What happens to providers when chaos is their norm?

This story has been edited for the print edition of Modern Healthcare. Read the full special series "The Other Victims of Gun Violence"

Seventeen years ago, Dr. Christopher Colwell was called to a scene much like the one that recently played out in Orlando, Fla.

Entering Columbine High School alongside a SWAT team, Colwell, then a young emergency department physician, had not yet been trained for what he was about to witness. Colwell recalls walking through a sea of bodies in the school library.

“I don't think anything prepares you for that,” he says.

Of the 15 people who died that day, he pronounced them all dead. Most of them were students.

Back at Denver Health Medical Center, Colwell's colleague, Dr. Wade Smith was treating the survivors.

Thirteen years later, both doctors, both lifelong veterans of the ED, would tend to victims who had been shot while watching a movie in an Aurora, Colo., theater.

In the years since, hospitals have ramped up preparation for active shooter situations and mass casualties, but Modern Healthcare found none that addresses the emotional toll and exposure their employees face dealing with everyday gun violence. Experts say any research or outreach would undoubtedly reveal anxiety, sadness, depression and even suicidal thoughts or actions.

Smith describes treating victims of mass shootings like any normal day at a trauma center, but amplified. Treating one wounded patient is just as upsetting as treating several, he says. The staff at Orlando Regional Medical Center might still be working to save patients, and officials there say staff members have received some counseling. But Smith said when the media frenzy dies down and the patients are discharged, they must come to grips with what they have experienced.

Smith admits that nearly two decades after Columbine and Aurora, he still hasn't processed his emotions.

“It helps if you compartmentalize,” says Smith, now an orthopedic trauma surgeon at Swedish Medical Center in Englewood, Colo. “If I ever thought about all of the misery I'd witnessed, I'd probably blow my brains out.”

That ability to shut off feelings can serve patients well. Trauma personnel work at breakneck speed. They don't have time to stop and feel. But once their shifts end, physicians and nurses go home with images in their heads that most of us, if we're lucky, only see in the movies.

“You have to tend to the needs of victims, their emotional problems are so great compared to what we are going through, we have to be careful not to compare,” Smith says.

He says he looks for colleagues who can handle the pressure and who he can rely upon.

“There is a certain amount of pride and toughness expected that says reacting to something is a sign of weakness,” says Colwell, who is now the director of emergency medicine at Denver Health. He adds that it's also important not to force help on someone who is not asking for it.

Offered the anonymity of social media, many providers seemingly acknowledge their vulnerability. Figure 1, the image-sharing app for healthcare professionals, earlier this year asked its 500,000 global members to describe the effects of gun violence in their workplace. They received 2,067 responses from the U.S., with U.S. users reporting a significantly higher rate of gun violence cases than those in other countries.

Nurses said they were hardened and doubted humanity. They shared stories of being on lockdown to protect shooting victims from retaliation.

“It makes for a tense workplace. You feel unsafe,” one nurse said.

Research in countries with less gun violence, such as Belgium and Denmark, have concluded that an estimated 10% to 20% of ED doctors have symptoms of post-traumatic stress disorder. Some foreign hospitals offer staff regular counseling.

“Hospital-based and outpatient-based group therapy programs would be a welcome relief,” said psychiatrist Dr. Art Lazarus, who suffered from PTSD as a resident more than 35 years ago.

He sought treatment after one particularly traumatic incident, but anxiety has plagued him. Lazarus understands that doctors worry they could lose their licenses and the respect of their colleagues if they get help.

Foreign studies show that ED doctors and nurses who feel symptoms of PTSD often avoid treatment. Not surprisingly, the longer they remain in the ED, the higher the rate of those with symptoms. Yet, many remain in the unit their entire careers, driven by the adrenaline and satisfaction of saving the most critical patients.

Left untreated, PTSD symptoms can lead to substance abuse and suicide. Some studies estimate 400 doctors commit suicide every year in the U.S. And nurses in the U.S. are four times more likely to commit suicide than workers in other professions.

And the workplace, which is like home for many healthcare professionals, is often the last place where those with PTSD will exhibit symptoms, said Dr. Elspeth Ritchie, a psychiatrist. “What we usually see after suicides is colleagues will say, 'There were all these red flags I missed.' ”

Despite the pressure to hide emotions, Dr. Leslie Zun, chair of emergency medicine at Mount Sinai Hospital in Chicago and president of the American Association for Emergency Psychiatry, said the culture is changing. Some state medical board certifications have stopped asking whether physicians are being treated for PTSD so they don't feel stigmatized or fear losing their certification for seeking help.

Physician leaders are making themselves more available to talk about any issues, he says. “I think we're doing better. People are ready to admit, 'I need to talk to someone, and I need some help.' ”

After the Orlando mass shooting, the worst in modern U.S. history, the American Medical Association passed a resolution supporting efforts to end the ban on federally funded gun research. The data could show why gun violence prevails and how patients' injuries are changing. All that, medical societies say, would help save lives.

But when asked whether the AMA would fund research to determine the impact of gun violence for the physicians it represents, the society's new president, Dr. Andrew Gurman, said the cost should fall on the federal government.

“Most physicians have a high degree of frustration over the ongoing gun violence in our culture,” Smith said.

In the meantime, Colwell and his colleagues have their own coping mechanisms. Every April 20, the anniversary of the Columbine shooting, they check in on each other.

“It takes a keen eye to identify some issues in people who are really trying to hide their feelings,” he said.

“But we have to do our best to not demean normal coping behavior.”