PTSD Sucks

My partner and I were recently assigned to the report of excited delirium in the parking lot of an apartment complex on the south side of town. We arrived to find a very large, very naked man lying prone below a pickup truck shouting commands. Dude was about six foot five and two hundred fifty pounds of muscle. He was calling in airstrikes onto my position. Excited delirium is a topic for another day; let’s talk about post-traumatic stress disorder.

By: Cpl. Andrew Johnston [Public domain], via Wikimedia Commons

As an unfortunate side effect of modern times, I’ve seen plenty of PTSD. I’m sure you have too. Besides the giant naked man calling imaginary airstrikes onto the ambulance, I’ve seen memorable PTSD at fireworks events, in counselor offices, and in jails. I remember a psychiatric transport with PTSD; she had been abused extensively as a child. It is a common diagnosis.

PTSD began appearing in American consciousness as “shell shock” during the world wars of the Twentieth Century. It used to be psychologically grouped as one of the anxiety disorders, but the new DSM-5 has moved it to a trauma- and stressor-related disorder.  Something like 7% of adult Americans live with PTSD to varying degrees and about 20% of Iraq and/or Afghanistan military veterans are estimated to live with the condition.  The Anxiety and Depression Association of America says that 7.7 million American adults have PTSD.

Not all trauma is obvious.
By Journalist 1st Class Preston Keres [Public domain], via Wikimedia Commons

The symptoms of PTSD can be remembered with three words: reliving, avoiding, and arousal.  PTSD involves persistent remembering or reliving of a traumatic event. The trauma can be obvious (war) or more subtle (long-term abuse). This remembering manifests itself with flashbacks, vivid dreams, and such, when exposed to circumstances similar to those of the traumatic event.  The flashbacks and other “remembering events” are unpleasant, so patients with PTSD try hard to evade similar circumstances that would trigger the memory events (avoiding). Finally, PTSD patients either have amnesia (partial or full) to the trauma, or have persistent psychological arousal. Arousal manifests itself in insomnia, irritability, anger, concentration problems, hypervigilance, and a heightened startle response.  All of those symptoms needs to exist for at least a month and, like with most psychological diagnoses, should negatively affect a patient’s life.

Treatment for PTSD begins with psychotherapy. Talking with a counselor trained in trauma care is the foundation of PTSD treatment. Serotonic antidepressants (SSRI or SNRI) can be added, so medications like fluoxetine, paroxetine, and sertraline can be used. Prazosin (minipress) is used to reduce nightmares and aid sleep. Tricyclic antidepressants are occasionally employed, but their use is unproven. Prescribed benzodiazepines worsen or prolong PTSD.

Post-trauma stress debriefing was extremely popular at the beginning of my career. The most current science (1-5) seems to be leaning away from debriefing, especially debriefing from peers or others who do not specialize in graduate-level post-trauma therapy and counseling. The American Psychological Association says psychological debriefing has “No Research Support/Treatment is Potentially Harmful.” You certainly shouldn’t force debriefing on anyone who doesn’t want it after a potentially traumatic call.

PTSD in the prehospital setting should be managed in a common-sense manner. My treatment paradigms run from walking away to chemical and physical restraint, depending on the patient presentation, the setting of the call, and the specific details of the events. For example, a veteran who had an episode of anxiety triggered by post-game fireworks resulted in my leaving. He was with his sober wife and several friends. He was not in such distress as to be non-functional or dangerous to himself (or others). People around him obviously had a handle on things and suggested my presence was not helpful. I made sure they knew I was sympathetic, could offer a quiet space for him to recover himself, and was willing to offer whatever help (pharmacological or otherwise) modern healthcare could provide. They were appreciative, but left without my help.

On the other hand, naked men hiding under pickups in daylight are difficult to leave to their own devices. Talking to the patient in a calm but firm voice can be helpful. (It couldn't hurt.) Remind the patient that s/he is safe, that you are with the paramedics, and that you are there to help. In the case here, my job was difficult. The patient’s flashback lasted an especially long time, upwards of twenty minutes. The police officers on scene felt that their uniforms were causing the problem, so they left. The first responders thought it was disrespectful to physically manage a veteran, so they were disinclined to help my partner and I. We waited out the episode, talking to the patient all the time.  After an interminable amount of time, the patient calmed. He was frustrated that “it happened again.”  We took him to the hospital and learned another lesson: An ambulance feels similar to a Bradley fighting vehicle and can retrigger some veterans’ PTSD.

Like with all psychiatric patients, PTSD must be managed on a case-by-case basis. Some patients respond well to talk, while others may require physical or chemical restraint for their own safety (my safety too). The most important step in the process is understanding, balancing respect with safety. 

Paramedicing is tough. We see some heinous shit. If you have signs of PTSD, even mild signs, know that help exists for you. Get yourself to a professional. There is no shame in asking for help with your medical condition. 

1. Feldner MT, Monson CM, Friedman MJ. A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions. Behav Modif. 2007;31(1):80–116.

2. Lewis, S.J. Do one-shot preventative interventions for PTSD work? A systematic research synthesis of psychological debriefings. Aggression and Violent Behavior. 2003;8:329-343.

3. McNally, R., Bryant, R.A., Ehlers, A. Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest. 2003;4:45-79.

4. Rose S, Bisson J, Churchill R, Wessely S. Rose, Suzanna C, ed. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews (2). 2002; Art. No. CD000560.

5. Van Emmerik, A.A.P., Kamphuls, J.H., Hulsbosch, A.M., & Emmelkamp, P.M.G. Single session debriefing after psychological trauma: A meta-analysis. The Lancet. 2002;360:766-771.