%% [[Forming Identity]] tags:: #on/trauma | #on/bias | #on/dei | #on/patientcare people:: # trauma informed is treating everyone like they have had some trauma Lon Setnik dates:: 2022-05-22 %% *treat everyone like they've had some tough times.* This reminds me of the Hippocratic oath, first do no harm It's kind of like how accessible devices are better for everyone - see Oxo design This is the process of not asking people to relive their trauma this matters because when people relive their trauma, it is another unnecessary trauma on top of that. This adds up to worse outcomes and less [[trust is the currency of relationships]] --- ## Notes from the podcast: **Dr. Andy Barnett joins Miz and Matt DeClerck to discuss chaperone use in trauma informed genitourinary exams. Choosing the correct language and rehearsing what to say for these exams can make patients more comfortable.**  **Pearls:** - **It’s safest to assume that all care should be trauma informed (shame and stigma often prevent disclosure).** - **Intentional offer of control over the exam/space should be made (e.g. self swabs, self-insertion, inquiring about comfort and consent to proceed, as well as the option to revoke consent at any point).** - **Liberal use of drapes and only exposing the minimum necessary body part is essential to making a patient feel comfortable.** - **Language matters as much as action, so rehearse your talk track – use sensitive/clinical language. AVOID sexualizing the encounter (table NOT bed, drape NOT sheet,...).** - **Trauma informed care should be in every provider’s repertoire – even more so as it relates to the GU exam.** - **What is a trauma informed exam?** - The person performing the exam recognizes a patient's prior trauma or adopts a mindset that this person may have experienced prior trauma. - The examiner creates an environment that honors and respects the patient but tries to reduce the stress, anxiety, and fear that's associated with the exam or being touched/positioned in a way that may recreate some of their trauma. - If you approach every sensitive exam as if the patient has had prior sexual  trauma, you're not going to go wrong. - **Specific tips and “talk tracks” for performing this exam:** - Many patients with trauma history experienced it in the context of a loss of control. **Giving patients intentionally worded control over the exam** and the experience is important. - _"I just want to make it clear to you that you're in control of this exam. We want to make sure that you're comfortable. If at any point you're not, please let us know. If you need to adjust positions, or if you need us to stop entirely, that's completely fine."_ - The goal is to make the patient feel very much empowered in a context where they may have felt a profound loss of power in the past. - **Do all sensitive body part exams with a chaperone present.** - Make sure that the **patient has clearly given affirmative consent** for the exam. - _"We're going to go ahead and do the exam for the reasons we’ve discussed. Is that okay with you?"_ - **Choose words that desexualize the encounter** of doing a sensitive body part exam.  - For example, instead of “bed” say “exam table”,  instead of “sheet” say “drape”. - _"I'd like you to position yourself on the table. We're going to place a drape across the lower half of your body."_ - During the exam, **only expose the minimum amount of the patient's body** that is necessary. - **Describe what you're going to do before you do it.** - _"I understand that this may be uncomfortable for you. I want to make sure that you understand that you're in control. If at any point you're uncomfortable and need to change positions, take a break, or stop entirely, please just let us know and that's completely fine."_ - The most trauma informed way to do a bimanual exam is to step to the side of the patient.  - Don’t stand in between the woman's leg and then put fingers in the vagina. This may sexualize and traumatize that encounter. - After a sensitive exam, leave the room and **allow the patient to redress before you continue with your discussion of your plan**and/or discharge instructions. - **Self-swabbing, self-insertion of the speculum, and self-exposure techniques:** - Self-swabbing for STD checks and wet mounts have been shown to provide accurate samples and are recommended. - [A recent study](https://pubmed.ncbi.nlm.nih.gov/16164528/) supports offering self-insertion of the speculum as it “increases women's comfort and satisfaction and potentially makes sexual health screening less threatening to women of all ages”. - Self-exposure  for rectal and perianal exams both increases comfort and almost invariably yields a better look at the area. - **If a patient becomes visibly uncomfortable during the exam, what should you do?** - You have to stop immediately whatever you're doing.  - _"I'm sorry. I didn't mean to make you feel uncomfortable. Do you need a moment here, or do you want me to take the speculum out and stop the exam?"_ **References:** 1. Wright D, et al. Speculum ‘self-insertion’: a pilot study. Journal of Clinical Nursing. 2005; 14(9): 1098-2111. [PMID: 16164528](https://pubmed.ncbi.nlm.nih.gov/16164528/) 2. Adult Manifestations of Childhood Sexual Abuse. American College of Obstetricians and Gynecologists website. Updated August 2011, Accessed February 2015. 3. Ravi A, et al. Providing Trauma-Informed Care. _Am Fam Physician_. 2017;95(10):655-657. [PMID: 28671409](https://pubmed.ncbi.nlm.nih.gov/28671409/) ## Sources: ERCast: May, 2022 Chapter 7 | Trauma-Informed Care: The GU Exam Matthieu DeClerck, MD, Andy Barnett, MD, and Mizuho Morrison, DO