5 questions: After trauma, how do we heal emotionally?

Early in Therese Richmond's career, medical trauma research was focused on how to save lives.

But few were looking at what happens next, after the person survives the horrible injuries – from an auto accident, a shooting, a fall.  How do survivors fare mentally, after they recover physically?

Richmond decided this was the area in which she wanted to work.  For her doctorate from the University of Pennsylvania, she focused on recovery after serious traumatic injury that did not involve the brain or spinal cord.

Now, as the Andrea B. Laporte professor of nursing and associate dean for research and innovation at the University of Pennsylvania School of Nursing, she studies human responses to injuries.  Two decades ago, she cofounded the Penn Injury Science Center, where she is on the executive committee.

In recognition of her work and her achievements, she was elected for membership to the prestigious National Academy of Medicine this year.

She recently spoke to us about her work.

Tell us about trauma. 

Trauma accounts for one in 10 deaths in the world.  It's a huge, huge health issue.  In the U.S., one out of 10 adults seeks medical care for an injury every year.

Early on, I loved figuring out the injuries.  It's like a puzzle.  It was intellectually challenging and exciting to work with an interdisciplinary team.  But the thing I really fell in love with is considering what it must be like when you're fine one minute, and the next minute you have a serious traumatic injury. How do you handle that?

Was there anything in particular that prompted your interest?

Early in my development as a trauma nurse, I had a patient who had been shot during a robbery at a convenience store. It was a close-range shotgun blast to his abdomen. It was a devastating injury. Statistically speaking, he was lucky to be alive. He survived. We were thrilled. He eventually went home.

Then, maybe a month later, he came back. He was irate. He said to our team: "You saved my life, but I'm not healed. Nobody understands what I've been through." That was, for me, a turning point. I thought, "Wow, I never really thought about what happens when you get out of the hospital and you recover."

Everybody has emotional responses to injury. That's normal.  Whether you break your leg or get stabbed in the chest, you're going to have an emotional reaction. Most people work through it. If you have a car accident, you may feel tentative, but eventually you get back behind the wheel. But some don't. It's the people who don't that we need to pay attention to.  It's when something lingers, if you don't get past it, that it becomes problematic.

The two big players I have found in my work are depression and post-traumatic stress.  Both of those can intrude on everything that goes on in a person's life.

In a study I'm just finishing, we're finding that 30 to 35 percent of the people who survive traumatic injury developed significant depression, and 30 percent developed post-traumatic stress disorder.  There's some overlap, but that comes out to at least one in three people who have psychological responses that may be problematic.

In this context, what does recovery mean?

One way to define a good outcome is that you live vs. you die. If you take the next step, you say a good recovery is if all your wounds have healed. The next step is that you didn't have any complications. All of those are good things.

But what people really care about is, Can I care for my grandchildren, can I cook for my children, can I go back to work and be productive, can I be a student?  It's not "Did my incision heal?"  It's "Am I able to go back to my normal roles and activities that I participated in before the injury?" If you have psychological symptoms that are problematic, that gets in the way.

Families are important in this.  People are out of the hospital really quickly these days.

They are not necessarily prepared to recognize the psychological symptoms. We need to prepare patients and their families, to let them know it's normal to have emotional responses.

If you find that these symptoms concern you or become problematic, you need to reach out and get help.

In an early study I did, we asked a simple yes-no question: Do you anticipate any problems when you go home?  What we found was that people who didn't anticipate problems had more psychological distress.

Is the psychological response related to the severity of the injury?

Who do you think is going to have the worst psychological outcome? Someone who had a horrible injury, or someone who broke a leg and is out of work for a few weeks? You'd say the person with the life-threatening injury.  But we've found that the severity of the injury isn't related to the psychological response. However – and here's the clincher – the psychological response contributes a lot to how we recover.

By the way, sometimes, as clinicians, we'll say, "You're so lucky; you should see so-and-so down the hall."  The reality is, when it happens to you, nothing is minor. Take the word minor off the table.

We've looked at whether the injury is intentional – a shooting, a stabbing — or unintentional, such as a motor-vehicle crash or a fall.  Our work is showing there are a lot of commonalities, but also some differences. Among victims of intentional injuries, we see a little more PTSD. We see people who feel the world is unsafe in a different way.  The dynamics are different. Do I know the person who hurt me? Will I have to face him in a courtroom?

We recently studied over 600 urban black men who had been injured. For many who were intentionally injured, the world had changed.  They were less trusting of other people around them.  If you're injured in a car crash, you might be scared to drive, but you probably wouldn't be thinking you couldn't trust the people around you.

How are you working to prevent injuries?

At the Penn Injury Science Center, we're really interested in how we can decrease injury and death from gun violence. As a society, we obviously haven't done that. We've been pretty successful in reducing the number of car injuries and deaths.  But we haven't done that with gun violence.

It is politically charged, so we have to change the dialogue. This is not pro-gun or anti-gun.  I'm not a Second Amendment scholar. I'm a nurse. All I want to do is decrease injury and death.  So I ask people, Can you join me? Are you going to tell me you don't care about that?

Decades ago, when we figured out that cars kill people, nobody said to get rid of all the cars. In fact, we have more cars now than ever. But we've decreased death by cars. We did it by having data that told us in what way cars were killing. We have a federal agency – the National Highway Traffic Safety Administration.  We collect data and make it available to scientists.  We put in place new regulations. When I was a little girl, we didn't have seat belts.  How did we find out that air bags kill kids in the front seat? We had data.  We changed road design.  We changed car design. We made it unacceptable to drink and drive.

All that is applicable to gun violence. Except there's little data, little funding, no federal agency. What if we change environments?  What if we change weapon design? What if I had personalized weapons where only with my fingerprint will the gun shoot? There are many, many things you can do.  The first step is to change the dialogue. Then we use data and science.

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