Putting Trauma Informed Care into Practice – Part 1

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

Part I:  Implementing Trauma-Informed Care in Pediatric and Adult Primary Care Settings  (Nadine Burke-Harris MD Center for Youth Wellness and Edward Machtinger MD, Women’s HIV Program UCSF)

Link to audio of entire webinar session: https://www.youtube.com/watch?v=VbqwJ1h1Qy8&feature=youtu.be

Definition of trauma: Event or series of events, or set of circumstances that are experienced by the individual as physically or emotionally harmful or life threatening that can have lasting effects on the individual’s mental, physical, social, emotional, or spiritual well-being.

Types of Adverse Childhood Experiences (ACEs)

  • Abuse: Physical, emotional, and sexual
  • Neglect: Physical, emotional
  • Household Dysfunction: Mental illness, mother treated violently, divorce, incarcerated relative, substance abuse

Increasing number of ACEs experienced increases impact on all aspects of physical and mental health, behavioral outcomes (e.g., smoking, addiction, alcoholism), and life potential (school and work success).

SAMSA data on ACE outcomes.  The landmark Kaiser study on ACEs.

Leading Causes of Death in US, 2013 Odds with 4 or more ACEs
1 Heart Disease 2.1
2 Cancer 2.3
3 Chronic Lower Respiratory Diseases 3.0
4 Accidents
5 Stroke 2.4
6 Alzheimer’s 11.2
7 Diabetes 1.5
8 Influenza and Pneumonia
9 Kidney Disease
   10 Suicide 30.1


The biology of adversity:

  • Neurologic:
    • Dysregulation of HPA and SAM Axes
    • Activation of the amygdala
    • Inhibition of the prefrontal cortex
    • Hippocampal neurotoxicity
    • VTA and reward center dysregulation
  • Immunologic:
    • Increased inflammatory mediators and markers of inflammation such as interleukins, TNG alpha, IFN-y
    • Inhibition of anti-inflammatory pathways
    • Impaired cell-mediated acquired immunity
  • Endocine:
    • Long term endocrine changes in ACTH, cortisol, adrenaline and other hormones
    • Inhibition of thyroid function
    • Alterations in Growth Hormone and pubertal hormones
  • Cardiovascular:
    • Increased plasma endothelin 1, total peripheral resistance, DBP and pulse wave velocity
  • Epigenetic:
    • Altered epigenetic regulation leads to differential gene expression
    • Changes in way DNA is read and expressed lead to changes in the way brain and organ systems respond to stress
    • Telomere erosion leads to premature cell death and altered cell replication

What is trauma-informed care in a nutshell?

  • Take the person’s experience into account
  • Don’t ask “What’s wrong with you? Ask, “What happened to you?”
  • Needs to be addressed at clinical and organizational level.

Core principles of trauma-informed care:

  • Empower patients—use their strengths to develop treatment plans
  • Provide options, let patients choose
  • Maximize collaboration—patients, family members, staff
  • Ensure physical and emotional safety
  • Create trust through clear expectations regarding who, what, and how’s of treatment

Tools to screen for ACEs:




ACE score 0-3 without symptoms = Provide Anticipatory guidance

ACE score 1-3 with symptoms or 4 or more ACEs = Counsel and refer

Basics to Institute Trauma-Informed Primary Care:

Foundation: Train ALL staff, use clinic champions, support providers, ongoing evaluation

Screen:  Inquire about current and lifelong abuse, PTSD, depression, substance use

Create Environment:  Calm, safe, empowering for patients AND staff

Respond:  Use onsite and community based programs that promote safety and healing

What can you do tomorrow!

Realize that a lot of who we are and what we do is because of what happened to us.

Embrace trauma-informed values.

Distribute literature about impact of trauma on health

Get training for staff

Assemble a team to support the process

An Ounce of Prevention

It has been predicted that the 2017-2018 influenza season may be severe.  It is starting early – having shown up in Southern California earlier than usual.  It causes or is a part of the cause of death in thousands of people in the US every year – mostly small children/ babies and the elderly.  The Centers for Disease Control and Prevention (CDC) has published guidance for preventing seasonal influenza in the workplace.

  • Promote influenza vaccine: “The single best way to protect against the flu is to get vaccinated each year.”   There are several types of vaccine that can be used depending on your particular health situation.  It is recommended for everyone 6 months and older.   Otherwise there are few people for whom the vaccine is not appropriate.  Vaccination during preganancy can help protect your newborn who is particularly at risk if the baby catches influenza.
    • Unfortunately, as the vaccines are prepared early in the year in anticipation of the major predicted strains of influenza in the fall, this year the vaccine was off the target from the prevalent strain causing influenza this year. However, protection against the 2 or 3 other strains involved in causing influenza remains.   It is still highly recommended.  I got mine – even during the fires!
    • The influenza vaccine is given at a time of the year when common colds show up in the population (kids back in school) – so many people have said they thought that the vaccination gave them the illness. THIS DOES NOT HAPPEN.
  • Hygiene
    • We have become familiar with cover your cough (either with your elbow or a tissue) and dispose of the tissue properly – stand away – it doesn’t take much distance to reduce exposure.
    • Wash your hands – transmission from hands can be prevented by washing. I do frequently during the day and when I arrive home from work.  Don’t be nuts about it but have common sense.
  • Know the signs and symptoms of influenza – influenza is NOT the common cold (people do come to work with colds – kinda unavoidable and a nuisance).  I consider influenza with the following symptoms that can often develop quickly:
    • Fever – almost always (or chills)
    • Cough – influenza is a respiratory illness
    • Body aches – yeah, this is part of the misery – ache all over
    • Headache – another typical part of the misery.

So you can see how influenza is different from the run of the mill cold or stomach ailment.  You can have sniffles, sore throat, stomach complaints, fatigue too, but I pay attention to the top four.

  • If you think you have influenza – GO HOME – STAY HOME– WATCH NETFLIX! (although you may want only to sleep) – Check in with your health care provider if you are at high risk or take a turn for the worse.   Don’t be a part of the spread of influenza in the workplace.

I practice these measures for five reasons

  • I don’t want to get sick – influenza – not the common cold – is miserable
  • I don’t want to use my valuable PTO time being ill! (hmm vacation or home feeling like I’ve been run over)
  • I don’t want to bring it home to my family (what a way to spoil the holidays and new year – and they will get mad at you)
  • I don’t want to bring it to work – “IT WAS YOU!”
  • AND I’m a doctor – walk the walk – I’m a believer

If you have influenza – stay home, rest, take fluids, medications like ibuprofen to feel better (don’t give aspirin to kids or adolescents).  If you worsen seek medical advice or help.   Don’t return to work until your fever is gone for 24 hours – you’ll know, the relief is remarkable.

Vaccine, cover, wash, recognize, stay home.

And Now for Something Completely Different

By Jeff Ribordy M.D., Regional Medical Director

As medical directors at Partnership HealthPlan of California, we are honored to review an array of medical records, treatment authorization requests and sundry other medical documentation on a daily basis. Every so often we encounter documentation that makes us scratch our heads and entices a chuckle. Here are some of the best-

Before the current “Golden Age” where everyone has an EHR and now loves charting endlessly (sarcasm intended) there were these things called “medical errors”. I know it’s hard to fathom, doctors making mistakes, but it’s not just fake news. Most of the “errors” were typically related to undecipherable hieroglyphics known as “doctors’ handwriting” leading to medication mistakes or other orders either being ignored or completed incorrectly.

While typed or dictated notes now allow legibility, comprehension can still be a struggle. Whether from stream of consciousness HPIs, dictation errors or excessive reliance on standard templates without reviewing, errors still are found. In our review of submitted medical records we have found a few mistakes that make us chuckle or even laugh out loud. I’m going to share some of these here – not to point fingers but with the understanding we all have made similar mistakes.

Sometimes we have to take a patient’s history with a grain of salt…

Fig 1

From the category of “How Do You Find The Time To Do Anything Else”:

Fig 2

 From the Physical Exam:

Fig 3

Family history can be…very revealing:

fig 4

And from the Catch-All category of “Huh?”:

fig 5

And good advice for everyone:

fig 6