Medical Trauma
Medical trauma happens when a person, especially a child, feels that something painful or scary is happening to them and they have no choice, and no ability to escape or buffer the fear or pain. This can trigger the brain to release stress hormones and cause this event to be saved in memory by the brain in a way similar to events that cause PTSD. The memories can be suppressed or fractured, causing a physical stress response to happen in the future when something reminds the person of this event. Sometimes this stress response continues after the event is over, as if it is still happening all the time. Medical trauma could also happen when a child has a near death experience, such as a bad asthma attack or near drowning causing a hospital stay.
Co-Regulation
Having a trusted parent or care giver present not only provides support and reassurance to the child, but it enables a child to tolerate previously intolerable stressors. The parent is the buffer for the child. We know infants are externally regulated by the adult caring for them. (Bernier et al, 2010) They are completely dependent for comforting, calming, swaddling, etc. Young children are in a developmental stage of co-regulating with an attachment figure or trusted adult. They look to that person to see if what is happening is okay, can be tolerated, or if they should be worried and upset. When a caregiver is unable to stay overnight with a child in a hospital room, we need to be concerned and evaluate our procedures for this situation. A child should be upset at being left alone. If the child is not upset, that is cause for concern, as that child may have already internalized that when they cry, no one will come to meet their needs. Therefore. they stop crying. This internalization can affect their view of the world for the rest of their lives, if it goes unnoticed and untreated.
Procedures
Our common practice, especially in hospitals, has been to take young children away from their parents prior to performing procedures, introducing anesthesia, getting imaging studies, etc. We need to take a hard look at these procedures and consider if they were made for our own convenience or even just because that is how we have always done it. We must keep in mind that we are causing distress, potentially greater than the physical pain itself, while removing the natural buffer(the attachment figure) from the child at the same time. If the patient is conscious, regardless of the age, then a parent, or trusted adult, should almost always be encouraged to be present, calm, and supportive of the patient. The parent should be present until the child is unconscious in cases of anesthesia use. If the parent needs a staff member to support them, in order to remain calm, that should also be possible in a trauma informed healthcare setting. With explanation and coaching, most parents should be able to be supportive of their child in these situations, and the investment of time is minimal when compared to the benefit to the child.
Pain Management
Historically, the health care establishment has denied that infants could feel pain. Unfortunately, surgery was performed on infants without anesthesia, only a paralytic was given, as recently as the 1980’s. There are remnants of this thinking still present today. When healthcare professionals believe that a painful procedure will be quick and the child won’t remember it, they may feel there is no need to provide pain management or local anesthetic. We are starting to understand that although the child may not remember the exact procedure, the body and brain may have a stress response that is then recorded by the brain. This stress response may affect how the child experiences pain, or pain-relieving medications, in the future. They also may have “triggers”, similar to PTSD, such as having a physiologic panic response when held down in a manner similar to the procedure. Adults can understand what is happening and use coping skills to deal with pain, but infants and children have not developed coping skills yet. Let’s remember this and give them more accommodations for pain management than we would give an adult. Let’s work together to move medicine forward.
Screening for ACEs
For those with chronic health and social issues, an ACE score may be helpful in determining the best course of treatment. Often treating the physical manifestations of trauma will miss the root problem. Treating trauma specifically with mental health interventions can allow a person to move beyond the physiologic manifestations of trauma. Frequently adults with high ACE scores are also parents or caregivers of young children and teens. By treating their trauma, or toxic stress, you are also reducing the likelihood that their children will experience inter-generational abuse, neglect, and family dysfunction. A multi-generational approach is needed to break the cycle of trauma and deliver improved health and social outcomes for future generations. There is no current consensus or national recommendations regarding screening. However, each community and practice can work in a collaborative way with staff and patient advocates to decide what type of screening and intervention may be most helpful in their location. Using a general screening question like the one below may be an easy place to start. And becoming familiar with the Treatments page will help you feel more confident that you will know what to do with positive answers.
Treatment
The ACE questionnaire screening tool should not be thought of as a diagnostic tool. Many people have high ACEs, but are nevertheless resilient and become healthy productive members of society. The science of resilience factors is still emerging. Many individuals who have resilience factors in place endure great adversity with little physiologic or social impairment. Conversely, many people with low ACEs have chronic health conditions or other mental health or social issues. The ACEs questionnaire is a screening tool used by healthcare providers to discuss the effects of adversity on the health and development of children. It can be a springboard to referral for specific treatments which would be beneficial to the patient. It also provides opportunities to encourage positive parenting practices and other activities that build resilience and relieve stress. For more information on treatment and resilience practices please see our Treatments page.
Research
When you screen for ACEs, and develop strategies for interventions when they are positive, you move the practice of medicine forward by adding to the body of evidence available about ACEs and interventions. This information can lead to better decision making for organizations and systems of healthcare, better community and social services, policy, education, and justice systems. There is room for much more research into interventions and resilience as well as how patients with high ACEs may need different medical treatments from those with low ACEs in order to have the best health outcomes.
Secondary Traumatic Stress
Secondary traumatic stress is the emotional duress that results when an individual hears about the firsthand trauma experiences of another. The essential act of listening to trauma stories may take an emotional toll that compromises professional functioning and diminishes quality of life. Individual and supervisory awareness of the effects of this indirect trauma exposure is a basic part of protecting the health of the worker and ensuring that patients consistently receive the best possible care from those who are committed to helping them.
Here is a link to my article on Secondary Post-Traumatic Stress published by Op-Med - LINK
Post Traumatic Stress is a Normal Response to an Abnormal Situation.
Coping Strategies
Anything that helps reduce your cortisol response can help reduce or prevent secondary trauma.
1. Exercise
2. Mindfulness/Meditation - apps like YouTube, Calm, Headspace, MoodTools, Abide
3. Grounding exercises
4. Tactical Breathing
5. Spend time with family
6. Spend time with pets or animals
7. Hobbies
8. Gardening, Hiking, time in nature
9. Journaling - If you don't like to write a lot, you can write 3 things you are grateful for, 3 good things that happened today, and 3 things you are looking forward to tomorrow.
10. Prayer
11. Connecting with Faith Communities
12. Talk to a colleague who understands
13. Humor, comedy
Make a Plan for Coping
Every day - Exercise, mindfulness or prayer
At work - talk to a colleague after your shift
After work - Spend time with pets or family, watch a comedy on TV
Know the resources your workplace or community has in place if you become distressed or have your mood affected by traumatic experiences or secondary trauma. You should not have to suffer alone.
Medical trauma happens when a person, especially a child, feels that something painful or scary is happening to them and they have no choice, and no ability to escape or buffer the fear or pain. This can trigger the brain to release stress hormones and cause this event to be saved in memory by the brain in a way similar to events that cause PTSD. The memories can be suppressed or fractured, causing a physical stress response to happen in the future when something reminds the person of this event. Sometimes this stress response continues after the event is over, as if it is still happening all the time. Medical trauma could also happen when a child has a near death experience, such as a bad asthma attack or near drowning causing a hospital stay.
- Trauma Through a Child's Eyes, Levine and Kline, 2006, and The Body Keeps the Score, van der Kolk, 2014
Co-Regulation
Having a trusted parent or care giver present not only provides support and reassurance to the child, but it enables a child to tolerate previously intolerable stressors. The parent is the buffer for the child. We know infants are externally regulated by the adult caring for them. (Bernier et al, 2010) They are completely dependent for comforting, calming, swaddling, etc. Young children are in a developmental stage of co-regulating with an attachment figure or trusted adult. They look to that person to see if what is happening is okay, can be tolerated, or if they should be worried and upset. When a caregiver is unable to stay overnight with a child in a hospital room, we need to be concerned and evaluate our procedures for this situation. A child should be upset at being left alone. If the child is not upset, that is cause for concern, as that child may have already internalized that when they cry, no one will come to meet their needs. Therefore. they stop crying. This internalization can affect their view of the world for the rest of their lives, if it goes unnoticed and untreated.
Procedures
Our common practice, especially in hospitals, has been to take young children away from their parents prior to performing procedures, introducing anesthesia, getting imaging studies, etc. We need to take a hard look at these procedures and consider if they were made for our own convenience or even just because that is how we have always done it. We must keep in mind that we are causing distress, potentially greater than the physical pain itself, while removing the natural buffer(the attachment figure) from the child at the same time. If the patient is conscious, regardless of the age, then a parent, or trusted adult, should almost always be encouraged to be present, calm, and supportive of the patient. The parent should be present until the child is unconscious in cases of anesthesia use. If the parent needs a staff member to support them, in order to remain calm, that should also be possible in a trauma informed healthcare setting. With explanation and coaching, most parents should be able to be supportive of their child in these situations, and the investment of time is minimal when compared to the benefit to the child.
Pain Management
Historically, the health care establishment has denied that infants could feel pain. Unfortunately, surgery was performed on infants without anesthesia, only a paralytic was given, as recently as the 1980’s. There are remnants of this thinking still present today. When healthcare professionals believe that a painful procedure will be quick and the child won’t remember it, they may feel there is no need to provide pain management or local anesthetic. We are starting to understand that although the child may not remember the exact procedure, the body and brain may have a stress response that is then recorded by the brain. This stress response may affect how the child experiences pain, or pain-relieving medications, in the future. They also may have “triggers”, similar to PTSD, such as having a physiologic panic response when held down in a manner similar to the procedure. Adults can understand what is happening and use coping skills to deal with pain, but infants and children have not developed coping skills yet. Let’s remember this and give them more accommodations for pain management than we would give an adult. Let’s work together to move medicine forward.
Screening for ACEs
For those with chronic health and social issues, an ACE score may be helpful in determining the best course of treatment. Often treating the physical manifestations of trauma will miss the root problem. Treating trauma specifically with mental health interventions can allow a person to move beyond the physiologic manifestations of trauma. Frequently adults with high ACE scores are also parents or caregivers of young children and teens. By treating their trauma, or toxic stress, you are also reducing the likelihood that their children will experience inter-generational abuse, neglect, and family dysfunction. A multi-generational approach is needed to break the cycle of trauma and deliver improved health and social outcomes for future generations. There is no current consensus or national recommendations regarding screening. However, each community and practice can work in a collaborative way with staff and patient advocates to decide what type of screening and intervention may be most helpful in their location. Using a general screening question like the one below may be an easy place to start. And becoming familiar with the Treatments page will help you feel more confident that you will know what to do with positive answers.
Treatment
The ACE questionnaire screening tool should not be thought of as a diagnostic tool. Many people have high ACEs, but are nevertheless resilient and become healthy productive members of society. The science of resilience factors is still emerging. Many individuals who have resilience factors in place endure great adversity with little physiologic or social impairment. Conversely, many people with low ACEs have chronic health conditions or other mental health or social issues. The ACEs questionnaire is a screening tool used by healthcare providers to discuss the effects of adversity on the health and development of children. It can be a springboard to referral for specific treatments which would be beneficial to the patient. It also provides opportunities to encourage positive parenting practices and other activities that build resilience and relieve stress. For more information on treatment and resilience practices please see our Treatments page.
Research
When you screen for ACEs, and develop strategies for interventions when they are positive, you move the practice of medicine forward by adding to the body of evidence available about ACEs and interventions. This information can lead to better decision making for organizations and systems of healthcare, better community and social services, policy, education, and justice systems. There is room for much more research into interventions and resilience as well as how patients with high ACEs may need different medical treatments from those with low ACEs in order to have the best health outcomes.
Secondary Traumatic Stress
Secondary traumatic stress is the emotional duress that results when an individual hears about the firsthand trauma experiences of another. The essential act of listening to trauma stories may take an emotional toll that compromises professional functioning and diminishes quality of life. Individual and supervisory awareness of the effects of this indirect trauma exposure is a basic part of protecting the health of the worker and ensuring that patients consistently receive the best possible care from those who are committed to helping them.
Here is a link to my article on Secondary Post-Traumatic Stress published by Op-Med - LINK
Post Traumatic Stress is a Normal Response to an Abnormal Situation.
Coping Strategies
Anything that helps reduce your cortisol response can help reduce or prevent secondary trauma.
1. Exercise
2. Mindfulness/Meditation - apps like YouTube, Calm, Headspace, MoodTools, Abide
3. Grounding exercises
4. Tactical Breathing
5. Spend time with family
6. Spend time with pets or animals
7. Hobbies
8. Gardening, Hiking, time in nature
9. Journaling - If you don't like to write a lot, you can write 3 things you are grateful for, 3 good things that happened today, and 3 things you are looking forward to tomorrow.
10. Prayer
11. Connecting with Faith Communities
12. Talk to a colleague who understands
13. Humor, comedy
Make a Plan for Coping
Every day - Exercise, mindfulness or prayer
At work - talk to a colleague after your shift
After work - Spend time with pets or family, watch a comedy on TV
Know the resources your workplace or community has in place if you become distressed or have your mood affected by traumatic experiences or secondary trauma. You should not have to suffer alone.
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