Trauma Informed Care

We have talked quite a lot about medical personnel exposing patients unnecessarily.  We know it is harmful not only to the mental but also to the physical well-being of patients.  We have talked to those including Cindy and about my husband who have experienced this.   We have talked about patients getting medical PTSD.  We have even talked about the unjustifiable reasons medical personnel give for treating patients as though as they are not worthy of bodily respect.  But yet it keeps happening.

I have run into a couple stories this week.  One article* I was reading (which I will post on the website) give an example of an elderly lady in the hospital who needed an injection.  The female nurse entered her room and said she needed to give the injection only this time it was to be in her abdomen.  The older lady just clutched her blanket so the nurse couldn’t yank back the covers.  The nurse told the women to cooperate but the patient didn’t and the nurse had other patients to see so she noted in the patient’s file the patient was “difficult and refused the shot.”

Another example was from a man on a blog I participate in.  He has been fighting for his bodily rights for a long time.  However, during a recent hospitalization, he too fell to being unnecessarily again even after telling them and having a note in his MRs that he required medical modesty.  I don’t like the term modesty because it implies there is something mental issue the patient has rather then it being a responsibility of all medical providers to respect each and every patient’s right to bodily dignity/respect.  However, once his mind cleared from sedation it was a different story.  Nurses would come to examine his wound trying to reach for the blanket which would have exposed him unnecessarily but he would control it by holding on to the blanket and exposing only what needed to be examined.  This happened multiple times. 

Why you ask is not being exposed unnecessarily so important?  There are a couple of reason but some that come to top of the list is there is no justifiable reason for medical personnel to believe it is their right because you are a patient to expose your genitals just to show they control the situation.  The other is one that is not always obvious—both of these people from the 2 different stories are survivors of sexual abuse.  The male was a survivor of sexual abuse from his childhood and the guilty party was a female nurse.

So this begs the question of how do those like my husband who has suffered sexual abuse/assault from the hands of medical providers or anyone who has been a victim of sexual assault deal with medical encounters.  It is tricky.  My husband had a traumatic experience even though we had told them it needed to be noted in his MRs that he is a victim of medical and sexual assault with the sexual assault having been done by female care staff.  It was a very simple example of how the medical community objectifies patients as a female MA told him to “strip to his waist” for a 3 lead EKG.  First off, no one needs to strip for a 3 lead EGK nor should any medical personnel ever order a patient to “strip” and stay in the room to watch.  In addition, all patients should be offered a gown if they need to undress for an exam.  Along with that, they lied about putting his sexual abuse past in the MR as he had previously requested.  As all this brought flooding back memories of the sexual and medical assault, he just stood there.  About the time she reached towards him to unbutton his shirt I yelled at her to “stop” which froze her into place.  After I explained to her what she did and the circumstances, I asked her if she knew what Trauma Informed Care was.  She did not.  Even though I do not believe this MA’s actions was meant to harm my husband.  However, by her ignorance and because the medical practice was negligent in omitting this vital information from his MRs, he was re-traumatized thus adding more mistrust of a system that had already severely harmed him. 

The very nature of medical exams is invasive whether they are physical or mental exams.  Exams can involve asking sensitive questions, examining intimate parts of the body, delivering uncomfortable and/or painful treatments.  To add to the trauma, most of the time all of these are delivered to us by strangers.  We are told we must blindly trust all medical providers. 

Trauma Informed Care improves how healthcare providers interact with patients by espousing practices that promote a culture of safety, empowerment, and healing.  For a person who has had a terrifying life experience such as sexual assault, any medical encounter can bring back prior suffered trauma to the surface.  Just like when the MA commanded my husband to remove his shirt and then proceeded to touch him, brought back to the surface the helplessness and the assault he suffered from the other female RNs who sexually assaulted him.  This can lead to people suffering anxiety about medical encounters, flashbacks and even avoiding medical care.

Trauma Informed Care advocates that medical providers assume all patients have experienced severe trauma sometime during their life.  There are different models of Trauma Informed Care but for simplicity’s sake I will use the basic one of the “The Four R’s”.

**ronhuxley.com/2018/04/25/the-rs-of-trauma-informed-care

Some important principles of Trauma Informed Care are:

ü  Promoting atmosphere of honesty, hopefulness, and trust in the relationships between staff, between staff and administrators and most importantly between medical providers and patients.

ü  Provide a safe, secure and calm environment for all involved.  Spaces should be comfortable and welcoming to patients.  Exits must be clearly marked because traumatized patients generally have fight or flight characteristics.

ü  Nurture a working collaboration between staff and patients where everyone’s voice and choice(s) can be equally heard.  True informed consent must be practiced meaning the provider should be providing information about choices, options, risks, etc. so the patient trust the relationship is open and honest.  Medical providers should encourage patients to ask question such as what the procedure entails.  This is especially true with sexual assault survivors as it can re-traumatize them at the thought of having intimate by the gender of their abuser.  Traumatized patients can also be very frightened at the prospect of sedation as it leaves them vulnerable and unable to have control which having control is generally vital for survivors.

ü  Providers need to recognize and understand that not everyone shares their own culture and belief system.  No provider should tell any patient the need for bodily privacy is a mental issue for the patient and should not use dismissive words such as “we have seen it all before” etc.

ü  Medical providers must understand how prior trauma can impact future care and use that to assume all patients have suffered trauma at some point during their life.

Medical staff should understand a patient may have a bad reaction to whatever they are doing it is not personal but that the person is responding in the best way they can based on whatever trauma they have suffered in the past.  This is key.  My husband froze but some may become visibly agitated or act out.  Many men when faced with being exposed to female RNs become “flirty” because they are nervous about the situation.  The RN may think the patient is sexually harassing them when in reality this a mechanism used by the patient for self-preservation.  The medical provider needs to act in a respectful manner and do their best to diffuse the situation. 

Here are some important tips for medical providers in order to carry out Trauma Informed Care protocols in all patient encounters:

ü  Medical provider must always explain and ask for permission before touching any patient.  They should not assume they have rights they don’t really have just because a patient is there.  Going along hand-in-hand with this, they need to make sure the patient (especially during vulnerable situations ie. genital exam) feels safe by making sure there are no interruptions such as a someone entering the room thus unnecessarily exposing the patient.  Before bringing anyone other than themselves in the room, they must explain and identify to the patient who will be there, why and seek permission before the patient is placed in the vulnerable position of being undressed. If a medical provider fails to do this, it can cause a deer in the headlight reaction in many patients especially those who have been sexually harmed.  If a patient reacts in a negative manner, the medical should be responsive and work towards remedying the situation.  Medical providers always need to be mindful and respectful. 

ü  Medical providers always need to be patient by building trust and help make the patient feel safe.  They need to be mindful about the tone of their voice and the language in which they converse.  The MA should have never said “Strip” but rather should have said, “In order to evaluate your heart, an EKG is needed because…. “Would you like to put on a gown while I step out of the room or can you unbutton your shirt for access?”  If the he had chosen to unbutton his shirt she should have turned away while he did it.  This are small things for most patients but for a survivor of abuse it is important for them to remain in control of their body.  Medical providers must make patients feel like the provider needs to be elsewhere or is not engaged in the patient.

ü  Medical providers must not bully or command their patients into accepting treatment or medical advice.  Medical providers must explain why something should be done.  They should not use words such as “you must, order, etc.” as these words infer a power imbalance.   Many patients especially those who  have suffered trauma especially sexual may have a negative reaction to this.  Also, medical advice is just that:  advice.  It is the patient’s decision as to whether they follow it or not.  Whether they follow will generally depend on how well its positive merits are explained by the medical provider.

ü  Listen to the patient.  Even though the medical provider may have time constraints, they need to listen carefully to what the patient is saying and what is not being said.  This may be done verbally or by gauging a patient’s reactions.  If a patient looks uncomfortable or frightened, the medical provider needs to stop and ask if the patient is okay and what needs to be done.  They should always then ask the patient if they want them to proceed with the exam. 

ü  Medical providers should always keep their word and if they fail to do so, admit it so the patient knows they do not think they are superior to them.

ü  Always recognize the patient’s autonomy.  Medical providers must not fall into the routine of “Because I am the medical provider, you must do what I say without question.”  The medical provider should beware they are only a part of the patient’s healthcare teams of which the patient is the captain.  It is the medical provider’s job to be a tour guide (so to speak) guiding the patient through the complex system of healthcare.  They are there to provide options and choices which would ultimately lead to treatment/care.  Patients are not obligated to follow orders.  Patients need to beware of all the options and risk so they become responsible participants in their own healthcare. 

ü  This cannot be said enough, if a patient looks uncomfortable or frightened, the medical provider must stop and ask them if the patient is okay and what can they do to help the patient.   Medical provider should ask again if the patient wants to proceed with the exam.  If at any point a patient tells a medical provider to stop, they must stop or else it is medical assault.

For patients, it is entirely up to you whether or not you share with any medical provider your story of trauma.  My husband has specifically asked for notations to be made in his Medical Records that he has suffered both medical and sexual assault in the past.  He has asked for no female care staff in any action requiring intimate access or exposure. He also insists that I be present for any and all medical encounters as he has no trust in them.   He has also asked for Trauma Informed Care protocol to be used.  All patients have this right but not all medical know what Trauma Informed Care is and some don’t think they should have to practice it because after all, they are a medical provider and you are there for their expertise.  He also has a very detailed Advanced Directive along with wearing a piece of jewelry identifying vital information.   For him, these are vital steps he needs to feel he is control of his body.

**journals.lww.com/ajnonline/fulltext/2019/10000/when_a_childhood_sexual_abuse_history_influences.7.aspx