sMater | Dr Georgia Heathcote | Trauma Informed Care

In this week's episode, Mater Obstetrician and Gynaecologist Dr Georgia Heathcote takes a deep dive into trauma informed care, and the impact of a trauma response on physiological and mental health.

Dr Heathcote is passionate about the establishment of universal precautions for trauma, and discusses the value of sympathetic nervous system therapy.

GP Education activity log:
  Podcast title - sMater: Trauma Informed Care
  Provider - Mater Misericordiae Ltd
  Date published - October 11, 2024
  Certificate of completion - click here

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Jillian Whiting and we're coming to you from Meanjin the land on which this podcast is being recorded. Hello I'm Maggie Robin, Community GP rural GP obstetrician at Beaudesert Hospital and coordinator of Mater's GP shared care education program.

In this episode, we're talking about trauma informed care with Dr Georgia Heathcote. Georgia is an obstetrician and gynecologist at Mater Mother's Private Brisbane. She treats a wide range of conditions affecting people across their life including menstrual problems, cervical abnormalities and menopause.

Dr Heathcote adopts a trauma informed approach and has special interest in persistent pelvic pain. Georgia is joining us to talk about how critical a trauma informed approach to healthcare can be.

We are Mater. We are Mater. We are Mater. This is sMater.

Georgia, welcome to sMater. Thanks for having me. Now trauma can look different to each person they can experience it in different ways. I think it's important to begin with an explanation in this context. What is trauma?

Yeah so trauma is where our body's normal coping mechanisms become overwhelmed by the sensory input and so you know where an event is normally processed initially in the limbic system, in the amygdala, in the hippocampus and then heads up towards the you know medial prefrontal cortex to actually be analyzed and then logged in the brain. This process is disrupted and so a lot of trauma is stored in our midbrain in our you know emotional brain, in that amygdala and hippocampus and when that happens it can really disrupt the normal functioning of our executive functioning particularly but the functioning of our of our brain in general so the impact that this can have on women can be huge and lifelong.

Georgia, what do we know about the physiological impact of trauma on the body? Yeah it's actually in the last 20 to 30 years with the development of the adverse childhood events studies or you know the ACE studies that have really shown that trauma in childhood for example whether that be through neglect abuse or specific events that have occurred in childhood can actually rewire the way that you know that child's brain functions and can result in that that child and then adult being quite sympathetic driven and when we're sympathetically driven we exist in a state of cortisol dominance, we exist in a state of you know adrenaline overdrive. There's lots of studies showing for example that baseline heart rate variability decreases and that our breathing and heart rate are no longer coordinated and those things are associated with high blood pressure,  it's associated with high cholesterol. For people who exist in a state of sympathetic drive then they're often seeking soothing behaviors and those soothing behaviors can be quite maladaptive like excessive alcohol drinking you know other substance misuse and also depending on the source of that trauma it can also result in a complete lack of engagement with healthcare and so you have this you know late presentations, you have people who just you know haven't done for example their their screening cervical test and so the ramifications for you know these women down the track can be really significant but trauma it is widespread and the impact is huge and the changes that happen in the brain also can result in a decrease in cognitive function so for example functional MRI imaging actually shows that there's decreased blood flow to the medial prefrontal cortex for people who have experienced trauma.

Do you have any numbers to really get a grip of understanding the size of this and therefore going on to say how important trauma informed care is?

So it really depends on how we want to define trauma so if we're talking about complex PTSD for example which is a very specific diagnosis then the numbers are a little bit smaller you know one of the numbers I saw I think was 5 million Australians living with complex PTSD. Depending on the studies you read if we're just talking about somebody having experienced a traumatic episode in their life then that's up to 70% of people whether or not that traumatic episode has resulted in a trauma response is you know that it does trauma doesn't necessarily always follow that there's going to be a maladaptive traumatic
response but we should be approaching all of our patients as though they have a lived trauma experience and we should be adopting universal precautions in that setting.

Georgia, when we hear that term universal precautions I think a lot of us initially think of universal precautions against transmitting or picking up infections.

How do we use that word universal precautions in terms of trauma and informed care. When we think about you know people who have lived experience of trauma or people who have experienced trauma and we think of you know potentially 70% of the people we encounter have lived with trauma in their life, then adopting universal precautions is an absolute no-brainer. You know universal precautions just simply describes a standard of practice that we should all be trying to meet where we treat our patients you know with empathy and make sure that they are feeling safe  in the consulting room with us and there's some really simple practical things that we can do there to make that a reality.

Georgia can you give me an example of what trauma informed care looks like in a clinical situation?

So really simple thing so you know when a patient comes into the room obviously introduce yourself, making sure
that your patient has easy access to an exit so that they're sitting close to the door,  that you really bring them along the journey with them so when you're
having discussions with them about you know what the your recommendations are you know you're actually explaining to them reasoning behind that they have more collaboration in their care so explaining exactly why you're wanting them to go for a 40-minute walk three times a week and what that actually does for their lower back pain and what that actually does to help regulate their nervous system. If we're doing an examination really explaining to them to your women what is it that you're wanting to get out of this examination. They're really intimate exams pelvic exams and  for a woman to feel as though this examination was necessary is really important. When we are examining you know there's no need for a woman to get completely naked of course 

if she's wanting we can you know keep dresses on and just move you know bits of blankets at a time to expose as needed. Always letting them know when we're about to touch, exactly what it is so when I'm examining my women from a gynecological point of view I'll say I'm looking at your vulva

or I'm just going to touch now, my fingers going inside, I'm feeling your cervix and I'm just going to do a manual examination now, I want to see if there's any nodularity around the uterosacrual

ligaments that could indicate endometriosis. Is your uterus mobile, I'm just assessing that. I'm heading out to your ovarian region now to see what I can feel and now I'm just going to run the pelvic muscles you know to see if there's any spasm or any exquisite pain there as well and you know I talk to them about what I'm feeling as I'm doing it and it also gives them much more knowledge about their own body.

Georgia, when we're talking more specifically about perinatal healthcare, what kinds of traumas do GPs need to particularly bear in mind?

So when I'm thinking about perinatal healthcare, I think about it in two ways. Firstly childbirth can be traumatic.

No matter how well we manage a pregnancy and a birth some women are going to have a big bleed some women are going to have a shoulder dystocia some women are going to have a third or fourth degree tear. That is an unavoidable fact of life. So firstly recognizing that child birth can be a trouble is is a high risk life event for trauma exposure and then ideally identifying which women we think have had a traumatic response to that birth and it doesn't have to be a complicated birth to have a trauma response and so making sure that we're thinking about the risk of trauma with delivery not just from complications but just from the birthing process itself. Identifying women who potentially are at risk of trauma from birthing and finding ways to deescalate their trauma response and help them complete their stress cycle in an adaptive way that allows them to resolve those memories in a way that they can reflect on and say 'that was tough' but not reflect on and relive in a traumatic way and then the other thing I think about him in perinatal care as well is what is this woman's specific risk for trauma. So you know does she have a history of developmental trauma and significant adverse childhood events? Has she had traumatic episodes? You know is she a survivor of domestic violence? Is she a survivor of sexual abuse? Was she in a big car crash that resulted in a long hospital stay. Things like that let me know that this woman is higher risk again for trauma from the birthing experience so you know thinking about it in those two ways.

You spoke earlier George about completing a trauma cycle. How does someone do that? Are there different ways that someone can do that and how can we help them to do that in a better way?

So we want to complete our stress cycle and this is when we talk about top down versus bottom up, you know kind of moderation of our stress cycle and top down is things like CBT DBT where we actually try and you know cognitively reframe what's happened in our minds. That can be really difficult to do in the moment and it can be really difficult to do in the in the days after and so having a chat to your patient about talking about bottom up ways to complete the stress cycle so you know when our body is so symptomatic from what's happened thinking about trying to rethink things probably isn't going to work and so this is where embodiment techniques and sematic therapy comes into it and so that's things like for example
you know vagal breath work, yoga has great evidence in terms of just improving baseline heart rate variability and helping decrease you know PTSD symptoms. There's ongoing evolving evidence around sound therapy in terms of decreasing PTSD symptoms and anxiety and depression symptoms as well and so looking at ways to calm the body down and if we can slow our heart rate slow our breathing decrease those tremors in our body then that can send signals back up to the brain that we are safe my body is safe and therefore my brain can be safe again and so that's a way that we can reduce that sympathetic drive and bring us back into parasympathetic or vagal dominance and allow our brain to incorporate that traumatic event back into our brain in a in a you know more adaptive way.

It's such an interesting area. How much research has been done, is being done? Where does the future lie because I'm thinking probably not every Medical Professional will be following a trauma informed care approach.

This wasn't taught in medical school. If you're wanting to learn more the obvious place to start is with Bessel Van Der Kolk's work. He wrote this you know great book called The Body Keeps The Score in 2016 and it is just the trauma Bible and it goes from starts off at the physiology and goes all the way down to different treatment modalities that you can you know help assist your patients with but you know if you have a look online at you know a lot of the different sematic techniques. There is emerging evidence out there to support you know sematic sound therapy in reducing anxiety and depression, acupuncture to in reducing stress levels as well so having a think about some more alternative therapies that focus more on the body and less on the mind. Psychiatrist and Trauma specialist Bessel Van Der Kolk is the founder and medical director of the trauma Research Foundation and a professor of Psychiatry at Boston University Medical School. In his book The Body Keeps The Score, Van Der Kolk shows that the terror and isolation at the core of trauma literally reshapes both brain and body. His research also shows that yoga can have better results than any drug studies have to date for PTSD adding that every trauma survivor would benefit from engaging in practices that increase their inner bodily sense of control, safety and flexibility.

As you said before a lot of this isn't taught to us in medical school. As a GP if we feel that we're uncovering significant trauma in someone's background and we feel that we need some extra help and support for that patient what should be our approach? You know particularly in the perinatal setting I would you know you'd probably want to repeat your EPDS right there and then just to make sure there's you know no the score isn't well above 12 implying that we need to do some quite acute interventions. I would be talking to them about further psychological support.
Maybe this woman's already linked in with a psychologist and maybe should just be increasing the frequency of her reviews. I'd also be having a chat to her about what type of psychological support are you having? Is there any sematic therapy tied into that psychological support and then having actually having a low threshold to refer to perinatal occupational therapists. You know the Mater occupational therapy team are wonderful and they can actually teach grounding techniques, they can teach breath work techniques if she is pregnant and imminently birthing we're not talking about trying to resolve her past trauma we're just trying to get her through this episode without her being further traumatized by the birthing process. Medical traumatization is real you know we have you know so many patients who are avoidant of health care because of an experience they've had in the past and usually that medical almost always that medical trauma or traumatization I should say is unintentional but that's why universal precautions are so important because if we keep that concept at the front of our mind and we fold those behaviors in so they become habitual we're far less likely to cause unintended medical trauma for our patients. So I think, well for most of us who work in health and particularly for those of us who have done a lot of perinatal work, we often carry our own traumas and we often carry memories of challenging clinical things that we've gone through. How do we manage our own secondary trauma or vicarious trauma and how do we manage our compassion fatigue so that we can still be effective caregivers for our patients?

It's actually about recognizing that the work that we do is really energy intensive and if we want to do it well it does create a fair bit of empathy and that can be really draining for ourselves and you know making sure that of course we're you know not taking on the patient's trauma for ourselves but then looking at ways of co-regulation so it's you know our job to make sure that we ourselves are regulated otherwise how can we help somebody else become regulated if we need to recognizing those symptoms and being willing to take a break because I think some of us the culture in medicine is changing but it has always been very much you just work work work until you burn out and then you have to have a break and then you go back and work work work.

Is there acceptance within the medical profession about taking that time for yourself or is it still a little challenging? It's growing. The acceptance is growing. So positive signs a little bit more work to do. Exactly. Okay Georgia thanks so much for joining us today.

Before you go though we have a little segment we like to call The checkup. So we have Maggie about to ask you five quick questions and this is just a little surprise for you. But to understand more about you as a medical professional and more of a person. So Maggie you ready? Over to you Georgia what was your first ever part-time job? Well my first part-time job I was I used to babysit a lot but that was like money under the table. Does that count?

So I like I had a whole lot of families around my neighborhood and I'd just go duck over to their place for a couple hours on a Saturday night so they could go out. 

Do you have a pet peeve like something that just really bugs you? I don't know if I've got one really I mean I'm pretty relaxed. Excellent.

If you weren't doing this, if you weren't doing medicine what would you be doing? Be a gardener. Yeah I'd be out in the garden just like I don't know trimming hedges pulling out weeds. Is that how you distress? It is it is much less than I would like to at the moment I've got a lot of babies being born but yeah I love to de-stress in the garden. 

If you could impart one piece of advice to a medical student what would it be? Just say go into each of your rotations with curiosity and take the time to have a think about not what the job is right now but what the job will be in 20 years so have a look at the consultants you're working with and is that the lifestyle you want is that the day-to-day living experience that you want because the realities of being a resident and a medical student are very different from the realities of being a consultant.

Do you have a go-to karaoke song? When I'm at karaoke and with my husband it's Tainted Love. Oh fantastic. I thought you going to say Island's in the Stream.

Thanks again so much for joining us on sMater. Thanks for having me - appreciate it. Fr our listeners at home or in the car or having a well-deserved break between patients, thanks for tuning in. See you next time on sMater.