President, Monterey County Medical Society
CRAIG A. WALLS, MD PhD
a framework that involves understanding, recognizing, and responding to the effects of all types of trauma. All physicians can and should employ it with their patients. Sure, you have heard this kind of stuff all before, you say. Violence begets violence and the cycle grinds on from generation to wounded generation. But, no, this is different and here is how: Trauma informed care affirms that our youth are not broken! Rather, the bad behaviors they display do not represent who these young people are innately, but rather how they have learned to react to the world. Their aggression, withdrawal, and neglect are all seen as natural survival responses they employ in response to the life-threatening trauma they survived as children. In this paradigm, all youth should be approached with unconditional love and high expectations. When we stop telling them that they are broken and start understanding that they are a member of a species that has evolved to survive trauma, we create a real opportunity to generate insight and even change. According to Dr. Ginsburg, this approach can be applied to the whole healthcare and social system to allow for supportive healing without retraumatizing children. A systemic implementation of trauma informed care in a community increases understanding of the connection between behaviors, symptoms, and past trauma history. When an entire system becomes trauma informed, every part of its organization, management and service delivery is assessed and potentially modified to include a basic understanding of how trauma impacts the lives of those seeking services. CHOICE is Monterey County’s first and only hospital-linked violence intervention and prevention program and it is housed at the county’s trauma center. It is modelled on UCSF’s Wraparound Project at San Francisco General Hospital which has demonstrated a decade of consistent reductions in retaliation, re-injury, and criminal activity among youth and young adult victims of violence. CHOICE is embracing trauma informed care and bringing it to the bedside of our youth victims of violence. No matter what field of medicine you practice in Monterey County, you can lend your hand in unplugging the trauma generator by realizing that many of your patients are adaptive survivors of traumatic childhood.
MESSAGE FROM THE
E
very system is perfectly designed to get the results it gets.” This quote is widely attributed to Dr. Paul Batalden, MD, Senior Fellow at the Institute for Healthcare Improvement (IHI) and Professor Emeritus at Dartmouth Medical School. I was fortunate to recently attend the IHI’s annual conference and heard these words repeated multiple times. On returning to Salinas, where I work as an emergency physician and hospital administrator, the sentiment had me reflecting on the violence in our communities. Chicago’s homicide rate was in most news reports I heard over the New Year holiday weekend but for a small city, we give them a run for their money. Chicago had 24 murders per 100,000 people in 2016. In Salinas, the rate was 26 per 100,000 in 2015. Is there a system that generates these levels of trauma and resulting homicide? Surely not a system that was intelligently designed to do so, but what systemic factors contribute? There is enough written on this subject to fill a library, yet the problem persists. Drugs, poverty, weapons, parenting, gangs, and morals are a few of the usual suspects. These are the cogs in the trauma-generating machine. What are doctors supposed to do about it? Is there anything we can do about it? Does it help to have the bearded man in the white coat give the young violence victim a lecture on these various subjects while inserting his thoracostomy tube? “Why don’t you get a life, kid?!” I have met a doctor who might know part of a real answer. Kenneth Ginsburg, MD, is a pediatrician who specializes in adolescent medicine at the Children’s Hospital of Philadelphia and is an expert on trauma informed care. He wrote the American Academy of Pediatrics’ text Reaching Teens: Strength-Based Communication Strategies to Build Resilience and Support Healthy Adolescent Development, and I believe he is worth hearing. Ginsburg developed his thinking while directing health services at Covenant House, the organization that provides shelter, food, immediate crisis care, and an array of other services to homeless, runaway and marginalized youth. He writes about how adverse childhood events, or childhood trauma, has life-long consequences. Trauma takes control away from children, and many of their later, unhealthy and dangerous behaviors are adaptations that give them back some control. One of the greatest gifts we can give a young person is to help restore a real sense of healthy control. Trauma informed care is
MCMS PRESIDENT
Unplugging the Trauma Generator
Craig A. Walls, MD PhD, is the 2016-2017 president of the Monterey County Medical Society. He is an Emergency Medicine doctor with the California Emergency Physicians Medical Group and is currently practicing with Natividad Medical Center in Monterey.
JANUARY / FEBRUARY 2017 | THE BULLETIN | 7