When mass casualty incidents (MCI) occur, attention rightly is paid to those injured or killed. Yet physicians and other health professionals providing care during MCIs also often experience trauma in the events’ aftermath.

As a volunteer first responder at ground zero on Sept. 11, Michael Karch, MD, an orthopedic surgeon in Mammoth Lakes, California, was compelled to help but came away from the experience feeling grossly unprepared to deliver effective assistance during an MCI and deal with its aftermath.

“We’re all going to be very enthused and ready to jump in when this happens to us, but we never want to let our enthusiasm overshadow our lack of knowledge,” Dr. Karch told a recent gathering of physicians. “We never want our lack of knowledge cause undue harm.”

Dr. Karch said that proper training, staying within protocol and taking appropriate steps in the aftermath can help physicians handle the toll of MCIs.

Hospitals have ramped up their preparation for MCIs, but don’t address the emotional toll and exposure their employees face dealing with everyday gun-violence situations.

In the aftermath, physicians may experience secondary trauma, especially if it is a man-made event such as the shooting at the Mandalay Bay Resort and Casino in Las Vegas or the Pulse Nightclub in Orlando. To better prepare for incidents like these and to minimize physician burnout in the aftermath, Dr. Karch shared a few tips.

Mass casualty incidents are not for everyone, but that doesn’t mean physicians. It’s about the patients. Certain patients will not survive the incident. If physicians understand the critical indications ahead of time, they can become more resilient and objective to the situation.

“If you’re untrained, all three parts of your brain will freeze like a rabbit on a January day,” said Dr. Karch. “Ninety percent of us have auditory exclusion. We become deaf in a mass casualty incident or in combat. Everything goes silent like a movie.”

“If we don’t practice, it’s going to come,” he said. “We have to practice. We have to practice again and then we have to do it again and again and again.”

During an MCI, critical thinking often goes out the window. This is where training is important.

“We need to train ourselves not to look at the big, the bad, the ugly of the horrible things that a hurricane or shooting can do to a human, but rather train ourselves to start and stay within protocols,” said Dr. Karch. “Stay within the protocol and you will avoid mistakes. Deviate outside of the protocol, you will make mistakes and you’ll lie awake at night.”

“We have to avoid this compulsive urge to help everyone with every resource that we have. Do no harm. Have the knowledge beforehand,” added Dr. Karch, who spoke during an educational session at the 2018 AMA Annual Meeting in Chicago.

Adapting to situations is important, especially when it comes to school shootings. When these incidents occur, physicians need to take appropriate steps in the aftermath.

“When and if a mass-casualty incident occurs, you will be expected to do superhuman things,” said Dr. Karch. “[Society] will expect you to do this at a high level performance and they will scrutinize you, very highly. There’s probably no other profession on Earth, with the exception of the combat-ready military, where that is the expectation.”

Physicians should become self-aware. Being able to look at one’s experiences and identify triggers is crucial to overcoming an MCI. And while eliminating stressors is nearly impossible, physicians can try manage them more effectively by getting enough sleep, eating well, exercising regularly, and engaging in mindfulness meditation, Dr. Karch said.

Lastly, he urged physicians to practice self-compassion. That generous approach allows you to treat yourself with the same level of care that you would treat a friend or patient.

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