Embedding trauma informed care into your practice: Tips for providers

In the U.S., 34 million children have experienced an “adverse childhood event,” or ACE – a stressful or traumatic event that is strongly related to a wide range of health problems. Prolonged, pathological stress disrupts healthy brain development and creates significant lifelong implications for learning, behavior, health and adult functioning.

By understanding the widespread impact of trauma, as well as the potential paths for recovery, practitioners are empowered to respond by fully integrating knowledge about trauma into their practice. This is known as “trauma-informed care.”

Trauma-informed care understands the impact of trauma and the potential paths for recovery, and aims to respond by adapting certain practices. By viewing patients through a “trauma lens,” practitioners better understand that traumatic experiences may be contributing to somatic symptoms or challenging behaviors.

CHOC has worked diligently to embed trauma-informed care into the treatment and interaction with patients and families across locations and specialties, says Dr. Dani Milliken, director of the Cherese Mari Laulhere Mental Health Inpatient Center at CHOC.

Dr. Dani Milliken, director of the Cherese Mari Laulhere Mental Health Inpatient Center at CHOC

Here, Dr. Milliken offers three simple things providers can do routinely to begin to integrate trauma-informed care into their practice:

1. Ask “What happened to the patient?” instead of “what’s wrong with the patient?”

Changing your mindset while evaluating patients is one of the most effective ways providers can implement trauma-informed care. A shift from the typical thought process during patient evaluation to a trauma-informed thought process includes:

  • “The patient is sick, ill or bad” becomes “the patient is hurt and suffering.”
  • “Patient behaviors are immoral and need to be punished” becomes “patient behaviors are survival skills developed to live through the trauma, but are maladaptive in everyday society.”
  • “Patients can change and stop immoral destructive behavior if they only had the motivation” becomes “patients need support, trust and safety to decrease maladaptive behaviors.”
  • “We need to manage or eliminate patient behaviors” becomes “we need to provide opportunities for patients to heal from their trauma.”
  • “System of care should be created to minimize short term costs and contain immoral behaviors” becomes “system of care invests in healing trauma, saving money over the long term.”
  • “The patient is manipulative” becomes “The patient is trying to get their needs met”

2. Adjust what you say

There are certain words that can be avoided when describing patients and their behavior, such as “refused,” “resisted,” “non-compliant,” “unmotivated” and “low functioning.” By shifting away from words and phrasing that portray a patient as having difficult or non-ideal characteristics, providers can promote recovery.

Words and phrases that encourage this recovery include:

  • Declined
  • Chose not to
  • Experiencing
  • Has a history of
  • Has difficulty with

3. Adjust what you do

The way providers interact with patients matters, and a few key changes can support children who have experienced adverse childhood effects:

  • Ask before touching
  • Introduce yourself each time you enter the room
  • Explain procedures prior to performing
  • Offer choices as often as possible
  • Create a therapeutic relationship
  • Alter the environment

Learn more about the Cherese Mari Laulhere Mental Health Inpatient Center at CHOC.

Talking to children after traumatic events: Six resources to share with families

Helping children cope through the aftermath of a traumatic event can be difficult.

Acts of mass violence bring up widespread worry, anxiety, uncertainty and trauma, and it can be overwhelming for parents to know where to start when talking to kids about it.

People often turn to healthcare providers for advice about the best ways to approach tough conversations with young people. The following is a list of helpful resources you can share with families about coping with the complicated feelings after a traumatic event.

Guidelines for helping youth after the recent shootings

This fact sheet by The National Child Traumatic Stress Network (NCTSN) offers guardians tips about helping children after an act of mass violence. It is presented in both English and Spanish versions.

For teens: coping after mass violence

Another NCTSN resource, this handout is tailored to parents of teens and includes information for adolescents on self-care after trauma.

American Psychological Association response to mass shootings in Texas, Ohio

American Psychological Association President Rosie Phillips Davis, PhD, offers an official statement, as well as a helpful list of resources, in the aftermath of mass gun violence.

How to help your child navigate the emotional aftermath of a traumatic event

This CHOC Blog post presents the five E’s, a clear series of steps parents and guardians can follow when talking to children, alongside a list of additional resources.

Talking to Children About Violence: Tips for Parents and Teachers

The National Association of School Psychologists offers points to emphasize when talking to kids of all ages about violence. Companion flyers are also offered in English, Spanish, Korean, Vietnamese, French, Amharic, Chinese, Portuguese, Somali, Arabic and Kurdish.

Should you talk to young children about tragic events?

This CHOC Blog post breaks down factors parents should consider before talking to their kid(s) about tragedy, including appropriate approaches by age group.

American College of Surgeons Grants CHOC Prestigious Trauma Center Verification

CHOC Hospital has been verified by the American College of Surgeons as a Level II pediatric trauma center.  This achievement recognizes CHOC’s commitment to providing the highest quality trauma care to injured patients.  CHOC opened its trauma center in 2015.  It is Orange County’s only trauma center focused exclusively on children.

To earn verification, CHOC submitted an extensive application and data.  This was followed by a site visit from a team of surgeons.  They commended CHOC for exceptional work in several areas, including support by the medical staff, nursing educational excellence and the commitment of hospital administration.

Dr. David Gibbs, director, trauma services, and Amy Waunch., MSN, FNP, CEN, trauma program manager
Dr. David Gibbs, director, trauma services, and Amy Waunch., MSN, FNP, CEN, trauma program manager

“Our team of pediatric subspecialists, nurses and staff are dedicated to providing the highest levels of care to   seriously injured children, from the moment they arrive to the day they go home.  Our goal is to give each patient the best chance of survival and recovery,” says Dr. David Gibbs, director, trauma services, CHOC. “We are honored to serve the children and families in Orange County, and are proud to join an elite group of hospitals committed to improving pediatric trauma care.”

As a verified Level II pediatric trauma center, CHOC is a referral resource for communities in Orange County and surrounding regions, and provides:

  • 24-hour coverage by board-certified pediatric trauma surgeons and quick access to pediatric specialties including orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, and critical care
  • Injury prevention and education to the community
  • Continuing education and training for trauma staff
  • Substance abuse screening and patient intervention

CHOC’s trauma center also meets verification standards based on its patient volume and comprehensive quality assessment program.

To be designated a Level II pediatric trauma center, CHOC goes above and beyond to meet the requirements set by Orange County Emergency Medical Services by offering the following.

  • An award-winning pediatric intensive care unit providing intensive and acute care to critically ill surgical and medical patients
  • State-of-the=art operating rooms for performing immediate or emergency surgery using the latest and safest procedures
  • Support services, including child life, social services and psychology, for pediatric patients and their families dealing with traumatic situations
  • Additional hospital services, including a blood bank, radiology and rehabilitation services

Learn more about CHOC’s trauma center.

In the Spotlight: Seth Brindis, M.D.

In addition to providing high-quality medical care, physicians and staff at the Julia and George Argyros Emergency Department at CHOC Hospital strive to make the experience less stressful for children and families.  One physician, in particular, has a few tricks to ease his patients’ fear and anxiety.  Dr. Seth Brindis, a board-certified pediatric emergency medicine specialist and medical director of informatics, performs magic for his patients.

“For me, magic makes my job easier, instantly transforming what can be a scary experience for children to something fun. I incorporate magic into my physical exam as it makes the exam easier and more reliable when patients are comfortable with me and distracted. I tend to use coin tricks because they appeal to a wider range of ages, with the added benefit that the coins can be disinfected between patient contacts.”

Luckily, it doesn’t have to be an emergency in order to see Dr. Brindis’ magic. With help from child life, he occasionally puts on impromptu magic shows in the CHOC theater for inpatients, their siblings and parents.

Dabbling in magic since childhood, Dr. Brindis’ interest in magic was revitalized while in residency at Harbor-UCLA Medical Center, where he realized that simple tricks with cards and coins could help make connections with patients and staff. Since then, he has continued to study magic, even taking courses tailored for magic in medicine. Seeing thousands of patients each year, Dr. Brindis gets ample time to try out new tricks and help patients and their families leave with positive experiences and smiles on their faces.

Exclusively dedicated to the treatment of pediatric patients, CHOC’s ED features 31 exam rooms, including two trauma bays, and three triage suites. The ED is staffed with doctors who are board-certified in emergency medicine and specially trained nurses who provide the very best patient- and family-centered care. Child life specialists work with patients to help them feel safe and secure, and make the process a lot less stressful for the entire family.

“The ED is often the gateway for many families who are coming to our organization for the first time. We’re working together to deliver the best care to those who need it most. My job is to understand what is distressing to a parent in the middle of the night and either educate and reassure the family or intervene when called for.”

As the only trauma center in Orange County dedicated exclusively for kids, CHOC is ready to treat injuries 24 hours a day. The trauma team is trained to care for children and their unique physiological, anatomical and emotional needs, and CHOC’s protocols and equipment are specially designed for pediatrics.

The ED saw over 49,000 patients in the first year it opened. This year, it’s on pace to see more than 85,000 patients – an incredible rate of growth, which Dr. Brindis credits to the coordination and cooperation between the ED physicians, EMSOC leadership, and nursing, as well as CHOC administration.

“I love being a part of this team. I feel like we provide exemplary care to every person who enters our doors. Often, I feel like the conductor of an orchestra of care. There is no way I could do my job without the incredible people I work with. It really is impressive to watch our team working in concert to stabilize a really sick child.”

Dr. Brindis received his medical degree from Vanderbilt University. He completed his pediatric residency and pediatric emergency medicine (PEM) fellowship training at Harbor-UCLA Medical Center. In addition to caring for patients in the ED, he is actively involved with the training and teaching of pediatric and emergency medicine residents as well as the PEM fellows.

In his spare time, Dr. Brindis enjoys spending time with his wife, son and daughter. He also enjoys cooking, painting and, of course, working on his magic.

Meet Dr. Mary Jane Piroutek

CHOC wants its reffering physicians to get to know its specialists. Today, meet Dr. Mary Jane Piroutek, a pediatric emergency medicine specialist.

CHOC Children's

Q: What is your education and training?

A:  I graduated from the University of California, Irvine School of Medicine. I completed my pediatric residency at CHOC and my pediatric emergency medicine fellowship at Loma Linda University Medical Center.

Q: What are your administrative appointments?

A:  I hold the academic appointment of assistant professor, Department of Emergency Medicine at Loma Linda University.

Q: What are your special clinical interests?

A:  I am especially interested in pediatric trauma, environmental injuries, and endocrine emergencies.

Q: How long have you been on staff at CHOC?

A:  I have been on staff for five years.

Q: What are some new programs or developments within your specialty?

A:  CHOC’s emergency department became a level II pediatric trauma center in 2015. We are the only trauma center in Orange County dedicated exclusively to kids. Or trauma team consists of physicians, nurses, pharmacists, radiology technicians, respiratory therapists, social workers, child life, and a hospital chaplain.

Q: What are your most common diagnoses?

A:  Abdominal pain (from gastroenteritis to appendicitis), seizures, traumatic injuries (lacerations, closed head injuries, fractured arms and legs), and respiratory illnesses (bronchiolitis, asthma, and pneumonia).

Q: What would you most like patients and families to know about you or your division at CHOC?

A:  At CHOC, our emergency department is staffed with fellowship-trained pediatric emergency medicine specialists. Our dual training makes us especially knowledgeable and skilled in caring for your child during their visit. CHOC is the only emergency department in Orange County that exclusively treats children. Treating children in an environment created especially for them makes what could be a scary experience into something more enjoyable.

Q:  What inspires you most about the care being delivered here at CHOC? 

A:  CHOC delivers the highest level of pediatric care while embracing and caring for the entire family.

Q: Why did you decide to become a doctor? 

A:  In high school I volunteered in a community hospital in the labor and delivery unit. I really enjoyed being part of a family’s joyous occasion. In college I volunteered in the emergency department and marveled at the fast pace, acuity and unpredictably of what the next patient’s case would bring. My academic love for science and solving problems made becoming a physician a very natural fit.

Q: If you weren’t a physician, what would you be and why?

A:  I honestly don’t know. Once I decided that I wanted to be a doctor, I never really considered anything else. I put all of my energy and focus into medicine.

Q: What are your hobbies/interests outside of work?

A:  I like spending time with family and friends and traveling. I am also an avid Anaheim Ducks hockey fan.

Q: What have you learned from your patients? 

A:  Children are brave and have a remarkable capacity for resilience. This is evident in the child that sustains a broken leg playing soccer and is unafraid and eager to play again. Or the teenage cancer patient that is most concerned about how their family is being affected by and is dealing with their illness. My patients are humbling and help me to be a better person.

Q: What was the funniest thing a patient told you?

A:  Kids say funny things all the time. One of my favorites was a little 4 year old girl that had ingested coins and they were stuck in her esophagus. When I asked her what happened she shrugged her shoulder and with a mischievous look in her eyes said, “I ate the money, I’m not supposed to eat the money.”  Also recently a patient told me I looked like Snow White (which I don’t) and she called me Dr. Snow White the whole time I took care of her.