Chapters Transcript Trauma Informed Care: The Impact of Physical and Psychological Trauma Course: Interdisciplinary Palliative Care Conference 2024: Geriatric Trauma and Palliative Care Yes, a little bit about why I'm here today. Um, I'm the director of mental health, uh, for the World Trade Center Environmental Health Center which treats community members exposed to the terrorist attack on 9/11, 2001. Our clinic is an integrated. Medical and mental health clinic and since we're directly treating folks who are exposed to a discrete environmental and psychological trauma, the interface between medical and psychological is knit into the very fabric of what we do. I have no conflicts to report. So what is trauma? We're gonna talk about psychological trauma here. Um, the term trauma is, is used very broadly these days in popular culture. There's a phenomenal trend right now, uh, in the normalization and acceptance of mental health struggles that people face. There's also been a a broadening of the meaning of the word trauma. Um, in common parlance, there's a subjective component to trauma, uh, what for one person may be traumatizing may not be for someone else, and this is identified and defined by the individual. Um, the term is sometimes used these days somewhat loosely, however, for example, to include experiences that were mildly uncomfortable or disagreeable to an individual. Language certainly does change and evolve, but we wanna be on the same page for this talk about what we refer to when we talk about trauma. So the diagnostic and Statistical Manual of Mental Health Conditions, the DSM-5, uh, for the sake of diagnosing stress disorders, um, has a very strict definition of trauma that requires either firsthand or very close secondhand exposure to death, threatened death, serious injury, or sexual violence. The Substance Abuse and Mental Health Services Administration, SAMSA came up with a working definition of trauma that could be relevant to public health agencies and service systems. Uh, and they came up with this from talking to survivors, uh, talking to practitioners and researchers, and they stated that individual trauma results from an event, a series of events, or a set of circumstances that is experienced by an individual. as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. It's a mouthful, uh, but, um, again experienced by, uh, what is experienced by one again, uh, as traumatic is not experienced necessarily by somebody else's being so, um, and there needs to be a lasting effect that is negative. Um, and, and note here too that this definition is quite a bit looser than the DSM-5 definition. So, um, in their list they include, for example, childhood neglect, poverty, racism, living with a family member with a mental health or substance abuse disorder. And starting around 2011, uh, injury, life-threatening disease, and invasive medical interventions were also uh being considered and recognized as events that could be experienced as traumatic. There are a few different kinds of experiences considered to be uh psychologically traumatic. Some of them are discrete events, uh, one time events such as a flood or a violent attack, uh, in invasive medical treatment, and others can be chronic and pervasive such as neglect, abuse, war, poverty, uh, they're also not mutually exclusive, um, things can be in both categories as well. So with this more inclusive definition, um, I, I'm sure many of you recognize uh experiences that our patients have had as well as we ourselves. Um, an important study was published in 1998 that looked at adverse childhood experiences in a large medical system population. For the purposes of the study, 10 experiences were identified in 3 different categories as traumas that one might experience in childhood abuse, neglect, household dysfunction. And you'll notice that many of these are in line with the Samsa definition. 17,000 adults were surveyed in San Diego within the Kaiser Permanente system. 62% of those surveys had at least one adverse childhood experience. 1 in 8 people had 4 or more of these adverse childhood experiences. I'm just gonna go back there for a second for you to take a look at that and consider that 1 in 8 had 4 or more. And uh this information was then analyzed with the medical records, and they found that compared to those with no adverse childhood experiences, if a person had 4 or more, they were twice as likely to have heart disease, diabetes, cancer, twice as likely to smoke, 7 times as likely to abuse alcohol, 12 times as likely to attempt suicide, and their life expectancy was 20 years shorter than those with no adverse childhood experiences. And a study based on that one was done on an urban population as well. Um they uh used those adverse childhood experiences we, I showed you those uh three different categories, and they added an extra urban measure of uh adverse childhood experiences, um, that included neighborhood safety and trust if people felt so safe in their neighborhood, felt other people were looking out for them, it's that kind of thing, bullying. Uh, witnessing violence, racism, and foster care. Foster care was, were you ever in it or not? And this study found that 83%, or more than 4 out of 5, had at least one adverse childhood experience compared to the Kaiser study, uh, with 62%. Um, 37% had 4 or more adverse childhood experiences compared to the Kaiser study at 13%. Um, we know from the, the 2018 results of the behavioral risk factor surveillance system that's the BRFSS for any of you guys who know that, um, that one's risk for adverse childhood experiences are elevated for populations who identify as black, Hispanic, multiracial, gay, lesbian, or bisexual, have less than a high school education, have uh are lower income or are unemployed and unable to work. So whether it's a trauma in childhood or a trauma experienced as an adult, one can develop a post trauma stress disorder. Um, acute stress disorder is what it's called if a person has functionally impairing symptoms, uh, within 3 days of a trauma and no more than a month, uh, and, um, I'm not gonna focus too much on this because the symptoms are largely the same. I will talk about it a little bit later, however, but we're gonna focus mostly on, uh, post-traumatic stress disorder. Which is a condition that involves alterations in various physiological and psychological processes. It's associated with functional and cognitive impairment, psychiatric and medical comorbidities, and increased mortality and suicidal thoughts and attempts. OK, so how is a formal diagnosis of PTSD made? Well, I spoke before, uh, a little bit about, uh, what, what a trauma event is for the DSM, um, it has to be direct or very close exposure to real or threatened death, injury, or sexual violence. Symptoms have to last for more than one month. It has to cause significant impairment, um, and it can't be attributable to something else, substance abuse, or medication, uh, a medical illness. And there are 4 different groupings of symptoms we call those symptom clusters, um, and you need one from a couple of these categories, 2 from a couple of the other categories in order to, to make a uh a diagnosis, but I'm gonna go through some of these cluster the all all the clusters actually, uh, because, um, you will probably uh uh identify many of these as things that you've seen your patients experience. So, the first cluster intrusion symptoms, some we call that re-experiencing, um, recurrent, involuntary and intrusive thoughts about a trauma. Distressing nightmares about it, flashbacks, um, which is a particular phenomenon, uh, in which the individual may feel or act as though the trauma is happening right now, the thing from their history, it's, it's considered a dissociative, uh, uh, process, um, intense or prolonged psychological distress when reminded of the trauma and physiological reactivity like increased heart rate, uh, blood pressure, that kind of thing. Avoidance of thoughts or memories about the trauma and avoidance of any reminders that could bring up thoughts or memories of the trauma. Negative alterations in mood or cognition feels like negative beliefs and thoughts about oneself, about the world after a trauma, blaming oneself or blaming others. Uh, for the trauma, negative emotional states such as fear, guilt, anger, shame, anhedonia, a diminished ability to feel any pleasure at all, um, feeling alienated, estranged, or detached from others, inability to experience positive emotions such as happiness or love. And alterations in arousal and reactivity we often call this hyperarousal, um, irritable or aggressive outbursts with little or no provocation, reckless or self-destructive behavior, hyper vigilance, exaggerated struggle response, problems in concentration, and sleep disturbances, uh, this refers to specifically like um difficulty falling asleep, staying asleep, that kind of thing. OK, so after trauma, PTSD occurs in approximately 5 to 10% of the population. Studies have shown that rates vary very much depending on the particular population that's being considered, um, but it's important to note that not everybody develops PTSD. Um, but we've been talking here about a strict definition, OK? So like what's according to the SM, how you make a diagnosis or not. Um, the reality is rarely as black and white as that. Um, presentations are often sub threshold with some but not all of the diagnostic criteria met. And those with chronic traumatic experiences in childhood, for example, um, through, uh, you know, some of those exposures, as we know before, um, don't necessarily meet the criteria, uh, for the strict diagnosis, um, but their presentations can often be the same. Um, one of the potential differences that can be seen, uh, between, um, a chronic trauma, uh, presentation versus an acute trauma presentation, not always, but sometimes can be seen in personality structure. When people experience chronic trauma, especially in childhood, a personality structure can sort of, um, uh, develop to adapt to the situation. Um, and that structure may have been very necessary at that time for survival, um, but it might be maladaptive later on, um, in other relationships that a person has or that kind of thing. This is a little bit less likely to happen when a person has a discrete trauma in their adulthood because personalities are usually rather well formed, but it absolutely can happen as well. OK, here are some of the risk factors for developing PTSD. These are based on research done primarily on US samples. One is more likely to develop PTSD if one is female, younger, less educated, of lower SES of African American or Hispanic race ethnicity, if one has had a prior trauma, uh, or an adverse childhood experience, if the trauma was very severe, if one had pre-morbid psychiatric disorders. And if one has a lack of social support. OK, a great deal of research has been done on PTSD. Tons of research is being done on PTSD, um, and, uh, specifically a lot has been done on, uh, PTSD and associated conditions. Um, remember back to the studies, uh, that, uh, looked at adverse childhood events and associated medical conditions in adulthood. Um, PTSD has been found to be associated with what you see here, um, and more as well. For example, inflammation, cardiovascular disease, stroke, diabetes, asthma, cognitive impairment, these associations are generally independent of socio demographic factors and independent of depression. OK, so what do we know about the pathophysiology of PTSD? It's very complex and it's not well understood, um, but just to touch on a little bit, uh, of the current research, the hypothalamic pituitary adrenal axis, the HPA axis, um, is a, uh, uh. Ple system that regu regulates the stress response in PTSD some research shows that cortisol levels um are high uh some research shows that cortisol levels are low, uh, but the cortisol dysregulation, uh, impacts metabolism and inflammation. corticotropin releasing factor CRF is high, resulting in an increased sympathetic response, increased heart rate, blood pressure, that kind of thing. Um, the neuro uh neurotransmitters, um, such as, uh, serotonin, GABA, glutamate are imbalanced, uh, impacting emotion, memory, mood regulation, neurophysiology and anatomy of the brain are also impacted, uh, for example, um, the amygdala is a region of the brain responsible for processing emotions, particularly fear and anxiety. In PTSD, the amygdala is often often hyperactive, leading to an exaggerated response to trauma stimuli. The prefrontal cortex is responsible for executive function, decision making, emotional regulation. In PTSD there is prefrontal cortex dysregulation leading to difficulties in those areas. Neuro inflammation is also implicated, um, linked to uh symptom development and symptom maintenance. And these are the same systems that are impacted during childhood with all of the consequent developmental impact uh on the brain anatomy and on these delicate systems. So, how does trauma impact a patient's presentation? Uh, well, it can impact health behaviors, it can impact interpersonal interaction with us, with staff, and, uh, their response to the interventions as well, and to the medical setting environment. So let's talk a little bit about how health risk behaviors might be impacted. So I want you to remember back to the symptoms that we talked about, um, patients, uh, when they have PTSD experience negative emotions, depression, anxiety, shame, they're unable to feel positive emotions, difficulties regulating their emotions, difficulties in relationships, people are anhedonic, they experience impulsivity and are prone to reckless or self-destructive behavior. All of these can lead to maladaptive coping strategies such as smoking, drugs, alcohol, unhealthy eating, engaging in unsafe sexual practices, and avoidance of medical care. How about relationships? So trauma can result in irritability, aggression, difficulty with trust, feelings of betrayal, persistent negative emotional states like anger, uh feeling alienated, estranged, or detached from others. These can impact interactions with one's family, uh, with one's community, um, social systems, and it can impact our relationships as providers with our patients. It can also incline a patient to engage less with the medical, uh, system. What about engaging with care? Uh, symptoms that might impact these interactions, irritable or aggressive outbursts with little or no provocation, exaggerated startle response, difficulty with emotional regulation, flashbacks, again, that's when a person thinks that uh a historical trauma is happening right now, um, psychological and physiological distress and activation when reminded of the trauma and distorted negative beliefs about oneself and about the world and avoidance. These can result in patients avoiding health care altogether um, it can also uh result in triggering of somaticized memories so I'm gonna give you a little example um a blood pressure cuff can remind one of being restrained potentially during a trauma. So this is an example of an an inappropriate response to a non threat. situations so someone being restrained during a trauma um and having a stress response is absolutely the appropriate um uh response at that moment but in this case the body's stress response is inappropriate since since the situation is actually not a threatening one. Um, also comments from providers might trigger, uh, a trauma response. Being told to relax, just relax, uh, being told to stay still may potentially remind one of prior traumas. Sometimes when patients are with us, um, they also have a medical trauma or an accident while in our care and any or all of these responses uh can be seen. OK, in 2001, a paper was written by Harris and Fellow, uh, envisioning a trauma informed service system. They said, we treat people who have trauma without knowing about it, mostly, um, which can result in unwitting re-traumatization, and they called for provision of services in a manner that's welcoming and appropriate to the special needs of trauma survivors that will facilitate their participation in treatment. Trauma informed care came out of these ideas, which is care that acknowledges a complete picture of a person's life, historical, cultural, familial, economic, sexual, etc. Um, it takes people's trauma histories into account. Um, and this conceptual uh organization is supposed to happen, um, across the system, um, organizational, administrative, and clinical, the aim being for patients and caregivers to engage more effectively and joyfully in treatment. So trauma informed care is a very specific thing as it's, you know, uh, as a standalone um uh there's a very specific structure of care provision, key ingredients, um, but there are very important elements, um, that many of you all of you probably practice already, um, I would bet that many of your own clinics use most of the practices in trauma informed care, uh, because palliative care settings are often by necessity more aware of the whole picture. OK. There's not a great deal of literature on trauma informed palliative care. But I wanted to point out a number of salient points on the topic for your consideration. 70 to 90% of adults, depending on what research you're looking at, 70-90% of adults aged 65 or older have at least one traumatic life event. Makes sense as we uh get older, we've lived more. People may re-engage with trauma memories at the end of their life, just as people tend to re-engage with non-trauma memories at the end of their life. Uh, it's the same with trauma memories. Trauma and post trauma symptoms fundamentally shift how a person experiences the world. Remember, uh, we talked about negative alterations of cognitions and of mood, and these changes can have an especially pointed impact at the end of one's life when people often do some perspective taking. Pain, trauma symptoms can be triggered in the presence of pain. Um, pain, uh, can itself, it can trigger a trauma memory or it can also just trigger the, uh, the stress res the physiological stress response. And there's a bidirectional relationship between pain and PTSD. Those with PTSD report higher pain levels and people with pain report more trauma-related symptoms. Trauma symptoms can be exacerbated in the context of anxiety, of delirium, of dementia. Those with uh trauma histories and cognitive impairment may be particularly vulnerable um why is this? Well, they sometimes cannot understand the environment uh that they are in and the care setting may seem terrifying may seem scary, um, they. Can't necessarily use previously used coping strategies. They went through their life, um, after their trauma and, uh, were able to to cope well with whatever, um, you know, tools that they had and then they're no longer able to utilize those sort of the, the, the floor is is removed from beneath them. And then additionally, it's helpful to acknowledge the impact of trauma on family members. Witnessing a relative who might be experiencing a trauma response, uh, can be very, very disturbing. Um, another thing to keep in mind relative to the whole picture of the palliative care experience. So what do we do? We have a patient who's agitated, who's refusing a diagnostic test. How do we help? Here are some ideas. Use a team and I know most of you are doing that already um don't feel like you need to struggle, uh, to understand or help a patient alone. Use your interdisciplinary team. Help and problem solving might come from the least likely corners. Team members from different disciplines can help with novel problem solving, even if you're trying to solve a problem that's not in the scope of their training. Talk collectively about the problems. Many teams have social workers who are going to be very well versed in trauma and likely can help as well. um, if you don't have a deep bench to to pull from, um, you can always call a site consult um CL is a wonderful uh resource. Safety is the most important thing in the wake of a trauma recent or long past, people need to feel safe. It's been found to be the most helpful thing, safe from further bad events as well as emotional safety, helping patients feel safe in body and mind. Now, many of the next things I'm gonna talk about sort of speak to that, uh, notion of safety. Practical support. I think this was mentioned in the last talk as well. A patient might need concrete help, helping with food and shelter, helping with insurance, filing a police report, perhaps helping to facilitate basic needs, disability applications, those types of things. Social work staff can be extremely helpful in this regard. Um, assess for trauma. Any team member can ask about past traumas in their interview. Knowing what the patient went through can be very helpful if symptoms become exaggerated. Knowing what you're looking at. Um, it might help you, uh, understand what you are seeing. Ask a patient what we can do to make things easier for them. Um, what might be helpful for you in this medical setting? What can we do? What, what's harmful? What do you want us not to do? Those kinds of things engaging the patient in this kind of conversation can go very far toward gaining trust and making the patient feel safe. Let the patient take the lead. Help with trust and trying to give the uh help with trust and um and trying to give the patient a sense of agency and control over their treatment and over their bodies, and I'm gonna say a little bit more about that in a second. Emotional support Um, again, this speaks to helping patients feel safe. Um, emotional comfort and support can come from friends or family or anybody from the team. One of the most supportive things that we can do for a patient is to clearly and compassionately explain treatments. Explain prognosis, diagnostics, etc. etc. Transparency can be very, very salutary and supportive. Um, remember that one of the risk factors for PTSD is actually having a lack of support. So being able to offer that can be really, really, uh, right on. Trauma is by nature, being out of control of what is happening to you. This is also what patients experience often in a medical setting, um, and it's why it's common for people to have traumatic trauma responses in a medical setting, um, being clear and open about treatment can help. Um, and use the patient support system for assistance in understanding how to communicate effectively with patients. Maybe a family member has seen agitation in the past, uh, with this, uh, with this patient and knows that holding their hand, um, is a way to, to calm them, um, use the any sources of information, um, that may, may be around you. OK, so traditional psychotherapy for uh for trauma, trauma focused psychotherapy is generally not indicated in these cases. Um, why? Well, because these require intense engagement, um, and intense engagement specifically with the trauma, um, which causes significant, uh, uh, symptom exacerbation before it offers relief. Um, so supportive therapy is usually the best option in, in many of these cases. It's not true for everybody. It really depends, you know, we don't always have people, as we know, end of life and palliative care, so it really depends on where the particular patient is at any given time, um, but generally speaking. Psychopharmacology. So the FDA has approved only two medications to treat PTSD, sertraline and paroxetine. It's a broad sword, uh, and it takes a while to, uh, to, to take effect, um, but it can be helpful for some people for the mood symptoms. Um, it's not gonna be helpful for the intrusive memories and avoidance, those kinds of things. Prazicin is a an anti-hypertensive medication and can it can reduce the overactivation of the sympathetic system. It helps with nightmares, especially. It really for some reason, you know, they found it helps with nightmares. It's great. Uh, many people also anecdotally say that it helps them feel relaxed at night and helps them, uh, go to sleep as well, um. Trazodone is something that uh our uh MDs often use, um, which is an antidepressant but used, used in smaller doses, uh uh can be very helpful for sleep, um. It is very safe and very effective for most patients. Ambien is not usually recommended for sleep difficulties because of the disturbance of the sleep architecture. Um, so what do we do when a patient is in an acute stage? OK, so, so, so I wasn't gonna talk too much about, um, uh, immediate, uh, trauma reactions, but rather look at PTSD, um, but let's say a patient has had a fall, um. It used to be believed that um sort of a uh a trauma debriefing in the immediate aftermath was something that would help prevent PTSD um actually it turns out that the research is now showing that the opposite is actually true it actually fosters PTSD um so what can we do again it really gets back to helping patients feel safe and supported. Um, that's the way to go. Remember that safety and support. And a few other considerations. Uh, suicidality. Trauma is highly comorbid with depression, and those with trauma have higher rates of suicide, as do older adults. You can always ask a social worker or a CL attending to do a full suicide assessment, um, if you'd like, um, if you have any reasons to be worried about the patient's safety, um, from remarks maybe they've made or from a patient's history, that kind of thing, um, so use your team for assessment, um, and it. For you it may seem intimidating if this is not what you do regularly uh to ask a patient if they're thinking about suicide, but ask the question people will actually tell you, um, and often people really appreciate that you have uh that you're tapping into um their current experience. And finally I just want to point to supporting staff so this means supporting each other, um, talk to each other, uh, patient behaviors in response to trauma can be extremely upsetting for us to witness as well, not just for family members, um, debrief with each other about it. Remember, we are all also part um of the percent of people who have trauma histories. And um I, we need to understand that staff may become triggered by patient trauma reactions. Um, a collaborative supportive system also can go really far in preventing our burnout, um, which is something that we really want to try to avoid, um, it, you know, will help prevent burnout and hopefully enhance our feelings of, of, of being valued. OK, and since we're talking about trauma, um, I want to let people know that the next three slides contain photos of the aftermath of 9/11. So if you would like to avert your eyes, this would be the time to do that. So I have now some case examples, um, I wanted to give some examples of the intersection between psychological trauma and medicine in our clinic, uh, despite the fact that it's not a palliative care setting, um, uh, rather than using other examples because, you know, I, I know these patients and sort of I know the, the landscape of the patients overall, um. On a little background on September 11th, 2001, 2 planes hit the World Trade Center buildings in a terrorist attack. The buildings fell and nearly 3000 people were killed that day. Many worked in rescue and recovery and about 500,000 people, uh, community members were exposed. Community members called the survivor population includes local residents, local workers, students, passersby. People experienced both acute and chronic exposures. Acute physical exposure would be, you know, being caught in the dust cloud is the main, uh, acute exposure. Chronic physical exposures included being exposed to smoke, dust, and fumes. Acute psychological exposures included fears of one's own death, witnessing death. Chronic exposures included loss of loved ones, ongoing smells, and images of the destruction. The World Trade Center health program was created from the Zadroga Act in 2010, and it provides surveillance and treatment for physical and mental health conditions associated with World Trade Center exposures, and we work very closely in a multidisciplinary team with pulmonologists, psychologists, psychiatrists, other specialists, care managers, social workers, etc. OK, so, um, I'm gonna speak first about um uh Refusal of of doing necessary uh necessary diagnostics and things like that. All of our patients, whether or not they have PTSD or post trauma symptoms at all, um, they were all exposed to the trauma of 9/11. Um, this is a snapshot of a very typical patient. Um, I'm sure many of you have had these patients, someone who needs an MRI and refuses. Um, we have numerous patients who, uh, have refused necessary diagnostics or who have gone on the day of the, uh, the, um, appointment and then can't complete it and, you know, come back and the office calls us and says, oh, the patient couldn't do it, um, so 9/11 trauma can has resulted for many people in fear of being in an enclosed space with no escape. Uh, this is actually a situation, the MRI from the experience of 9/11, as I was talking before a little bit about generalizing, right? So, um, this is a situation in which the patient is generalizing their experience that was truly dangerous, which was, uh, 9/11 perhaps being caught in the dust cloud which is incredibly terrifying. People couldn't see, people couldn't breathe, um, to one that's actually not dangerous, the MRI imaging. In addition, the sound of an MRI is utterly terrifying and terrible, um, for anybody it's loud, really, really loud, um, and there were a number of deafening crashes on 9/11, um, 1 of the symptoms, um, of trauma you'll remember is hyper startle effect, um, when even small stimuli cause their stress system to go completely haywire. So what do we do to help such a patient? Well, um, the first suggestion would always be an open MRI which can help people, um, that that's not quite as loud either, which can be really good. Um, sometimes we give patients a benzo for the test so that they can, they can do it, can be very, very helpful, uh, for the right person. Um, some of our patients are in therapy, so we try to work with those. If they're not, if they don't happen not to be in therapy and they're having a hard time, uh, completing a, a diagnostic, we'll have a social worker or a psychologist, um, talk with the patient about the necessity of the test, um, and involve what's known as motivational interviewing, um, which is a technique that um. Uh, in which you kind of let the patient generate pros and cons of doing the test or not doing the test. Um, this doesn't always work. Uh, sometimes they, they definitely, you know, weigh in favor of the not doing, uh, but you know, sometimes it does, um, and at times we have called the patient before the procedure or we've walked the patient over to the procedure, that kind of thing, and it really has helped quite a bit, quite a bit. Um, OK, so how are we doing for time? Because I have a number of specific case studies, but, um, I also wanna get thoughts from, uh, the audience and cases that you might want to discuss, uh, as well. So what are we looking at for time? So, OK, 11:15. All right. So why don't I just do one sort of specific case example and then maybe we'll open it up. Um, OK, so AJ, uh, is a 71 year old African American divorced female. Um, her trauma history pretty extensive actually. Her parents were divorced, um, her mom, uh, significantly mentally ill, and, uh, the patient was very parentified. She had to take care of both the mom and of her siblings from a very young age. Uh, at one point she was locked in a closet by a babysitter. Um, and after that started developing symptoms of claustrophobia. She was sexually assaulted in her twenties. Her son was tragically killed at age 16 due to, uh, accidental, uh, gun violence. He was not the target. Um, a nephew was killed at age 16 that happened to be drug related. A sister died and discovered later in a very distressing situation, uh, uh, for the patient. On 9/11, she was a local worker. She was caught in the dust cloud, and after 9/11, her claustrophobia uh worsened. She was also locked. Another incredibly unfortunate event. She was locked in a hospital room, um, with her deceased brother. Her brother died in a hospital within about 15 minutes, um, uh, there was a fire on the hospital floor, um, and she reports that she, the doors were locked, um, to try to contain the situation. Um, she was alone with his dead body for about a half an hour. This also exacerbated her claustrophobia. Um, her trauma symptoms, um, presented pretty, pretty normally what you, what you expect a really sort of traditional presentation, um, hyper vigilant, uh, she would check things a lot, um, she would, uh, check the citizen's app all the time. Um, she would keep her purse on her bed, uh, fully packed at the ready in case she had to run out of her home, um, at a moment's notice, and also her claustrophobia, as I mentioned before, um, was pretty intense. Um, so this is a patient who learned from a very, very young age that her needs were superseded by her mother's needs and her siblings' needs. Um, the message was that she doesn't need it as much as other people do, um, and she's got no time to be sick. In fact, she's still the caregiver of her uh mentally ill mom who um has uh schizophrenia, um, she elopes, she goes gambling, and her mom has called the police on her at moments of paranoia, very, very stressful caregiving, uh, home situation. And again, um, she has claustrophobia due to her experience of being locked in the closet, 9/11 and uh the uh situation that happened to her in the hospital room. So needless to say, she didn't like going to MRI's. Um, and she had, uh, lymphedema at one point we learned that she had, um, a 4 days of a fever at 104. She did not go to seek care, um, in the context of an abnormal MRI with fecal and urinary incontinence and lower back pain, um, her treating psychologist basically just marched her over to the ER trying to get the patient to go herself, but the patient wouldn't go, so they went together. Um, and again these feelings that I don't have time to do this, who's gonna take care of my mother if I have to take care of myself, um, and still, uh, yet even when she went to the ER, um, uh, she told them that she was there because her stomach was bothering her again, not fully admitting to, um, uh, to her own needs. Um, this patient's trauma history significantly impaired her willingness and ability to get care. Um, we consistently have meetings about how to help her, you know, it, it's not always an issue up here. It's not heightened all the time, um, it has ebbs and flows depending on what's going on with her, um, but we work as a team to try to get her the best, uh, necessary care. We happen to have a an interdisciplinary. Um, meeting of the entire clinic, including administrative staff, uh, once a month, um, in which we talk about, uh, patients that have issues that are related to, to everything. Um, and in terms of therapy with her psychologists working on boundary setting, uh, with her, the people that she has to caregive with, you know, trying to figure out where there might be some boundaries where she can push back to, to take care of herself, um, working on her fears of the MRI, for example, what might you need to escape from in this particular situation? Um, and if you need to, you can, right? So like figuring out where all the movement in the person's fixed cognitions might possibly be. OK, so, um, shall I do one more about COVID vaccine refusal? All right, I'll do this one quickly, um, and then the last one on, I won't, um, so, uh, we have numerous patients who refused to get the COVID vaccine because of mistrust. Um, for example, some African American patients mistrust the government and medical establishment due to historical trauma of, uh, for example, uh, Tuskegee, um, which was, uh, carried out by the US Public Health Service, um, and, uh, maybe they also have uh personal negative experiences with healthcare, um, and many, many of our patients, especially local residents, mistrust the government. After 9/11, the community was told that the air was safe to breathe. This was untrue. The government actually knew that samples actually now it's come out now that it was uh not only was the air unsafe, but it was known, the community was lied to, um, and also we have a bunch of patients who have a tendency to turn to conspiracy theories post 9/11 to sort of try to make sense of their world, to make sense of things that don't make sense. Um, so what do we do for interventions? Um, well, you, you try to process the patient's concerns. What are your concerns? Let's talk about it. Do the concerns outweigh, uh, the benefits, that kind of thing, to help the patient make truly informed, uh, decisions and finally, um, maybe find the person on the team, um, that they trust the most. Maybe it's a medical doctor. Some people have incredible attachments to their medical doctors in our clinic, and just one word from a medical doctor works like a charm. Um, uh, maybe, you know, we will actually we have front desk staff who have said that patient would engage them about whether or not to get vaccinated, and they would engage the patient in the conversation, um, as well. So you never know exactly where help can come from. um, so I'm gonna stop there. And um I'd love to hear comments that you guys have. Um, I, I know that many of you utilize a lot of the uh uh the things I've talked about here. Um, I'm sure you have really fascinating cases as well. Um, maybe something was sparked by what you just heard, um, and, uh, I hope that some of this might have might help you conceptualize what you do see, uh, to help make your patient and your patient's experiences more joyful. Thank you. Questions Uh, I'm just gonna make one comment, um. Uh, I used to work at a VA and I did end of life care at the VA and, uh, many of my patients were, uh, experiencing long term PTSD. Some, some of them knew they had it and some of them didn't, so this was a really great framework to, to look at this. Um, end of life care in someone with really bad trauma can look very different than end of life care in a patient who has not had as severe trauma. The amounts of sedating medications to keep people calm and comfortable can be astronomical, um. That was my comment. My question is just um I'm wondering when If there's any little mini tools to um assess either with families because many of the geriatric trauma patients aren't conscious or are intubated and sedated um to sort of Anticipate whether you're gonna have difficulties with past trauma in the care of a trauma patient now. I, I can think of a million patients at Bellevue that, uh, probably every one of them have these traumas. I mean, I think at a safety net hospital. You'd be hard pressed to find a patient that doesn't have one of these, uh, early childhood traumas or current traumas, systemic traumas between bias, discrimination, racism, poverty, violence, um, like they like every one of our patients but I'm thinking in the acute. Geriatric trauma surgery service kind of situation. You know, how would you engage the family in, in cluing you in? Um, that's a good question. You can't predict a lot of psychiatric issues. Um, that's just it's, it's interesting that that's not something that's easily predictable. Um, somebody may have experienced 4 or more of those adverse childhood experiences and actually function all through their life extremely well. Why? Because possibly they had an amazing support. Um, having the support of a caring, uh, adult actually when one is a child, um, that can be really, uh, extremely healing, so you, you don't really know. The one predictor of a patient behavior is past behavior. So if a patient at home has experienced at any time, um, you know, a significant trauma response. It might happen again to them. Also, not necessarily, right? It is hard to protect, um, to predict uh psychiatric behavior, but the best predictor is past behavior. Yeah Um, I, it's more of a comment, really. I, I work in a safety net hospital in Brooklyn and I often say a lot of the staff that work at the hospital come from the community and I want to thank you for mentioning how staff are affected by patients' responses to trauma and how it triggers their own trauma histories, because that's so important. I think it's missed a lot, um. So thank you, thank you for, for, for highlighting that. Hi, um, thanks for this presentation. What strategies or um approaches have you seen to be helpful when trying to create safety and trust with patients with cognitive impairment, especially if it's hard to build a relationship over time given memory. I would love to hear your, your way of looking at that. I wish I had some advice and I don't really part of the reason is that um OK so uh you know I work in a specific service um and we have a a population that is aging, uh, and, uh, we are right now starting to experience how do we deal with this aging population on every front. Um, and so I don't, I do not have a lot of personal experience, uh, with this. We are starting to deal with some patients who, um, have a significant cognitive impairment, um, and mostly I find that working alongside with the family members, um, is the most effective. And you know whatever that may be um depending on the family uh member depending on, you know, because not all family members also, uh, are there for the patient, of course, uh, but, but that's really sort of for us we find that that's the end, um, working collaboratively with the family. Hi, I'm over here. uh, thank you for that. Um, my name's Heather. I'm a social worker and I, I was wondering your thoughts, you know, for those of us that work inpatient, especially in palliative care where we may not be able to follow a patient for a very long period of time. I noticed you talked about asking about the trauma, and I sometimes worry about that, um, with some of my colleagues who aren't as trauma informed that opening up a trauma and not kind of knowing what to do with it and how to close that up for a patient could be harmful, and I wondered if you have. Any advice for um the inpatient? Absolutely that's an amazing question because that's true uh you might not want to um uh open a person up and not be able to close them back up right because it can be very to be able to not confront a trauma um is allows one to function often right um and you only wanna confront a trauma when it's safe to do so and when you're able to work with somebody who's uh you know who's safe to to work on it with. Um, so I would say in the inpatient setting when you don't have a longitudinal relationship with the patient, um, you probably don't want to ask the question. Unless you've got symptoms that are presenting. If a patient is really incredibly agitated and you wanna be able to help them at that moment, that's when you might be able to wanna say, how can we help you? Um, is there something that happened in your past maybe when last time you were in the hospital that you wanna tell us about that might have been really difficult for you? We try not to do it again, you know, those kinds of things. So I think you would wait until symptoms present and then deal with it, um, if you're not having a longitudinal relationship. Yeah. Um, hi, um, is there a connection between patients who have PTSD and neuroinflammation? Um, is there a link to Alzheimer's? Um, to Alzheimer's itself, I don't know, um, but we actually are doing some research right now, um, in conjunction with the NYU Alzheimer's, uh, Research Center, um, on cognitive impairment in our population. Um, uh, and I, we've also published a little bit already on cognitive impairment, but we're going to be able to, we're, we're doing a longitudinal study now, uh, with cognitive functioning in our population, which is very exciting. nerve inflammation specifically, I, I don't know about. I don't, you know, I'm, I'm not 100% sure, you know, we're working with biostatisticians. I'm sort of. Heading up the neuropsych piece of it, um, and so the more biological piece I know that we're doing some, uh, blood, uh, we're looking at some blood biomarkers too, um, that piece of it I don't really know much about so I'm not exactly sure what what will be looked at, but, um, and I don't know if a frank diagnosis of, of Alzheimer's versus cognitive impairment versus Louis, you know, I don't know about different kinds of, of dementing processes um and how that relates to PTSD, but there is a lot of research being done. Um, and a lot, some of it's coming out of NYU. Um, hi, can you hear me? Yeah, um, I, I am, um, building on the comment and from the back about our teams and, uh, many of us obviously, um, are, are the same, uh, I'm certainly, I'm sure there's many in this room that have lived through 9/11, uh, in various ways, um. And I'm struck by your comment about debriefing is not helpful, but My, so how, how do you address the, how should we address the The issues when we have a traumatic event in the emergency department um for the staff for us uh in terms is debriefing helpful uh is it not helpful um because I think all of us are experiencing trauma in different ways in our profession absolutely again, you know, it's, it's the, the research is showing that debriefing after a trauma is not helpful. I'm not sure about the research on debriefing um when it's secondhand when you are witnessing uh you know that kind of a level um but I would say talking about it is very good for the team, um, knowing that other people are experiencing the same thing and oh my gosh, that was really, really hard, um, that can really help people feel supported. So in that situation, I would, I would actually recommend it. Uh, but you know, for, for the case of a patient who, uh, who's experienced a direct trauma, I would not recommend it. Uh, I wanna make one comment about that. At, at, um, in H&H we have uh this H3, this system of peer counseling for. Healthcare workers who are feeling like there was something impactful, loosely called traumatizing, not, not trauma, uh DSM trauma, and they're very careful about when they debrief. They usually do wait a little bit of time but not too much time because people need time to kind of process what happened and kind of have the like emotional volume kind of quiet a little bit before they do the debriefing so they're actually the the program is very well structured to sort of attend to that and I know a lot of palliative care teams for people here do help with those debriefings we get reached out to by ICUs to help with debriefings and. And oftentimes they want to do really a little mini Eminem and we're kind of getting at the emotion, but um I, I think that's a really great question and point about Uh, an acute, you know, a patient situation who, who, um, had the traumatic event happened to them versus a little bit more of secondary trauma from healthcare workers. We, we weren't, we weren't in a life threatening situation usually unless there was like a, a gun violence thing in the hospital or something. So that um we're kind of secondary trauma victims so there might be a little bit difference there yeah absolutely and another thing to to note about secondary trauma is that you know we as healthcare people can can experience what's known as a moral injury when. Not able to help people in the way that we want to be able to when there is a bad event that kind of thing because we're here to help you know that's what we're that's why we went into this and when we're not able to do so or when there's a bad outcome that kind of thing, it can be extremely difficult. Published May 3, 2024 Created by Related Presenters Rebecca Rosen, PhD View full profile
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