Secondary stress and the health care provider

The following perspective, offered by an ER physician, does not necessarily reflect the views of the Division of Mental Health, Developmental Disabilities and Addictive Disease. It is offered as a point of view about the personal and professional costs of working with suffering.

I think, perhaps, I have seen enough pain for one life. I know, I know, I'm only 40 years old. I'm soft now. I used to love intubations and resuscitations; I used to love the thump of the defibrillator, the thrill of blood from deep wounds, the surprise of something horrible on a CT scan. I was once thrilled by helicopter blades whirring and ambulance light bars flashing, by anxious voices over radios. I wanted to see bullet holes and bullet fragments. I was irresistibly drawn to the chaos of disaster. But then, I used to be separate from it all, outside it, a young, powerful man with a kind of immortality and immunity to the suffering of this world. But that is fading with the years, and fading fast.
I wonder how much pain we have to witness, or be part of, to make an adequate career. I have been informed that expertise in emergency medicine requires something like seven years, or 40,000 patient encounters. But how much suffering is sufficient to say, "Thanks, that's plenty. I quit"? I don't know the number. I'm sure that it differs for every woman and man who practices medicine. But we seldom admit it, because we equate that feeling with weakness.
We walk through it as if it is nothing. We put our clumsy hands into the bodies of the wounded, we take away their breath to give them synthetic airways. We listen as they open a dark door into their dark worlds, where daughters are raped by fathers, where children are left with strangers while mothers get high, and the strangers beat them mercilessly. We sit by strangers and say things like, "I'm sorry, but your child's injuries were too severe, and despite everything we did, she died."
She died. We say that over and over. He died, she died, they died. He has a hemorrhage in his brain, she has a heart attack, they are in surgery, he will never walk again. This is who we are. We are the messengers of chaos, the wardens of entropy, where the dissolution of the universe takes the very personal appearance of death and wounds and terrible illnesses. And where the technicalities of medicine's inadequacy simply mean loss, and loss becomes screams and sobbing before it becomes a sterile news clipping or obituary.
At the sharp point of medicine, the very tip where all bad things go first, we balance our lives, and cover up our hard secret with science and research, with our desire 'to help the suffering, to save lives', and with the necessarily callous humor that no one else grasps.
Our secret, brothers and sisters, is that for every bit of pain we see, a little bit stays inside. In some secret place in our hearts and minds, we accumulate it. Sometimes, a professional will be knocked down and out by a single dose of it. Like a nuclear weapon, it melts their circuits. But most of us get accumulated small doses, and the effects are stochastic, unpredictable.
But, I predict, the effects are greater than we know. Thanks to the politics and rules of modern medicine, we see more pain, more rapidly, with less chance to process it than ever before. It comes in great waves in some centers, day after day of violence and tragedy, death, pain and misery. And all those who face it are like Caligula's guards, ordered to drive back the sea with swords and shields.
In some places, like mine, it comes in smaller waves, but no less devastating. Worse, perhaps, since the longer I live here in one small place, the more likely I will see friends and family and co-workers and others I know, lying supine on the gurney before me, with cancers, accidents, assaults and death.
That's the thing. Love makes it all harder. When we are younger, we love intensely, passionately, but not with the depth, or desperation, of our years. Now, husband of my lovely wife, father of my perfect children, I fear for them. Or maybe, I fear for me, for the possibility that I might lose them, or that I might have to face their suffering.
And this love makes me feel the loss of other spouses and parents more acutely. I imagine myself in their situations. I hurt for them. Maybe I'm doing the right thing, 'mourning with those who mourn', but it takes so much out of me, out of all of us, when we do it over and over and over again, and when we put a little more inside us each time, one more artifact of someone else's agony, one more memory of a scream, of a look, of a sob.
As I grow older, I realize that some wounds will always be with us. I can call up images that I will never be rid of, at least not in this life. All I can hope is that in heaven, where suffering is not even a memory, I will see my patients, and they will see me, and the best we will be able to do is, "don't I know you?" I won't remember their troubles, they won't associate my face with their former pain, as people in this life certainly must.
That's my hope, for me and for all who labor in a job that casts us daily into all the troubles of humanity. And if you don't want to wait around for heaven to ease your pain, it's OK to say, 'enough'.


Those who interact with trauma survivors are themselves exposed to a form of traumatic stress. More recent diagnostic formulations of Post-traumatic Stress Disorder such as those in DSM-IV have broadened the definition of trauma to include participation in others’ traumatic response. As you see and treat patients who have experienced disaster, whether in the emergency period immediately following it or thereafter, you will be exposed to secondary stress and traumatization, the focus of this fact sheet.

Coping with secondary stress:

Fortunately, health care professionals have tools to manage secondary stress: we have knowledge of the ways in which trauma affects people, we have skills for soothing arousal and processing states of distress, and most importantly, we have each other, a support system with the potential to help each of us maintain perspective and find understanding during those times when we get caught in the web of secondary traumatic stress. We are not invulnerable, but if we maintain a strong sense of community among ourselves, we can be resilient.