On a cold March morning earlier this year, Roz Pichardo was driving into work on Kensington Avenue when she heard someone scream from outside her car window — “I need Narcan!”
With a rush of adrenaline, she pulled her car to the side of the road and parked near the scene, where a man was lying on the ground. Instinctively, she collected her Narcan — a brand name for naloxone, an opioid overdose reversal medication — and other supplies without looking to identify who was overdosing.
As she got out of her car and knelt beside the unconscious man, Pichardo realized she was peering down into the face of her cousin.
“I froze for a second and then my instincts kicked in again,” said Pichardo, a lifelong resident of Kensington. “It was nerve-racking. I was in tears because he wasn’t responsive, even until he got to the hospital.”
Pichardo administered four doses of naloxone to her unresponsive relative — an amount that she said is uncommonly high — and feared for his life as paramedics rushed to their location. But because of Pichardo’s intervention, her cousin lived to see another day.
The overwhelming number of overdoses in Philadelphia — there were an estimated 3,191 overdose deaths alone from 2016 to 2018, and the very public nature of the addiction crisis in Kensington — has motivated many neighborhood residents and community members to carry naloxone. In the medical field, these individuals are referred to as “zero responder,” or bystanders who step in to reverse the effects before medical professionals get to the scene.
Residents like Pichardo, along with organizations like Prevention Point Philadelphia, The Kensington Storefront, SOL Collective, and even the Free Library of Philadelphia, have been leading the charge in overdose reversals in the neighborhood. So have people who use drugs, who are often trained and equipped with naloxone by harm reduction organizations like Prevention Point and SOL Collective.
But after reversing more than 100 overdoses in the last couple of years — in one case, three in one hour — Pichardo is fearful she is becoming numb to seeing her neighbors and loved ones so close to death. She is also fearful for those like her in the neighborhood, who regularly experience the trauma of witnessing and reversing overdoses, too.
Secondary traumatic stress
The effects of trauma on people experiencing violent or life-threatening events have been well-documented. However, Pichardo feels that the trauma experienced by people like caregivers, social workers, therapists, doctors, and in some cases, bystanders who are assisting people through these events, hasn’t gotten enough attention.
“This kind of work will drain you,” Pichardo said. “You will be struggling mentally, physically, and emotionally if you don’t keep yourself in check.”
Mental health experts describe what Pichardo and other bystanders who step in to respond are experiencing as “secondary traumatic stress.”
“Secondary traumatic stress is a term that we reserve usually for professionals in the business that come across trauma on a regular basis, like firefighters, nurses, police officers, and first responders,” said Dana Branson, a licensed clinical social worker and vicarious trauma researcher at Southeast Missouri State University. “They are people struggling with their desire to help but feel like there’s too much need for them to do it all, and they become overwhelmed.”
According to the research of Charles R. Figley, who developed the term in 1995, secondary traumatic stress is “an extreme state of tension and preoccupation with the suffering of those being helped.” Figley found individuals who engage in compassionate relationships with clients and are exposed to their traumas, like the people who Pichardo and Branson mentioned, will often absorb the stress of their clients’ experiences.
Those experiencing secondary traumatic stress may be frequently “on guard,” easily startled, have nightmares or repeated thoughts about a particularly traumatic situation or feel the secondary trauma of a patient’s experience as their own, according to the Centers for Disease Control and Prevention. And according to the Substance Abuse and Mental Health Services Administration, an estimated 30 percent of first responders experience behavioral health issues, including depression and post-traumatic stress disorder. The rate for the general population is about 20 percent.
“You literally feel like you’re fighting a battle,” said Rohit Mukherjee, a Drexel University medical student and member of the harm reduction organization SOL Collective. “You can only deal with so much as a person, but we are kind of forced to do it a lot.”
Mukherjee said burnout is a common side effect that responders have to deal with regularly. Recently, he was shaken up for about a week after finding someone who appeared to have died from an overdose. Mukherjee attempted to revive her anyway, knowing she likely couldn’t be resuscitated. She died.
“It can be triggering doing that overdose reversal,” he said. “And I’m a privileged med student, but there are other people from the most marginalized groups — active drug users — that are reversing over and over and losing people, too.”
Compassion fatigue in medical professionals
Emergency physicians who treat patients with traumatic injuries have described a common result of this secondary trauma as “compassion fatigue.”
Joseph D’Orazio, an emergency physician at Temple University Episcopal Hospital on Lehigh Avenue near Front Street, said compassion fatigue is something not unique to the medical field as it also affects police, firefighters, and other human service workers.
A caregiver’s first reaction to a traumatic event will naturally bring an adverse emotional reaction, he said, but after experiencing the same event on a regular basis, the experience becomes normalized to the caregiver.
“If we continue to feel terrible about it, we wouldn’t be able to come back to work,” D’Orazio said. “We get this desensitization to the problem that eventually leads to losing the emotional attachments to the event that’s happening.”
However, he added that, “If I develop compassion fatigue, it actually hinders my ability to care for people.” All too often, physicians are expected to compartmentalize traumatic experiences to move to the next patient, he said.
“It’s not easy when you see it on an hourly basis to continue to have the compassion and emotional experience that goes along with an event like an overdose,” D’Orazio said.
D’Orazio said compassion can be regained through talking about those traumatic experiences, looking at a problem from a different angle, and empathizing with a patient’s issue. Temple’s hospitals try to encourage hospital staff to regain compassion for those who experience overdoses and substance use disorder through “debriefings,” in which they take to take time to reflect after an adverse emotional experience, he said.
Resilience training for Philly’s workforce
For the last 25 years, the discussions around trauma experienced by caregivers have stayed mostly within the research and medical fields, D’Orazio and Branson said. It wasn’t until recently that medical institutions, nonprofits, and public agencies have reacted to this issue.
In Philadelphia, a subcommittee of the Adverse Childhood Experiences Project, which includes more than 100 pediatric, behavioral health, education, law, and philanthropic professionals, started looking into adding resilience training to city workforces through the #TakeCarePHL initiative, Generocity reported in February. Resilience training teaches people to adapt well and recover quickly after stress, adversity, trauma or tragedy, according to Mayo Clinic.
In December, City Council’s Committee on the Disabled and Persons with Special Needs, chaired by at-large councilman Derek Green, held a hearing to discuss the trauma city first responders experience.
“Our paramedics, emergency medical technicians, and firefighters respond to various types of medical incidents which include shootings, stabbings, suicides, fire deaths, and injuries to children,” Crystal Yates, the assistant deputy commissioner of EMS for the Fire Department, testified at the hearing. “The stress associated with responding to traumatic events can have a cumulative effect on first responders.”
“As the number of annual responses increases, Philadelphia’s emergency medical services personnel undoubtedly face the possibility of provider fatigue, secondary stress, and burnout,” she added.
With funding from a grant from SAMHSA, the city will soon add resilience training for its firefighters and EMS providers. A portion of the nearly $1 million grant will help the Fire Department partner with the Department of Public Health and the University of Pennsylvania for the program.
Penn will offer the resiliency training to a group of people in the Fire Department’s employee assistance program and a few other groups, department spokesperson Kathy Matheson wrote in an email to Kensington Voice. The people trained by Penn will then train others as necessary.
The other stakeholders will include Fire Department groups supporting Black and Latinx firefighters and EMS personnel, Matheson added.
Resources for people who respond to overdoses
In the case of a traumatic event, like the loss of a patient, hospital staff will have time to reflect, and some nonprofits like Impact Services have implemented “safety plans” to address the mental health of their staff. These plans involve employees checking in with their coworkers, knowing who they can look to for help, and engaging in self-care throughout their days.
But in Kensington, where bystanders who respond to overdoses aren’t necessarily a part of a nonprofit or public agency, there aren’t resiliency trainings, counseling services, or support groups for them to work through the stress.
While Philadelphia has continued its effort to provide resources to citizens affected by the overdose crisis, there is still a need for resiliency programs in the nonprofit and public sector, Pichardo said.
As a part of Mayor Jim Kenney’s response to the overdose crisis in the city, the Philadelphia Resilience Project has allocated funding for citywide naloxone trainings and supplied community groups with the medication. Allison Herens, the harm reduction coordinator for the city, said secondary traumatic stress or ways to cope with the trauma of reversing overdoses are not currently discussed in the city’s naloxone trainings, but is something the city will be investing in through resilience trainings in the future.
“I think these are really important things to be thinking about,” Herens said. “Thinking about how we could better prepare people for these incidents and how you might advise them to deal with any trauma and emotional feelings about the experience.”
“Because we recognize it can be emotional, it can be triggering, it can be hard,” she added.
Kenney’s Opioid Emergency Response executive order also called for the Office of Community Services “to engage the public and mobilize community response by engaging additional non-profit and for-profit partners, recruiting volunteers and raising funds to support,” objectives like reducing overdose deaths and distributing naloxone.
Additionally, the mayor’s Five Year Financial and Strategic Plan for Fiscal Years 2020-2024 included a proposal for $3 million in neighborhood community services to help address the overdose crisis in Philadelphia, which Pichardo and others believe could be used for resilience programs for the Kensington community.
Meanwhile, Pichardo has expressed interest in gathering bystanders who respond to emergencies like overdoses to talk about their experiences in Kensington. In a field where there isn’t much attention paid to the trauma they experience, she believes there needs to be a space where healing can be done together.
“Watching people sleep in respite — that’s trauma,” Pichardo said. “Watching people shoot up every day — that’s trauma. Even listening to the stories on how they got there is trauma. Those [experiencing this secondhand] are the folks that we need to get to the table and say, ‘How can we heal?’”
“We have to learn from one another and we have to be able to get input from one another,” she added. “I think it’s important for us to stay afloat.”
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Editor: Jillian Bauer-Reese / Story Designer: Jillian Bauer-Reese / Translator: Kristine Aponte
