The Trauma Conference Organized by Trauma Recovery And Corporate Solutions, Changi General Hospital

30 Jul 2006

By Professor K. Satku, Director of Medical Services

Venue: Changi General Hospital

Mr T K Udairam,

CEO of CGH

Prof Fock Kwong Ming

CMB, CGH

Dr Angelina Chan,

Chairperson, Trauma Conference 2006,

Distinguished Guests, Colleagues, Ladies and Gentlemen,

Good morning. It gives me great pleasure to join you at the official opening of the Trauma Conference, organized by Trauma Recovery and Corporate Solutions, Changi General Hospital. I would like to take this opportunity to welcome our distinguished overseas participants - especially Dr Victor Welzant and Dr Richard Ottenstein. I hope that you will find your stay here enjoyable and your experience pleasant.

TRAUMATIC INCIDENTS - IMPACT ON LIVES

I am an orthopedic surgeon by training. Trauma, in my field of Medicine, is usually about fractures and the fixing of broken bones. But today's conference is about disruptions of a different kind - it is about the psychological impact arising from various kinds of violence, about the mending of minds and lives broken by trauma. While the treatment and rehabilitation of physical trauma can be very challenging, the impact of psychological trauma on people's lives is at least as far-reaching - if not more, and it is frequently unrecognized or under-treated.

Everyday, we read in the newspapers of the various kinds of violence afflicted on people. Some are a result of natural disasters like earthquakes and tsunamis. Many are the acts of human violence: wars, armed conflicts, terrorist bombings, murders, rape, child, spousal and elderly abuse, and even some types of traffic accidents. These are more preventable, or regrettable, depending on how we look at it - but no community or country today has been untouched by violence.

The World Health Assembly Report of 2002 stated that each year, more than 1.6 million people worldwide lose their lives to violence. In fact, the leading cause of death today for people aged 15-44 years worldwide is violence, accounting for about 14% of deaths among males and 7% of deaths among females. However, it is the large burden of injuries - physical and mental, resulting from violence that is of even greater concern. Given also the recent rise in terrorism - the number of people afflicted with psychological trauma and post-traumatic stress disorder is set to increase. In the event of terrorist activity, the widespread availability of media reports through cable TV and the Internet will also compound the problem by fanning the flames of public fear.

PERVASIVENESS OF PSYCHOLOGICAL TRAUMA

Violence robs us of our sense of security and safety. It undermines our innate need for habitats that are orderly and predictable. Research has shown that deliberate violence creates longer-lasting mental health effects than natural disasters or accidents. The consequences for both individuals and the community are prolonged, and survivors feel that injustice has been done to them. People most directly exposed to terrorist attacks or armed conflicts have been known to be at a high risk for developing post traumatic stress disorders. For example, research in the US showed that up to 44% of Americans reported at least one symptom of post-traumatic stress disorder by 3 to 5 days post 9/11. Within two months of incident, the proportion of cases of post-traumatic stress disorder ranged from 8% to a high of 30% with the higher figures being reported for people who were physically closer to the disaster site, within the actual building, or who were injured.

These figures correlate well with those obtained from other well-known terrorist incidents such as the Oklahoma City bombings and the Lockerbie Disaster. Such is the tremendous impact of deliberate violence.

But beyond terrorism and war, there are many other types of psychological trauma afflicted by deliberate violence. These range from personal threats, intimidation, and interpersonal and community violence. In some cases, psychological trauma can arise in situations where people should feel safest - in their own homes, or as a result of deliberate violence by people they love - as in the case of family and spousal violence. The spectrum also extends to include child abuse, and abuse of the elderly. In Singapore, while community violence is controlled, we still hear of random acts of violence amongst youths, sexual assault, and violence in institutional settings such as schools and workplaces.

EMERGING INFECTIOUS DISEASE THREAT & WORKPLACE PSYCHOLOGICAL TRAUMA

On a related note, closer to home and closer to the hearts of health care professionals, some of you might recall having been personally involved in the SARS epidemic. It was a deeply stressful period for many healthcare professionals. A few of us were taken ill and admitted to the ICU - falling in the frontline of care. Those were difficult times. We lost some of our best colleagues. But while the majority of us lived to tell the tale, not all escaped unscathed.

During the epidemic, health care professionals soldiered on dutifully, side by side their fallen colleagues - despite the severely stressful conditions and despite the constant threat of personal infection; back home, back within the heartlands, many health care professionals reported being shunned by friends and neighbors. Week after week of the harrowing epidemic, with no end in sight while we were in the thick of it - large numbers of health care workers suffered from stress and fatigue.

It is therefore not surprising to note the research findings of the psychological impact of SARS amongst Singapore health care workers in a regional hospital. Two months post-outbreak approximately 20% of the survey participants suffered from post-traumatic stress disorder. These are startling and sobering figures. Another worrying trend now looms on the horizon. Just last weekend - and in this very hospital - Exercise Sparrowhawk II was played to prepare our health system for the threat of an influenza pandemic. Health care professionals turned up in full personal protection equipment in every corner of the hospital. Even though it was just an exercise, there is no doubt that the psychological trauma of SARS could have been reprised in the minds of some of us.

Given the potentially severe public health fall out in the event of an influenza pandemic, we have little choice but to be prepared. And the psychological preparation and management of our health care workers before and during a pandemic will have a significant impact on our health services during an actual crisis. It is imperative therefore for our healthcare professionals to develop the mental resilience to cope with the psychological trauma of an influenza pandemic. We must prepare for this. I look forward to the assistance of the mental health community in this matter.

These problems are in addition to the various situations in which health care workers are abused, threatened or assaulted during work. While workplace violence affects practically all sectors and all categories of workers, the health sector is at particular risk. More than half of all workers in this sector may have experienced violent or traumatic incidents at some point in their careers. Ambulance and pre-hospital emergency staff are reported to be at greatest risk ????????? with nurses being three times more likely than other occupational groups, on the average, to experience violence at the workplace.

PUBLIC HEALTH BURDEN OF STRESS & VIOLENCE

So how does one make sense of it all? Generally speaking, the response of the health sector to trauma has been primarily to treat the physical injuries. The management of psychological trauma and stress associated with traumatic events has been largely reactive. In seriously distressed cases, referrals to professionals such as counselors and psychiatrists are often too late. Available expertise also tends to focus on special interest areas such as child abuse and spousal abuse. The wider picture and the connections between different forms of violence, and their effects, are often ignored.

Coming from the public health perspective - there is an urgent need for us to understand the full impact of violence, workplace stress and psychological trauma. For beyond the obvious disruption to society and economy, violence and traumatic events exact a heavy toll on its victims' well being. Another feature is that the "costs of violence" frequently continues months and years after the initial traumatic incident, because the mental and physical injuries that result from such incidents may be chronic or even permanent.

In the United States, the annual "cost of violence" has been calculated to be close to US$35 billion. But the annual cost of stress nearly 10 times greater. Based on these figures, the annual cost of stress and violence accounts for up to 3.5% of the GDP of the United States.

It has also been estimated that together, stress and violence account for approximately 30% of the overall costs of ill-health and accidents. It is no wonder that the 1996 World Health Assembly in Geneva adopted a resolution declaring violence a leading worldwide public health problem.

LOCAL PERSPECTIVES AND EFFORTS

In Singapore, we are beginning to recognize the full impact of trauma and its psychological effects. A National CARE Management Committee has been in place for some years now to identify and coordinate the training of staff working in government ministries and statutory bodies so that they can provide psychological first aid in the event of a major traumatic incident. "CARE" stands for Caring Actions in Response to an Emergency. The Secretariat for this nation wide effort is the Ministry of Health, and to-date, approximately 2,000 CARE officers have been trained across 7 ministries and 4 statutory boards. More will follow. For the workplace, the Institute of Mental Health runs a Workplace Emotional Health Programme which actively promotes the need for better psychological health in our workplaces. There are also numerous Family Service Centres located within our heartlands operated by charities and volunteer welfare organizations that provide counseling and social support for victims of domestic violence. But more can be done.

Today, there is no organized effort to monitor the psychological health of Singaporeans following a traumatic incident, in particular the victims of rape, accidents, or other kinds of community and domestic violence. Patients treated for their physical injuries may or may not receive a referral to see the medical social worker. While not all cases will require psychiatric help, there is a need to monitor them for symptoms of post-traumatic stress disorder. This is so that those who are truly distressed can be referred for early treatment.

Psychological trauma is more amenable to counseling and treatment during the early stages, and early recognition and treatment has the advantage of preventing full-blown post traumatic stress disorder. I urge the mental health community to consider more organized ways to improve the psychological health of victims of violence and trauma. My Ministry will be glad to consider any innovative proposals that can help the plight of these unfortunate victims.

CONCLUSION

I am especially heartened to see so many professionals gathered here to learn more about the psychological issues of trauma. I understand from the organizers that today's conference is the very first in Singapore that centres specifically on psychological trauma. I would like to congratulate the organizers for their foresight and for their tireless efforts in putting together a very successful conference. On this note, I now officially declare the Conference open, and wish all of you a truly enjoyable learning experience.

Thank you.