June is Post-Traumatic Stress Disorder (PTSD) Awareness Month. Brian Kwan, MD, SFHM, and Kathlyn Fletcher, MD, MA, two representatives from SHM’s VA Hospitalist Special Interest Group, shared their thoughts on working with patients with PTSD in a VA hospital setting.
Drs. Kwan and Fletcher were also among the authors of a January article in the Journal of Hospital Medicine, “Hospitalized Medical Patients with Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for Improved Care.”
What are a few things you’d like to share with other hospitalists about patient care in a VA hospital?
While the prevalence of PTSD is approximately 8% in the general population, that number rises to 10-30% in veterans, depending on which conflict a veteran participated in – for example, 30% in Vietnam veterans and 15% in Gulf War veterans.
Like other chronic conditions, including hypertension or diabetes, PTSD may not be the primary reason a patient is admitted to the hospital and can easily be lost in the shuffle of an extensive problem list. Unlike other conditions, PTSD cannot be caught with simple lab or vitals check, requiring intention to diagnose and treat.
Patients with PTSD often have other mental health and other diagnoses, too, so it is important to take a holistic approach to care for them.
What are some best practices for a hospitalist caring for a veteran living with PTSD?
For most patients, a beeping IV machine or a loud alarm from a telemetry station might simply register as an annoyance. For patients living with PTSD, these common hospital sounds may trigger anxiety, hypervigilance, and anger. Consider playing soft music to limit hallway noise and minimizing alarms in the patient’s room whenever possible.
Recent research has demonstrated how hospitalization can severely disrupt sleep. With nightmares occurring in more than 70% and insomnia in 80% of patients in PTSD, hospitalizations may exacerbate pre-existing sleep problems. Consider strategies that encourage good sleep hygiene, promote specific bedtime routines, and avoid stimulation (light, noise, or TV), or excessive liquids, intravenous fluids, or diuretics before bed.
Loss of control, including inability to self-administer medications, and disruption of normal routine, e.g., eating at a desired mealtime, is extremely common within the hospital This may trigger symptoms of anxiety and anger in patients with PTSD. Communication and partnership with patients with PTSD are key to mitigating the uncertainty and surprises that are a frequent element of hospital stays.
We know from survey research that patients with PTSD can identify parts of the hospital stay that are likely to cause problems for them.
How can hospitalists approach care through a more trauma-informed lens?
When encountering a patient who is anxious, angry, or hypervigilant, employing compassion to explore potential underlying triggers may prevent or ameliorate the stresses and anxieties of hospitalization that may be manifesting because of traumatization.
Similar to engaging patients about their triggers for other conditions such as asthma or heart failure, hospitalists should consider asking patients about what triggers their PTSD. For example, some patients may specify how they prefer to be woken up to prevent startle reactions, a simple but effective strategy in improving patient care.
So many Americans have experienced some sort of trauma in their lives, and the last year has taken a mental health toll on many people as well. Assume that everyone has suffered in some way and be mindful that hospitalization can further traumatize people. Follow your instincts. If a patient doesn’t seem “OK,” ask them why. Let them know that “It’s OK not to be OK” and that we are here to help.
For more information, read the article in the Journal of Hospital Medicine, “Hospitalized Medical Patients with Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for Improved Care.”
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