerer and other mental health workers advise developing a sense of resilience and good self-care habits. Talking to people close to you, recognizing your limits, eating nutritious foods, getting good sleep and exercising can help both before and after a traumatic event, Lauerer said. “In the EDs, they do a lot of disaster preparation. But I don’t think it ever prepares you for what this is going to feel like.”
Most hospitals have recognized the importance of staff debriefings within 48 hours after a traumatic event, Lauerer said, but they also need to keep checking in with people in the weeks and months following. EDs can better support their staff, Titus said, in part by creating an environment that does not tell people they need to move on before they are ready and by “debunking that myth that we can handle anything anywhere at any time and it never affects us.”
Many hospital workers recovered from the immediate stress created by the shootings within a month or so, nurses and mental health workers said. Some took longer. A few left their jobs and even their careers. “It was more than some people could deal with,” exposing themselves to trauma every day in their jobs and then going home to care for their children, Titus said. At Mercy, when trauma workers said, “I can’t do this anymore,” they were told, “That’s OK. You don’t have to,” Titus said. They were offered jobs in other parts of the hospital.
Participating in community rituals provided solace for some nurses. Kimberlee M. Hilty, BSN, RN, house supervisor in charge of trauma center admissions at Banner-UMC, drove a hospital van full of staff to the memorial service for Christina Taylor-Green, the young girl killed in the Tucson shooting. They brought Ben’s Bells — symbols of kindness created by the parents of another child in the community who had died suddenly in 2002.
After the service in a large Catholic church, attended by more than 2,000 people, they took the bells to Christina’s smaller family church and left them for churchgoers to find that coming Sunday. Later they heard how people were comforted by those bells.
ED nurses at Loma Linda University Medical Center who had received patients from a mass shooting in San Bernardino last December said they were sad and upset, but they also grew closer after the event in which 14 people were killed at a health department Christmas party. About a week after the shooting, the ED decided to hold a special debriefing — a baking session. People made dozens of cookies, brownies and other treats, and delivered them to those who had helped on the day of the shooting, including security at a nearby golf course. “That was the best day,” said Connie Cunningham, MSN, RN, Loma Linda’s executive director of emergency and trauma services. “It was really therapeutic.”
“We were saying thanks to them, to the first responders,” said Shannon Canright, RN, MICN, director of patient care for the pediatric emergency department, who had coordinated care for shooting victims in the ED. The first responders said the hospital staff were the ones who deserved thanks. On the scene, they told the nurses, everything was so chaotic. They felt so anxious. But when they arrived at the hospital and saw how well prepared everyone was, both inside and outside, and how everyone knew where to go and what to do, they could finally relax. It would be OK.
Passing it on
One of the most comforting things for nurses at Banner-UMC was the response from other hospitals, Hilty said, including a banner from those who cared for patients from Virginia Tech, where in 2007, thirty-two people were killed in the deadliest shooting by a single gunman in U.S. history. The Tucson hospital has since passed on its own messages of support to other hospitals dealing with similar tragedies.
On the day of the San Bernardino shootings, anonymous ED nurses in Boston and Texas had pizza delivered to the Loma Linda staff. The public relations office at Mercy Medical Center sent a gift basket to its Loma Linda counterpart. The Medical Center of Aurora in Colorado sent a banner with more than 100 staff signatures. In a letter of thanks, published in the Los Angeles Times, Loma Linda administrators pledged to “encourage other medical communities who must deal with what we hope no one will have to experience.”
But on Feb. 20, a man in the Kalamazoo, Mich., area randomly shot and killed six people, and seriously wounded two, including a teenager. A few days later, a gunman killed three people and wounded 14 at a lawn care company in a small town near Wichita, Kan.
Kris Hill, MSN, RN, director of ED and trauma services at Via Christi Hospital St. Francis in Wichita, which received some of the shooting victims, told local television reporters her teams, which included nurses from all over the hospital, took care of seven critically wounded patients in 45 minutes. All survived.
Cathryn Domrose is a staff writer.
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