Psychological aspects of physical trauma

Betty Thomas, RN Carol Alexander, RN

When I got up at last . . . and had learned to walk again, one day I took a hand glass and went to a long mirror to look at myself and I went alone. I didn't want any- one . . . to know how I felt when I saw myself for the first time. There was no noise, no outcry;

Betty Thomas, RN, BS, i s Editor of the AORN JOURNAL. She i s a graduate o f the Arkansas Baptist Hospital School of Nursing and received her BS degree at the University o f Colorado.

Carol J. Alexander, RN, MS, i s AORN Director of Education. She received her BSN degree from the State University o f Iowa and earned her MSN degree at the University of Colorado School of Nursing.

The material presented here i s adopted from the keynote speech presented by Mrs. Thomas at an AORN Regional Institute, "Trauma-evaluation and management," conducted by the AORN Central Nebraska chapter.

I didn't scream when I saw myself. I just felt numb. That person in the mirror couldn't be me. I felt inside like a healthy, ordinary, lucky person- oh, not like the one in the mirror! . . . when I did not cry or make any sound, it became impos- sible that I should speak of it to anyone, and the confusion and the panic of my discovery were locked inside me then and there, to be faced alone, for a very long time to come.

Over and over I forgot what I had seen in the mirror. It could not pen- etrate into the interior of my mind and become an integral part of me. I felt as if i t had nothing to do with me; it was

February 1972 45

only a disguise . . . put on me without my con- sent . . . as I looked in the mirror . . . I saw in the place where I was standing a stranger, a little, pitiable h ideous figure . . . It was only a disguise, but i t was on me, for life. It was there, it was there, it was real. Every one of those en- counters each time I looked in the mirror was like a blow on the head. They left me dazed and dumb and s e n s e l e s s everytime, u n t i 1 slowly and stubbornly my ro- bust persisent illusion of well-being and of per- sonal beauty spread all through me again, and I forgot the irrelevant re- ality and was all unpre- p a r e d and vulnerable again.’

How can I survive? How can I endure the chronic sorrow? Will I ever forget the went which changed my im- age?

No, it is impossible. Each time I close my eyes, I see the blinding glare of light and hear the roar of the motor- the deafening crash-the shattering glass-I feel again the splintering of my own body-the un- bearable pain in t e r - mingled with periods of silence and darkness . . . the fragmentation of my

own life-strange peer- ing faces-surgery-I’m cold, alone and afraid- I hurt.

The lines you have just read repre- sent, in part, the emotional response to physical trauma from a patient’s perspective.

The intent of this paper is to ex- plore the emotional aspects associa- ted with physical trauma and to pro- mote a better understanding of the integral part operating room nurses play in the team effort toward re- construction, recovery, and in helping patients through to their new begin- ning.

Initially, as the emergency team performs their life saving measures, the atmosphere is infused with drama and tension, The patient begins ex- periencing a series of feelings; fear, anxiety, pain, confidence, doubt, agi- tation, gratitude, anger, confusion, to name a few. The degree to which t,hese are experienced and the emo- tional scarring they precipitate is de- pendent upon the patient’s physical state, level of consciousness and psy- chological development. For clarity let’s look at some of those fears and feelings in greater detail.

Fear of death

Surprisingly perhaps, the fear of death is omnipresent. We recognize death as a multifaceted symbol. For some, i t is a teacher of transcendental truths; a friend who brings an end to pain; an adventure-a great, new on- coming experience; a great destroyer; a means of punishment; an escape from an unbearable situation to a new life; it may be a means of gaining

46

affection from others unable to give others and the individual, the patient us love in life; or a way of achieving begins to feel unsure; Will he be ac- importance or recognition.’ cepted or rejected by his friends?

The possibility of death also re- quires examination of religious and philosophical convictions. Basically, confrontation with death demands identity and compels one to answer the question: Who am I?D However, “The crisis of death is often not the fact of oncoming death per se, of man’s insurmountable finiteness, but rather the waste of limited years, the unassayed tasks, the lost opportuni- ties, the talents withering in disuse, the avoidable evils which have been done. The tragedy. . . is that man dies prematurely and without dignity, and death, even as life, has not become really his

Death is an abhorrence of “not- being.” Silently, trauma patients may struggle with the following questions: “What are my preferences in relation to my own funeral arrangements; how do I terminate or say goodbye to my loved ones; how do I resolve existing conflicts; and finally, for what do I want to be remembered and have I accomplished my goal?”

Fear of mutilation A second fear is the fear of muti-

lation and disfigurement. From earli- est childhood people develop a sense of personal identity and self-esteem. A mental image is imprinted which we identify as “body image.” When trauma physically changes one, that mental image must also be altered. This is accomplished slowly, with great resistance, and i t evokes severe emotional pain.5

Fear of ostracism Because a physical deformity is

often perceived as a stigma by both

How will strangers react to him? Subtly, a self devaluation process

begins. The patient tends to view himself as inferior. This self concept predisposes him to chronic feelings of insecurity, anxiety and jealousies. Gradually, he is engulfed by a fatal deficiency of the self system!

The anticipated loss of interper- sonal relationships, ostracism and iso- lation produces great loneliness.

Fear of dependency Gradually the fear of loss of con-

trol and dependency take on a nega- tive quality. Disfigurement has set limits on his sense of freedom and he is dependent upon others, a frighten- ing experience for anyone who values his independence.

Fear of punishment Eventually patients may fear they

are being punished for some sin, thought, or previous behavior. Ir- rational as this concern may be, the silent questioning of self intensifies adding diffuse guilt feelings to the patient’s emotional overload.

Fear of the future Constantly, t h e p a t i e n t may

wonder if he will ever move toward self actualization, control, and inde- pendence. Will he have the courage necessary for beginning again? Will he have the strength to find new ways of approaching life or will he succumb to doubts and fears of failure?

Other fears Although concept ions involving

death, mutilation, abandonment, un- ishment and the future predominate, there is also fear of pain; the un-

February 1978 47

known; loss of potential; and the im- tion, of his altered body image brings pact of deformity upon loved ones a period of mourning. The patient which must be recognized and under- knows a frenzied hopelessness and ex- stood. periences depression. His behavior

may vary from withdrawal to rebel- lion. He may refuse to eat or refuse treatment saying he wishes he were dead, or he may become sarcastic and argumentative. These demonstrations are strong cries for help.

Awareness and knowledge of the stages through which a patient pro- gresses in emotional reaction to trauma is also important in planning effective nursing intervention.

Jane Lee identifies four of these major phases as: 1) impact; 2) re- treat; 3) acknowledgment; and 4) re- construction.

Thc reconstruction phase: The need to mourn is replaced by the decision to try again. New approaches to living must be planned and initiated by the

The impact phusc: The initial en- patient in conjunction with the total counter with the critical situation health care team. produces a state of shock and deper- sonalization. Often the patient’s per- ception of what he is witnessing is clear, but he does not experience the event as happening to him.

The retwut phase: Once the reality of the situation begins to penetrate through to the patient’s conscious- ness, anxiety mounts and he retreats through the process of denial.

He may say, “Oh, I’ll be good as new in a few days,” or he may begin to make plans which are obviously in- appropriate and unrealistic.

This emotional attempt to return to the pre-trauma status quo is not necessarily refusal to face the reality of trauma, it is merely an inability to do so. Thus, denial allows the patient to obtain some relief from the trauma. It offers him a chance to rest, to re- coup and to reorganize his strengths for the work of recovery which lies ahead. Retreat may persist until the patient is brought face to face with reality again. Then he gets angry and is ready to fight back.

The acknowledgment phase: Ac- ceptance of the reality of the situa-

This phase involves three phenom- ena: the reintegration of the patient’s body image; the reorganization of his social values and; the adjustment to extend surgical and therapeutic pro- cedures and perhaps adjustment to prosthesis or other technical devices.’

Nursing interventions for trauma patients are planned in relation to the patient’s physical condition and the emotional phase through which the patient is progressing.

Emergency life saving needs are obviously a first priority. The exper- tise of the professional operating room nurse is a vital contribution to total team effort. Her initial evalua- tion and analysis of emergent needs may assist in saving the patient re- peat surgical interventions and insure shortened rehabilitation time.

There is no substitute for highly skilled technical knowledge during this phase. Emotional support is also vital for the patient throughout sur- gical intervention.

An important first is that we as nurses examine our own feelings re- garding the traumatic event and the

48 AURN Jownat

aftermath. What do we feel in rel- lation to death, mutilation, abandon- ment, ostracism, and punishment? Do we respond with repugnance or pity when we view a physical deformity? Do we judge those associated with the injury? Are we too sympathetic? Do we withdraw?

We must allay our own anxiety as well as the patient’s anxiety. “Short, simple, and truthful answers spoken in a quiet and reassuring manner have a positive effect in helping to keep reactions more reali ty-f ocused.”R

his own inner nature and his own po- tential; promote the patient’s aware- ness of the here and now through reality-confrontation; and encourage patients to talk about what has hap- pened.

Physical comfort and verbal sup- port alone do not provide adequate as- sistance. At times setting limits and administrating discipline are demon- strations of caring.

The patient needs help in exploring his need to retreat, his anger, his sorrow and his sense of loss. He at-

We should not contribute to the psychological death of the trauma pa- tient by engaging in communication sterility. For instance, do not resnrt

tempts to terminate with his former physical self and establish a new body image, and we as nurses must aid him in that process.

to intellectualizing, philowr ,ii clng, moralizing, inappropriate kidai- 1 3 not avoid questions by siler, Y, <j82&-

ing the subject, giving exec’ s, or communicating only in rel&ti,> I to procedures rather than listening to the fears and discussing the under- lying feelings which the patient has.

Nurses must keep the avenues of communication open. “Speech re- duces guilt. It provides an opportunity to explain, to apologize, to forgive and be forgiven. Speech comforts as pa- tients plan for the future and reflect on their philosophy and religious be- liefs. Speech dissipates loneliness and i t can be the vehicle through which inspiration and motivation are de- rived. With rare exception, i t makes the difference between life and death of the spirit.”ll

The use of touch is a valuable part of nursing iritenention, which must not be minimized.

We should remember the impor- tance of being physically available to the patient. Our presence is an ex- ternal form of hope which needs to be conveyed to the patient. For ex- ample: you are important; you need not face this experience alone; you have had a serious accident; but we are here to assist you; we have a competent surgical staff and we will take care of you.

We need to positively reinforce the new beginning through knowledge, support and encouragement.

We must understand the patient’s reluctance to initiate a new life style. It is a slow and painful process. The aftermath of trauma is a chronic sorrow filled with discouragement, exasperation and periodic remissions.

We must: avoid false reassurance and conveying generalized indiffer- ence; aid the patient to come to terms with his illness in his own way with Certainly, we as operating room a real sense of fulfillment; help the nurses, know we alone cannot perform patient become concerned with self, all of these nursing interventions.

February 1972 49

But we can be a very important part of the total team whose goal is to re- store trauma patients to a full life again. We can do that best through acceptance of an expanded profes- sional nursing role and through un- derstanding of the psychological as- peck of physical trauma.

REFERENCES

I . Goffman, E: Stigma and Social Identity: New Jersey: Prentice Hall. 1963, pp 7-8.

York: McGraw H i l l , 1959, p 126.

3. Fulton RL (ed.): Death and Identity: New York: John Wi ley & Sons, 1965, p

4. Plummer, CS: Thoughts regarding the Mean- ing of Death: (unpublished paper), 1965.

5. Golden, J: Psychiatric Management of Acute Trauma: Early Management of Acute Trauma: Na- hum, A (ed.) St. Louis: C V Mosby, 1966. p 6.

6. Goffman, E : op cit , p 13. 7. Lee, J M : Emotional Reactions t o Trauma: Nurs-

ing Clinics of North America: Vol 5 No 4 (Decem- ber) 1970, pp 578-585.

8. Lee, J M : op cit , p 580. 9. Barkley, V : Grief a Part of Living: Ohio's

2. Feifel, H ( e d . ) : The Meaning of Death: New Health (Ap r i l -May ) 1968, p 3.

More intensive education The Navy and Marines discharged 6,700 men last year for drug abuse.

problem in society as a whole.

convinced of the dangers of experimental use and reject this temptation.''

Navy Secretary John Chafee said tho situation was not surprising because of the drug

He has called for more intensive education of naval personnel "so all of our people become

Frozen sperm bank opens The first of an international chain of 20 "frozen sperm banks" opened off icial ly in New York

Already stored in the bank's nitrogen voult were 23 deposits made within the last 10 days. The youngest depositor was 21. The average age of the first depositers was 25.

Morton E. David, president of ldant Corp, which plans to launch the sperm bank systems also in England and Japan by 1973, said banks wil l be opened in 20 American cities, hopefully by the end of 1972.

Baltimore wil l have one by February, Chicago in Apr i l and San Francisco by J u l y . ac- cording to Dovid, a lawyer who formerly was chairman of the board of Holmes Protection Inc.

David said he is asking that federal regulations be set up for the banks within the National lnsfitutes of Health and under the Division of Biological Stondards.

The preservation of human semen is important fo men concerned about the possible ir- reversibility ol vasectomy, the male sterilization operation. Within the fast two years, the Association for Voluntary Sterilization (AVS) estimates, some three million American men have bad the operation.

The fee i s $80 for freezing three semen evaluations and $100 additional for storage charger for 10 years. "Most depositers are paying the $180 since storoge charges paid yearly would be $18 a year," David said.

c i t y .