Loading

DARK DAYS When Violence Hits Health Care

On November 19, 2018, Dr. Tamara O’Neal, 38, was shot and killed outside Mercy Hospital and Medical Center in Chicago during a confrontation with her former fiancé. Her killer had a history of threatening violence and restraining orders brought by coworkers, ex-girlfriends and an ex-wife.

As police arrived, her killer fired on squad cars and ran into the hospital. In the rampage that followed, he gunned down Dayna Less, 24, a first-year pharmacy resident, and Chicago Police Officer Samuel Jimenez, 28, who had just completed his probationary period with the department. Wounded in the abdomen, the assailant then turned his weapon on himself.

Dr. O’Neal was an emergency department physician trying to make a difference in her community. As a graduate of SIU’s MEDPREP program, her tragic death serves as the catalyst for this issue examining the intersection of violence and health care.

The articles that follow explore how SIU learners, physicians and front-line staff are taught to address the violence and trauma they encounter in their daily duties, and what options are available to help them process any effects the encounters could have on their health. We also discuss the guiding principles for trauma-informed care, a multi-disciplinary approach used to improve empathy and sensitivity when treating patients.

REMEMBERING DR. TAMARA O'NEAL

By Anneke Metz, PhD, Interim Director of MEDPREP

All of us at MEDPREP (Medical/Dental Education Preparatory Program) were heartbroken to learn of the death of one of our own, Dr. Tamara O’Neal, who was a MEDPREP student from 2007-09. After MEDPREP, Tamara went on to complete her MD at the University of Illinois at Chicago, followed by a residency in emergency medicine. She was working as an emergency department physician at Mercy Hospital in Chicago at the time of her death.

Dr. O’Neal, who was affectionately known at “TO” by her colleagues and friends, was beloved for her smile, her kindness, and her generosity of spirit. She had a passion for helping her community and wanted to be a physician to help the people of Chicago, particularly the south side. Her love for her community was evident in all she took on in life. Tamara entered college to study child psychology, and completed her bachelor’s degree from Purdue University in 2002. She then worked for several years as a case manager for troubled adolescents. She was proud of the role she played helping many of the youth she worked with to become more open and trusting, and even complete high school and attend college.

Despite her success in social work, Tamara knew medicine was her calling, and she returned to school to fulfill that dream. In applying to MEDPREP, Tamara expressed a desire to save lives in underserved communities, because those individuals’ medical care was often overlooked due to poverty. She dedicated herself to a grueling course of medical study, not to become rich or famous, but because she wanted to be a leader for change in her community, to right the wrongs, and to reach out to those who needed a helping hand. It wasn’t going to be easy, but Tamara was all-in.

Even as an aspiring medical student, she was tenacious and strong, and it was clear that Tamara had what it took to become an outstanding physician. She often spoke about experiencing many setbacks in her own life, which might encourage someone to give up. However, she always also said that she refused to give up on herself, and as a physician, would not do so on her patients, either. With that tenacity and dedication, she tackled MEDPREP, and medical school, and residency, and made it every time.

For her hard work, her great tenacity, her infectious enthusiasm, and her big, ready smile, she will never be forgotten.

Breanna Taylor, MD, who attended medical school with Dr. O’Neal, recalled how Tamara was the driving force behind organizing her fellow black medical students into a study group that would ensure they all succeeded. They came to call themselves the “One-Hitter Quitters”—for any test, they would do it right the first time—no failures, no repeats. Tamara was driven to get there herself, but it was also important for her to mentor others along the way. This is the Tamara that MEDPREP faculty remember; someone who did not just think about herself, but always made sure everyone around her was lifted up, too.

Tamara had as a personal goal to not only be a good physician, but to be a caring role model as well. As a MEDPREP student, in medical school and a successful physician, she continued to hold that goal in her heart, and lived every day of her life with that promise. She chose emergency medicine to help those that needed her the most: the underserved who often end up in the emergency department as a last resort when they have nowhere else to turn. Dr. O’Neal was a loving and generous soul, and a tenacious advocate for the least fortunate among us.

Although she was taken from us too soon, Dr. O’Neal more than made good on that promise made those years ago as a MEDPREP student, to serve as a role model and to help others as a good physician. She made every difference to those whose lives she touched, and she made this world a better place. For her hard work, her great tenacity, her infectious enthusiasm, and her big, ready smile, she will never be forgotten. Dr. O’Neal, we celebrate all that you accomplished, and keep your passion for service, your devotion to others, and your joy for life close to our hearts. Rest in peace, and may you serve as an example to us all.

Tamara O'Neal Scholarship

Dr. Tamara O’Neal holds a special place in the hearts of MEDPREP classmates like Kamilah C. Banks-Word, MD, MA. To honor her memory and carry Dr. O’Neal’s legacy forward to future generations of MEDPREP students, Dr. Banks-Word and a committee of MEDPREP alumni have started the Dr. Tamara O’Neal MEDPREP Scholarship.

To endow this scholarship and provide support to bright and motivated students for years to come, we need your help. Preserve Dr. O’Neal’s legacy by making a gift today.

Note: $25,000 is the minimum to establish a permanent endowment

#THIS IS OUR LANE

By Richard Austin, MD, '14

“Someone should tell self-important anti-gun doctors to stay in their lane….” On November 7, 2018, the NRA, in response to a position paper from the American College of Physicians, tweeted that doctors should stay in their lane when it comes to gun violence research. This tweet led to a massive response from not just physicians, but health care workers of all types as well as the general public. The majority felt that gun violence research was firmly in the lane of physicians.

The fact is that gun violence is responsible for 36,000 deaths every year. Unfortunately, this year it hit home for the SIU family. Dr. Tamara O’Neal, a graduate of the SIU MEDPREP program, was murdered while working as an emergency physician in Chicago by her ex-fiancé. Victims of domestic abuse are five times more likely to be killed if their partner owns a firearm, and over half of intimate partner homicides are committed with a firearm. Despite these facts, federal funding for gun research continues to be restricted, largely due to the Dickey amendment, which was passed after a study showing gun ownership was independently associated with an increased risk of homicide.

Setting aside the contentious nature of any debate surrounding firearms, there is common ground between most Americans on much of this topic. By almost every objective measure, more people die in the U.S. from guns than anywhere else in the developed world. Gun violence is a common thread linking deaths from suicide, homicide, mass murder and domestic violence. Similar to motor vehicle accidents, SIDS, HIV, or any other public health crisis, studying and attempting to reverse trends in morbidity and mortality is firmly within the lane of physicians and public health experts.

Researching gun violence is too often assumed to mean increasing gun control or restricting second amendment rights. Researching gun deaths is often combated with emotional appeals to a Second Amendment right, but that doesn’t have to be the case. Cars weren’t banned when we studied seatbelts and sex wasn’t banned when studying HIV. The successes came from safer practices that prevented injuries and transmission, and not for removal of rights.

Injury prevention of any kind is well within our scope, and we should be leading the charge to study ways in which we can improve the lives of those within our community. The beauty of this being in our lane is that more than advocacy groups on either side of the debate, we are well equipped to provide unbiased interpretations of objective data that can potentially save lives. The alternative is to continue to sit idly by, treating a growing number of increasingly devastating injuries and mourning alongside families, wishing we could’ve done more.

This is our lane.

Richard Austin, MD, is an assistant professor of emergency medicine and the assistant emergency medicine residency program director. His interests include medical education, public policy and simulation. He is a lifelong resident of Springfield and a graduate of SIU School of Medicine’s Class of 2014, and the SIU Emergency Medicine Residency. He practices clinically at Memorial Medical Center, an Academic Level 1 trauma center.

CRITICAL CONDITIONS

Training for Trauma & Violence at Work

Written by Steve Sandstrom | Photography by Sara Way

On an early Monday morning in March 2018, James Waymack, MD, was on his way to work at Taylorville Memorial Hospital. Waymack is the director of the emergency medicine residency program within SIU’s Department of Emergency Medicine, and on Mondays he accompanies a team of residents on a rural service rotation to a hospital 30 minutes east of Springfield. Nearing his exit, he was suddenly passed by three ambulances. Approaching the hospital, he found the parking lot teeming with police vehicles. Inside, emergency medicine director Rich Jeisy, MD, Waymack’s former SIU School of Medicine classmate, was providing care for the three gunshot victims who had just been transported from a nearby domestic violence crime scene. The law enforcement presence was there for protection, because the shooter was still at large.

That afternoon, officers spotted a man they believed to be the perpetrator driving on a rural Taylorville road. He had attempted to rob a convenience store in the interim. With the police in pursuit, the man drove into town and headed for the hospital. His truck struck the curb in front of Taylorville Memorial’s main entrance and came to a stop. The man got out carrying a pistol and headed toward the hospital door. When multiple officers confronted him and told him to drop his weapon, he shot himself in the head.

Dr. Waymack then found himself treating the man in the same nine-room ER where his victims had been receiving care earlier. The trio of victims—a man, a woman and a 13-year-old child—had been stabilized and transported to Memorial Medical Center in Springfield. With a life-threatening injury, the attacker was also stabilized and then sent to Springfield, where he died the following day.

SIU physicians, staff and hospital partners all receive training to prepare for active shooters and other threats. According to the Illinois Health and Hospital Association (IHA), physicians and clinical staff at hospitals across the state are trained in the “Run, Hide, Fight” response and use “plain language” and “color codes” to notify patients and staff of an incident. In addition, the IHA coordinates an annual Emergency Preparedness Exercise, giving hospitals the opportunity to rehearse for these harrowing incidents.

On Nov. 8, 2018, nearly 1,000 individuals participated in the IHA’s most recent statewide simulation. Different active-threat scenarios prompted teams to think through ways to keep patients and employees safe. Eleven days later, a domestic argument escalated into a triple homicide at Chicago’s Mercy Hospital and Medical Center, taking the lives of a doctor, a pharmacist and a police officer.

Both the Taylorville Memorial and Mercy Hospital tragedies demonstrate that no amount of preparation can guarantee total safety from workplace violence. But trained clinicians can help improve the odds of a safe environment for all.

TRAINING FOR LEARNERS

Violence against health care workers—including verbal and physical assault—occurs in practically all care settings, with the highest number of recorded incidents taking place in psychiatric wards, emergency departments and visitor waiting rooms.

The Bureau of Labor Statistics classifies incidents of workplace violence as “intentional injury by other person” in its list of occupational injuries causing days away from work, and reported nearly 18,670 such injuries across the United States in 2017. People working in service occupations made up about half of the incidents (9,110). Health care practitioners and technical occupations reported the second-most: 3,130.

One of the ways SIU medical students are taught how to deal with aggressive and potentially dangerous patients is through clinical simulations with standardized patients (SPs). Since 1981, SPs have been used in Springfield’s Professional Development Lab to simulate real-life medical encounters students may one day face as physicians.

SIU medical students see their first SP during the first week of medical school. It emphasizes the importance of becoming comfortable with taking patient histories, performing examinations and polishing communication skills. As the clinical skills curriculum builds each year, the SP encounters become more complex.

A Doctoring Physician Attitude and Conduct session in year 2 centers on intimate partner violence (IPV). It includes information on the demographics of IPV in society, how doctors encounter it, and methods used to interact with and treat patients. Following the didactic, the students are split into small groups and exposed to one of two standardized patient encounters involving IPV.

In the current SP scenarios, a woman presents with persistent headaches and makes no mention of domestic violence. In the second, a loud and domineering spouse accompanies a female patient to her clinic visit. The student-physician has to figure out how to treat the patient for what could be IPV while the abuser is literally in the room. The second-year SP cases require the learner to discreetly navigate from suspicion to action.

When appropriate, a faculty observer will call a time-out and discuss ways to address the volatile situation. The students are also coached with techniques to de-escalate aggressive behavior. This includes choosing verbiage and empathy for how the patient is feeling, and ways to openly acknowledge the patient’s frustrations and fears.

In addition to skills learned through SP scenarios, SIU’s Departments of Family and Community Medicine, Medical Humanities, Pediatrics and Psychiatry offer Year 4 electives that address aspects of violence. Topics include vulnerable patients, biological terrorism response, health care responses to violence, the role of community service agencies, the criminal justice system and health disparities. The school also hosts frequent educational opportunities to spotlight concerns related to violence and trauma-informed care.

TRAINING FOR FRONTLINE STAFF

Training nurses to deal with aggressive patients is a challenge which varies across clinics and departments. Jessica Barney, a nurse administrator in internal medicine, says that under very stressful conditions, “It’s important to try to stay calm, keep the patient calm and go find who’s in charge to take care of them. I tell my nurses ‘if it’s truly dangerous, just try to get yourself out of the room quickly and call Security. Then come find me.’”

Catie Myers, an SIU charge nurse in the Department of Cardiology says, “For a new nurse, any kind of confrontation with a patient is overwhelming. Through the years, I’ve found that de-escalation is the key to getting the situation under control, whether it’s on the phone or in the clinic.”

Nurse educator Leslie Montgomery and the nurses interviewed for this article all see the value in a debriefing conversation when a traumatic episode or death occurs in a “code session.” This gives the care providers time to reflect and acknowledge what they experienced. Connecting with other care providers afterward and talking with nurse managers was a standard operating procedure mentioned within the group. “You can lean on your peers,” Montgomery says. “After that, I would go home and talk to my family. Venting to my husband was my usual debriefing.”

She recommends debriefing sessions be made mandatory under certain circumstances, so nurses wouldn’t have the option of toughing it out and regretting it later. It could remove some of the stigma from requesting the counseling opportunity. “Our days are so busy,” she says. “Sometimes you won’t even know how much something has affected you until much later.”

EMERGENCY ROOM TRAUMA

When a critical incident occurs, an otherwise healthy individual’s coping skills can be shaken. After providing care, it is vital for clinicians to have the space to process their emotions about violence.

Dr. Rich Jeisy remembers the shock and trauma that he felt after treating patients in the triple shooting at Taylorville Memorial Hospital’s Emergency Department in March 2018. Afterward, he was simply staring at his computer. “I needed to chart but didn’t feel like I could focus,” says Jeisy. “All of the emotion of the last two hours seemed to come crashing down.”

Jeisy had been working an overnight when the countywide EMS radio went off, calling for response to a gunshot wound. While examining a patient for a general illness, Jeisy recalls the traumatic scene and sequence of events:

I was examining the patient when there was a commotion at the ambulance door. One of the nurses opened the door, and a firefighter walked in with two patients with gunshot wounds. They were immediately taken to our two trauma rooms with nurses taking each one. I quickly left the patient I was seeing and attended to the more seriously wounded patient. When I determined that patient was stable, I moved to the other. As I bounced back and forth between the two rooms, we received a call from EMS. They were on the scene and had a patient with a gunshot wound to the head. Amazingly, that patient was alert and responsive. I knew that we would need one of the trauma rooms, so we quickly moved one of the other patients. At the same time, our charge nurse and I declared a mass casualty event.

Jeisy says he could not be more proud of the nurses and techs who were in the ED that day.

“They did an amazing job of focusing on patient care and keeping the patients calm during a hectic situation,” he says. “They were all business and did a great job of ignoring the emotional aspect of this until everything else was done.”

Jeisy says he felt fortunate he was able to discuss the incident with his colleague and SIU classmate, Dr. James Waymack—“someone who understood the situation from a physician standpoint”—at the shift change. He then headed home to explain everything to his wife.

“Talking about it with someone who knows me so well was equally helpful,” he says.

With the nature of the work and long hours, emergency care faculty are especially watchful for how post-traumatic stress affects staff, Waymack says. Whenever necessary, a huddle or debrief will be called to capture the team that experiences a critical incident, so they can talk about everything and do immediate post-processing.

John Sutyak, MD, associate professor of surgery and director of the Southern Illinois Trauma Center, appreciates that residents have counseling available. “And we make certain they have a support system in place and encourage them to take time to care for themselves,” he says.

In addition to counseling and conversations with coworkers and family members, other popular stress relief options for health care employees include:

  • listening to music
  • getting sufficient sleep
  • eating with nutrition in mind, minimizing sugar and caffeine
  • avoiding alcohol and drug use
  • exercise, especially when alternated with relaxation

Both Waymack and Sutyak endorse exercise as a practical prescription. “When your mind’s not right, focus on your body,” Waymack said. But the crucial element is for the healer to recognize that he or she needs healing, and then to actively pursue it.

The Occupational Health and Safety Administration reports that approximately 75% of nearly 25,000 workplace assaults reported annually occurred in health care and social service settings. Workers in health care settings are 4x more likely to be victimized than workers in private industry. Episodes of workplace violence of all categories are grossly underreported: Only 30% of nurses report incidents of workplace violence; among emergency department physicians, the reporting rate is 26%. Underreporting is due in part to thinking that violence is “part of the job."

PLANTING THE SEED

USING TRAUMA-INFORMED CARE

By Jan Hill-Jordan, PhD

"Start where you are. Use what you have. Do what you can." -Arthur Ashe

If an audience standing in a conference room is asked, “If you or anyone in your family was a victim of child abuse, sit down,” a few people would sit down.

“If you know someone who was a victim or perpetrator of domestic violence, sit down” – a few more people would sit down.

“Did a friend or family member commit suicide? Please sit down.”

“If someone you know was murdered, sit.”

Eventually, nearly everyone would be sitting. Experiences with violence are widespread and the impacts can devastate individuals and even entire communities.

What we can achieve through trauma-informed care is to plant the seed that no one deserves abuse and that help is available when the person is ready.

Violence that culminates in death represents the furthest point along a continuum from verbal abuse and abusive behaviors to threats of violence to physical battering. However, approaches to prevention and intervention have traditionally been piecemeal and address a specific form of violence, such as mandatory child abuse reporting laws or anti-bullying school programs. Most health care professional ethics promote or require a proactive response to intimate partner violence (IPV). Under Illinois law, “Any person who is licensed, certified or otherwise authorized by the law of this State to administer health care in the ordinary course of business or practice of a profession shall offer to a person suspected to be a victim of abuse immediate and adequate information regarding services available to victims of abuse” (750 ILCS 60/401). However, efforts within health care systems to incorporate screening and services for patients experiencing violence have met with well-documented challenges at the institutional and provider levels. Research suggests that a multifaceted, systems-level approach produces the best outcomes for survivors.

Trauma-informed care (TIC) offers a holistic response to violence and trauma, building on research related to individual risk factors (particularly the Adverse Childhood Experiences studies), research on IPV screening, and the hard lessons learned from 50 years of victim advocacy. TIC is marked by a fundamental paradigm shift from “What is wrong with you?” to “What has happened to you, and how can we help you heal?” It is the individual’s experience of the event, not necessarily the event itself, that is traumatizing.

TIC recognizes that trauma is common across providers and patients. This can affect both the extent to which patients engage with treatment, but also how providers approach patients who disclose trauma. Our trauma experiences can also affect how we interact with colleagues who may be experiencing a violent event or traumatic memory.

Screening for specific trauma experiences, such as domestic violence, can be uncomfortable for both providers and patients. When asked in a way that sounds judgmental, the patient can feel pushed away or embarrassed. Alternatively, the provider can assume a history of trauma and provide universal education regarding the relationship between trauma and physical and emotional health. Universal education is designed to educate patients about trauma, relationship red flags, activities to help healing, and basic safety planning, in a nonthreatening manner. This approach, offered by Futures Without Violence, provides an opening for the patient to engage in further discussion, if they wish. Thus, universal education is integrally linked to an institutional infrastructure that facilitates meeting patients where they are with regard to their psychological and physical safety.

Health care professionals enter their professions with the goal of helping people achieve better health. In the case of survivors of violence, the “goal” of having the patient leave a violent situation may not be feasible at that moment. What we can achieve through trauma-informed care is to plant the seed that no one deserves abuse and that help is available when the person is ready. Changes in institutional culture and changes in practice revolve around each other in a complex dance. As individual providers change their practice, the culture changes. As the institution invests in infrastructure and training, individual practice changes. The goal is to create a safe space for both patients and colleagues to confront their trauma experiences and move toward a healthier future.

Trauma-informed care (TIC) uses an ecological framework that encourages culture and infrastructure changes at the institutional level, combined with individual-level practice change. Best practices in TIC are coalescing around an institutional-level response that includes the following:

  • Creating a safe and welcoming physical environment; using welcoming language on signage
  • A clinic environment that conveys a message that the patient can address violence and trauma with the provider; brochures and posters; perhaps a video playing in the waiting room addressing themes of trauma and health
  • Universal education for all patients regarding the relationship between trauma and health, combined with an interdisciplinary team approach that provides seamless provision of services to high-risk patients (e.g., integrating primary care and behavioral health)
  • Training providers to sensitively and safely ask high-risk patients about current violence and to recognize high-risk situations (for example, bruising, suicide threats, access to firearms by a perpetrator)
  • Training all staff (clinical and nonclinical) upon hire and at regular intervals to facilitate TIC with both patients and one another
  • Creating and encouraging a culture of staff wellness and educating staff members about vicarious trauma, burnout and the importance of self-care
  • Creating policies and procedures for patient emergencies (such as a suicide threat) and shielding confidential information from the perpetrator
  • Building partnerships with community-based agencies to facilitate “warm” referrals to domestic violence advocacy and other social services

STRESS MANAGEMENT TEAM OFFERS CARE FOR FIRST RESPONDERS

When critical incidents occur, it is the firefighter, police officer or emergency service driver who is called to the scene. Their willingness to confront dangerous situations and aid people in distress is “just part of the job.” Unfortunately, so is the post-traumatic stress that can sometimes result.

A group of volunteers in central Illinois have organized to help the people who help others. They are coordinated by Kathy Martin, LCPC, a Springfield police officer who has been doing personal and family counseling for a decade. The 11-member Sangamon Valley Critical Incident Stress Management (CISM) team is comprised of volunteers from SIU School of Medicine, other health care organizations, law enforcement, EMS and dispatchers. The team offers debriefings, counseling, education and more by appointment.

“Everyone is welcome, so individuals won’t feel singled out if they are struggling,” says Martin. “We’ll talk about the incident together. Maybe you’ll say something that can help someone else, or you’ll hear something that helps you.”

RESOURCES

Critical Incident Stress Management

SIU School of Medicine

  • Meghan Golden, LCSW, SIU representative on CISM team, mgolden49@siumed.edu; 217.747.0849
  • Christine Todd, MD, Chair of Medical Humanities and SIUSOM Center for Human and Organization Potential Wellness Leader; ctodd@siumed.edu; 217.545.4261
  • Jan Hill-Jordan, PhD, Center for Clinical Research and Department of Psychiatry, jhill2@siumed.edu; 217.545.7626

Credits:

Sara Way, SIU Medicine

Report Abuse

If you feel that this video content violates the Adobe Terms of Use, you may report this content by filling out this quick form.

To report a copyright violation, please follow the DMCA section in the Terms of Use.