Well, good afternoon, everybody. Thank you for joining us today for the TCAA webinar. My name is Missy Anderson. I'll be your moderator today. I'm the Pediatric Trauma Program Manager at Denver Health out in Colorado. And I have the honor and privilege of introducing Jenea Gordon, who is our speaker today. So Jenea is a Certified Child Life Specialist and is in a new role of Patient Emotional Safety Specialist at Children's Hospital Colorado. She co-wrote the paper, Trauma-Focused Medical Play, in the Handbook of Medical Play Therapy in Child Life, is co-author of the training manual, Engage, Calm, Distract, Understanding and Responding to Children in Crisis, and authored the paper, Emotional Safety in Pediatrics. Jenea created and taught a graduate course at the Erickson Institute entitled Trauma-Informed Practice in Child Life. And Jenea, we're very excited to have you speak, and I'll hand it over to you. Thank you so much. I appreciate it. Thank you all for having me join you today. I appreciate the introduction and everybody joining us. I am going to talk today about, like you said, trauma, and my lens is pediatrics, but what we're talking about, most of these things really can apply to all ages and all populations. So though I'm speaking specifically about our pediatric patients, just think about how this could look for you in your practice as you're working with adults, adolescents, young adults, and pediatric patients as well. And just a little bit of an explanation of what a Child Life Specialist is before we move into the presentation, because I am aware that not everybody works with child life. So our background is in human development family studies, and we study the psychology and children and how children understand and make sense of the world, how they cope, how they express feelings, what common things they think and feel at different developmental stages. And then we take that and apply it to the medical setting. So understanding how medical information and situations impact children, developmentally, emotionally, their thought processes. And then we implement tactics that will help decrease the stress and trauma of that experience for children. And then in this new patient emotional safety specialist position, I have now moved to the safety team, and we are really expanding our definition of harm to include emotional harm and looking at processes, policies and procedures, and the way we do things as an organization and how we can decrease the emotional harm while we're caring for our patients. In 2022, there was over 6 million children from the ages of birth to 19 who experienced a traumatic injury. And we know that not, I'm in a freestanding children's hospital, but we know that that's rare. We know that children are being seen in all types of environments. They're being treated on the scene of the trauma or the events. They're being seen in adult settings, in maybe a pediatric environment within an adult setting or in freestanding pediatric settings. But what I know is that we do a really good job about training our medical team members and healthcare professionals around how illness and injury and treatment looks different in children. The difference between an injury and what that looks like in a newborn versus a 20-year-old versus a 75-year-old and how we can treat them to meet their specific needs. And what I'm realizing in my 20-plus years in this field is that we're not doing as much educating of our professionals around how to care for that emotional impact that happens to kids. And so what we want to make sure is that while we're helping these patients heal, that we aren't creating this new trauma for them or exacerbating their existing trauma. The National Child Traumatic Stress Network reports that about 80% of pediatric patients and their families experience some form of traumatic stress following a hospitalization for a life-threatening illness or injury. When I found that percentage, it really struck me. One, as a child life specialist, I really felt this number. As much as we are well-intended and we're doing the best we can with our patients, that the treatment in and of itself is innately scary and oftentimes painful. So there are things that we can be doing better that can decrease the impact of that pain and decrease that fear for our patients so that they aren't experiencing this high level of traumatic stress. One of the other things that struck me about this percentage is that it's not just the patients who are treated, but it's their families as well. So siblings, parents, caregivers, this can extend to anybody who is close to the child. And it doesn't mean that they were necessarily even in the hospital setting with the child. Kids talk about their experiences. So we know a child can go home and tell their brother or sister about the frightening event that happened, and now that child might have this secondary trauma, and they may start to have their own fears based on that. So it really does touch the whole family. A couple of terms that are really impactful here. Pediatric medical traumatic stress is a term that I'm hearing more about recently. This isn't in and of itself a diagnosis in the DSM, but it is the symptoms, if they persist, can turn into post-traumatic stress disorder. So it's the physical and emotional responses that children have, not just to the illness or injury itself, but also to the medical experiences that cause fear and pain in them. So patients can be experiencing this pediatric medical traumatic stress while we're caring for them, and it can continue on and carry over through their lives. And as I said, with this new position of patient emotional safety specialist, we're really expanding our definition of that iatrogenic or healthcare-associated harm to say we are dedicated to ensuring that our patients do not leave here with an illness or an injury that they acquired while they were here. And usually we're talking about very physical, tangible situations, like giving the wrong med, or a patient falling and getting injured, or a central line infection. But what we need to start talking more about is that this medical traumatic stress, acute traumatic stress, which can all turn into, you know, long-term issues, but are equally as important when they're in the acute phase, that is a level of harm. And that is something that can cause physical and emotional harm for the patient in the short term and in the long term. And so we want to expand our definition to include that harm. We see the immediate impact of this level of pain and fear and trauma on patients when we're caring for them. We could see their psychological stress responses, so, or physiological, so you might see that heart rate increasing, breathing changes, maybe they're holding their breath or they're breathing rapidly. And that can make it difficult to figure out when we're looking at them physiologically, what is the injury, what is pain versus what is fear. So helping make a calmer environment and helping them stay calm can help you with teasing out what to focus on and what the impact of the actual injury is. We see the trauma responses and how that impacts their behavior, so their ability to cope, and understand what's happening in the moment. They may not be able to cooperate as well. So, you know, we often hear parents say, she's such a good kid, I'm really surprised she's behaving this way. If the child is screaming or fighting or hiding or, you know, holding their body away so that we can't assess them. And understanding that that is they're in that fight or flight, and they usually can't flee. So, you know, they're going to fight back or they may even start to shut down and we may see a child who is completely quiet, who isn't talking very much, who's sort of passively letting things happen to them. And that's very helpful from a healthcare perspective, because we're able to treat them without with minimal interference, but also just being aware that that is actually a trauma response sometimes. And that could be that they're very terrified still and they but they're internalizing it, they're not externalizing those experiences so much. So it looks like they're coping well, when in actuality, they're really internalizing all of that. And for those kiddos, we really want to make sure that their family knows how to continue to support them, especially when they go home, because they need to get that out in some healthy way. We also know that pain and fear are connected. So when children, but adults as well, when we are fearful, our perception of pain heightens. So helping create a calmer environment and helping a child understand what's happening in an appropriate way might decrease that fear, which actually helps us to get a better handle on what is actually pain, especially for smaller children where it's hard for them to have the language or even the self-awareness to differentiate these knots in my stomach from fear are uncomfortable. But also is that helping them tease out, do you think that your stomach is aching because you're really nervous right now? Or do you think that it's like something is hurting in there? And so helping them tease that out is great. It also shows up as noncompliance, missed appointments. They may not cooperate with meds, with procedures. It may be that they struggled so much and were so anxious that when they have that follow-up appointment, the family is like, they seem to be fine and it's not worth the additional trauma of trying to get them back in there. Those are just different things that we see in the immediate when we're caring for kids, whether it's on the scene or in the ED, inpatient or ICUs, but there also can be a long-term impact of this. So what we know is that adults who are needle phobic or medical avoidant can oftentimes pinpoint medical procedures in their childhood where that fear began. And that makes sense to us. We all know people who are in the ICU. And so then those folks tend to, like I said, only go if it's gotten so bad that they don't have another choice. And at that point, the progression of the illness or injury has gone a lot further, that they are going to need more treatment. It's more costly. It takes longer. Their life is more at risk. So understanding that while things might be faster for us as health care providers to be able to provide that care, it's not going to be faster for them to be able to provide that care. Things might be faster for us as health care providers in the moment. We could hold them down, get it done. They'll be fine. Kids are resilient. We don't know which kids will be resilient and which kids will have either short-term or long-term negative impact from how we're treating them. And what we know is that that long-term impact can really decrease their health-related quality of life. Talking about emotional safety, the Association of Child Life Professionals has done two big summits. One was in 2019 with frontline team members, nurses, child life specialists, physicians, psychologists. We had a couple of parents who were there. And we really talked about what is the definition of emotional safety and how can we support this emotionally safe medical practice in our organizations and with the patients and families that we're working with. And so this is the definition that we created that came from that think tank. One of the things that I think is really important to point out is that word intentional and understanding that oftentimes in health care, we react to the emotional situation once it's come up. So my professional background in clinical work is that I worked in the surgical trauma inpatient unit in the emergency department and in the PICU. And one of the things over the many years of working in those areas that I saw is that we often didn't plan for the pain and fear before we provided medical care. We waited until the child was not coping and we couldn't move forward. And then we started to plan. Maybe if you have child life specialists in your organization, that's the time that they would be called in. Or we might stop and think, OK, maybe we need more pain meds. But do we have time to order it, call it up, wait, readminister? Or is it better just to keep going and have them be at a high level of pain and fear and finish earlier? Which there's not a good answer for that, if which one is better for the child. But what is better is to be intentional about our planning. And we'll talk about ways to do that. Emotional safety is really this large umbrella term. And it covers a lot of things that we're hearing a lot and using a lot of different terms in health care of ways to really improve the experience and improve the level of care we're providing patients. And that it goes so far beyond the medical treatment that we're providing. So this emotionally safe care encompasses care that's developmentally appropriate, it's trauma-informed, it's culture-centered, it's age-traumatic, and it's family-centered. So this isn't a separate ban. It's not like this is another type of care. It's really pulling everything that we're already talking about together and giving it one clear name. So when we're advocating for our patients or we're planning for our patients' care, we can just pause and think, is this, it's almost like having a timeout, like an emotional safety timeout. Hold on, am I considering their development? Am I considering their fear? Am I considering their support system? Am I considering their culture and their sensory sensitivities, their developmental needs, all of these things? And so being able to say, hold on, let's think about this from an emotional safety perspective can mean any one of those things. It's pain, fear, experiences, needs, all of that falls into these types of care. When we're talking about trauma specifically, it's important to remember what happens to the brain when we're experiencing trauma. And knowing that the energy and focus of our brain when something traumatic is happening, it all goes to that center part of the brain, that reptilian part. So we have, you know, you've got your amygdala and hippocampus and this whole system that is working together to help us decipher what is a real threat. If it's a real threat, what do I need to do about it? Do I have any sort of memory to associate to help me understand if this is a real perceived imagined threat? And then how do I want to act? Do I want to fight, flight, freeze? There's the fall asleep, fawning, you know, we're expanding our definitions of what that limbic system does. And that takes a tremendous amount of energy and focus. So understanding that when we're working with patients and something frightening is happening and has happened, that that energy is like in that center part of the brain. And so when you're looking at that frontal lobe, prefrontal cortex, that's not functioning as well. We're really just thinking about our safety. So being able to absorb information, decipher information, follow steps, our ability to do this, then that, then that. If we're told to do three things sequentially, that that becomes harder for our brain to tease out. It's harder for us to even hear and absorb information and it's harder for us to articulate ourselves. And this is true for everyone, regardless of age or developmental level. So when we're giving our patients information and hoping that it's helping them cope better, understanding that they're not functioning at their highest selves in that moment. It's that kind of trauma brain. So adapting how we're speaking and adapting our level of care to understand that. And knowing that the trauma isn't over just when the incident has finished. So if the accident, the assault, the natural disaster, whatever it is, when we're caring for these patients, whether it's in the field or in our hospitals, or even sometimes in follow-up appointments, that is all part, for some kids, that's still a part of that peritrauma phase. They are still in a state of uncertainty, of fear, of unknown, and of pain. We're doing things that are frightening and painful to help them. So understanding that they are still in that trauma and supporting them appropriately. With the trauma-informed approach, we're really going to talk about how to develop trust, how to understand their responses, how to provide support for medical procedures, how to communicate, and ways to reduce trauma reminders in the medical experience. First, we'll talk about general tips in working with children and how to build rapport quickly and really just help create an environment where they're more calm and trusting and a bit more relaxed with us. One of the easiest, quickest things to do is to get physically on their level. So to squat down, sit down, make sure that we're eye-to-eye with them. Because having people tower over us, regardless of our age, is intimidating. So getting on their level, speaking softly, being honest and sensitive. We'll talk more about language choice later. Introducing yourself and letting them know what your role is and what you're there to do. Not every time somebody walks in the room are they going to need to touch that child. So letting them know that when they come in. Because what we know is that they are going to tense up sometimes. So we want to make sure that as a Child Life Specialist, I would introduce myself by saying, hi, I'm Jenea. My job is called Child Life Specialist and my job here is to help you understand what's happening and to just try to make things better for you while you're here at the hospital and we're taking care of you. Right now, I'm just going to sit by their bed and talk to you and your parents and I'm not going to touch you. And so just a quick introduction of your name, your role, and what you're doing is going to really help. Even if you're just talking at first and then you'll transition to assessing or touching, you could say, for right now I'm talking and I'll let you know if anything changes or if I need to touch your body or look at your body in any way. Ask them rapport-building questions. So asking questions that are pretty benign, just asking, you know, what are their favorite animals? Are there any TV shows or movies that they really like right now? Do they have a favorite comfort item at home? We want to avoid making assumptions, so we don't want to assume that this is mom and dad or grandpa or, you know, we definitely, families have an all different sort of, they present in different ways and also knowing that we have kids who maybe are in foster care, who don't have parents that are in their lives, or they could be here with their neighbors because the incident happened to the neighbor, not the parent. So it's always easier just to say to the child, who did you bring with you today? And let them tell you, this is my mom, this is my neighbor, this is my auntie, this is my foster mom or foster dad, instead of guessing and then having to backpedal because we've all done that, where we kind of step in it and then you have to go back. So just open-ended question, who did you bring with you today? Avoiding asking them to be brave or strong, fear is absolutely a normal and appropriate response in these situations. And so telling them to be brave or stop crying just adds shame on top of the fear and trauma they're experiencing and tells them that expressing their emotions is not okay. And so giving them specific choices and jobs to do is always helpful. So validating that this could be a scary experience and then offer realistic choices. So the choices aren't, can I listen to your heart? But it's, do you, I'm going to listen to your body now, do you want me to start with your chest or your tummy or your back? You know, when you're leaving the room, do you want me to leave the door open or closed? Would you like the TV on or off? Do you want me to look at your right arm or your left arm first? And this is great for adults too, like just giving all of us some control really helps with cooperation and trust. When we're helping children calm down, remember that oftentimes they're very concrete in that concrete thinking phase. So even if they're a little bit older in their adolescence and they can think abstractly and they understand humor and sarcasm, remember that piece of the brain of being in that limbic system that we need to, they might be operating at a more concrete phase than they would if they're like hanging out with their friends. So you know, we want to avoid teasing or sarcasm because in that moment of fear and uncertainty, they're not thinking as their full selves and they can misinterpret that and be offended or get confused. So saying things to kids like, just breathe, I've had kids actually say out loud, I am breathing. So instead of telling them, breathe, it's okay, honey, just breathe, show them. Have them put their hands on their stomach and say, can you breathe really slow and deep into your tummy like me? And show them what that looks like. Having visual aids is really helpful. So if you've got little pinwheels or if your hospital allows bubbles, you can get bubbles that can go on your badge or in your pocket or on your key chain. That really helps them take that slow deep breath and it's great for younger kids, especially because they visually can see what's happening. Encouraging them to squeeze a stress ball or someone's hand, letting them know, you know, sometimes they don't always arrive with their caregivers, obviously. And so if we know that the caregivers have been contacted and are on their way to the hospital, letting them know that. If we don't know yet, we're trying to find caregiver or find next of kin and sort everything out, then you could just tell them, you know, we have a team of people who are doing everything they can to find the adults in your life who will, who can come to the hospital and be with you, and we'll let you know when they're on their way. And then providing stuffed animals or comfort items is really helpful as well, if you're able to. It's a great way to engage the community to ask for donations of those types of things. Anything, soft blankets, stuffed animals. And understanding that when we're working with kids, just like that 80%, it wasn't just the patient. It was the parents, caregivers, siblings who experienced that trauma as well. So partnering with them and giving them a role, treating them with respect, keeping them with the children as much as possible. I understand sometimes the parents and caregivers are escalated and it's not helpful to have them in that space. But in all my years, like I'm thinking specifically in the ED, when you're still in that heightened crisis mode, it was very, very rare that we asked a family member to step out of the room because they were too escalated. If you connect with that parent or caregiver, you ask them how their child copes, you give them a job or give them a role, why don't you sit by, sit right here and hold their hand? Why don't you show them how to take slow, deep breaths? Or can you pull up their favorite movie on a phone? So just like we give kids a job to do to help them feel successful as adults, we need to feel like we're in control and we're helping the child in some way as well. It focuses that energy on the job and can help them calm down and regulate and help their child do the same. We're going to shift into talking about what trauma looks like in children and some simple things we can do to help them. Being separated from the caregiver, even for older kids, can be heightened when they're in this trauma state. So even a teenager who typically wants to be on their own and doesn't want their parent maybe even in their doctor's appointment with them, but they want to have eyes on their parent now. They'd like them to be bedside or to have eyes on them. So trying to keep them together and help the parent be supportive in that role. This is especially true, of course, for kids who are in the developmental stage of that separation anxiety and stranger anxiety. So if you could have the small child being held on the parent's lap, that's ideal. Obviously, it's not always medically possible. So having them as close to the child as possible, providing that comfort and being with them, because it's one less level of escalation. If you separate the parent and the child starts to escalate, it's harder for you to do your role. So if you can keep them there and give the parent a job in comforting the child, that can help. Understanding that sometimes trauma will look like they're withdrawing, so they don't want to talk, they don't want to play, they don't want to engage. And so it's helpful to offer both active and passive items for distraction and play for kids. So maybe it's just that we have a movie or music on, even if they're not looking at it, it's softening the environment for them. Versus other kids want to be more active in their fear and they want to play or they need to act and have some sort of active way to play. So giving them toys, games, those types of things can help them. And then for older kids, especially once they're more in the inpatient side of things and things have settled down, giving them a private journal so that they can process on their own is helpful. Knowing that there might be trouble with sleeping, with nightmares, so providing that comfort and routine and support. They may need a nightlight in the room, they might need white noise machine, they might need some soft music. Again, comfort items are really helpful. Trying to provide a sense of routine, they're pretty much in pajamas the whole time, but at this time we're going to brush your teeth and we're going to read a story, then it's lights out. So providing that little bit of routine back into this experience. Understanding that there's regression of skills, especially for littler kids who have just been potty trained or just learned to walk or crawl. Older kids, if they are learning to read or they're learning these new skills, just again, thinking of that brain going back to the center of the brain when we're in a fearful trauma state that those newer skills will fall off for a little bit. And just encouraging families not to shame or push them about, you were a big boy last week and you went potty on the bathroom last week. Their whole being is just trying to get through this moment. So practicing a new skill is probably not going to happen. So not shaming them and then just knowing that they will regain that skill. And we always want to give parents resources when they leave the hospital about things to look for if it continues and how to get help from there. But in our presence in the hospital, it's okay. We're obviously going to see mood changes, maybe some irritability. Fear can actually look like anger in some folks. And so understanding that anger, outbursts, crying, flat affect, any behavior change is actually normal during this time. So again, comfort, routine, choices, addressing that pain and fear to the best that we can, having support with them is going to help with that. That doesn't mean that we aren't providing boundaries though. We want to, especially for parents, we want them to know how to do this when they get home, that we don't throw all the rules out the window because something scary happened. That actually adds to the child's fear and uncertainty. But what we are, we're gentle. So if a child is really acting out and they're having this explosive moment of saying, it's okay to be angry. It's not okay to hit me. What you can hit is the stuffed animal or pillow, or you can rip up this paper, or we can go for a walk and get some of that energy out. So it's okay to feel this way. It's not okay to do this action and then give them a positive action to replace it because we're not just telling them to stuff the feelings and they need to get that feeling out. And here's some appropriate ways to do that. I mean, that's applicable for adults too, for sure. With children, we might really hear them repeating their story again and again about what happened. This is their way of processing. They are thinking through it, talking through it, and they'll also have repetitive play where they'll play that, even if it's not a literal like one-to-one of the events. So I definitely had kids who will play out like the car crashes, the ambulance comes, we come to the hospital, they'll play that over and over. But sometimes it's something that is seemingly unrelated and they'll just keep repeating it. And they are working through the trauma. So when they're repeating of it is their way of pulling that memory and that experience from that center limbic system. And they're pulling it into the entire brain, which is really helpful for them in the long run. So we don't want to stop that process. We want that memory to become diffuse and to have all the senses attached to it and reason and first then and future state attached to it. We don't want them to stay in that limbic system. But what we want to make sure when they are repeatedly telling or playing through a story is not to let them stop at the worst part. That's very common to say, I was crossing the street and all of a sudden I felt my body flying through the air. And then I looked down and there was blood everywhere. And then that's their telling of a story. What we don't want to do is stop there because that's not where their story ended. So then saying, who came to help you? Who called for help? I don't know. There was somebody there and they were on the phone. Okay. So they, a stranger saw that you were hurt and that you needed help. And they thought to call 911 to get you help. Then who came to the street to help you? Ambulance, fire, all these different people. My parents were there. So pointing out all the helpers that came to try to make sure that you were okay. And then you got to the hospital. Who's helping you now? Doctors, nurses, respiratory therapy, child specialist, social workers, talk about all the people that are helping them and their bodies to get better. And then it still doesn't end here. Again, this is the peripheral trauma phase. So they're going to move out and go home. So then who's going to help take care of you when you're home? And what's it going to be like when you get to hug your dog again? And what's the first thing you want to eat when you go home? And so you're pulling them out of the worst part of the story to a point of safety and to a nicer spot. Guilt is common. You know, especially for young kids who are in magical thinking stage that they can actually think that their negative thoughts or behavior caused this to happen. So it wasn't a trauma, but I had a patient who had an AVM rupture and they were critically ill. And the sibling felt like it was because they stayed up late playing video games, because his brother seized in that moment when they were up late. But he really thought that it was because they broke the rules that this was punishment for that. So it's important, especially with younger kids to say, regardless of if they're verbalizing it or not, because most of the time they're afraid and feeling shameful, so they're not going to say it. But just to tell them it's important that you understand that nothing that you said or did or thought made this happen. And then you could provide an age appropriate medical explanation for what happened or that this was an accident or, and just help them understand that it's not because you fought with your brother that this happened, or it's not because you were eating Cheetos and you weren't supposed to. It's not because you had mean thoughts about your brother three weeks ago and now this happened. For older kids and even for younger kids, sometimes there is a correlation between what happened, like they may have inadvertently caused or been a part of what happened. And so with those situations of really providing that support of, you know, we never thought something like this would happen. You never thought when you were playing by the river that your cousin would fall in. It's normal to want to play and you didn't realize that that could happen. Or even teens who do risk taking behaviors. So they knew that there was a risk attached, understanding that developmentally, they're taking risks. That's what they're doing. They're pushing the boundaries as these soon to be young adults. And so helping them understand that your brain right now doesn't always listen to what adults say about don't do this, it's dangerous. And did you ever think in your wildest dreams something terrible would happen and helping them understand that. But, you know, the guilt can be very real, especially when they were connected with it, with the event and maybe responsible for it. So again, giving families resources when they go home to continue that support. We already talked a little bit about the physical symptoms and helping them tease out what's emotion versus physical issues. And I think most importantly is understanding that no matter what, kids are so highly attuned to how the adults are responding. So if the child is, they're picking up on what we're doing to see what's okay, what's not okay. So for example, the child that's playing out the trauma, families might be like, oh, no, no, stop, don't do that. That's not nice. Or we don't want to think about that. We just accidentally told them that their story is too big and scary for adults to handle. And it's safer for them to keep it inside. What's really frightening about that, especially for young kids, is that magical thinking can so twist what happened and they could live for years of having some sort of guilt or misunderstanding about what happened, because we didn't allow them to tell their story and we didn't support them in that. And for older kids, too, of letting them know we don't talk about this, we pretend like it didn't happen, then they can really struggle with those internalized feelings, which can turn into, or externalize, it can look like more acting out, more risk-taking, aggression, or they can start to sort of cave into themselves with depression and anxiety. So as adults, we want to model keeping ourselves regulated. I love modeling that deep breathing for kids, especially when they were telling me their trauma story, or we were in the middle of a medical procedure that was really painful, because it actually calms me down, too, so we can co-regulate. Teaching them appropriate ways to deal with their feelings, helping them talk through their story in a safe way, having appropriate conversations, all of that is helpful because they are not just the child who's injured, but they're siblings, too. There's oftentimes where families say, we're not telling their brother or sister what happened, it's too scary. And so the first thing I do when I meet with the sibling and the parents is ask the sibling, what do you know about what's happened? And they will repeat bits and pieces of stories that they've overheard. They will fill in the blanks with their own misconceptions. So we just need to make sure that we are handling everything the best that we can as adults, and we're modeling that for the parents and caregivers, and that they're modeling that for their kids. Talking about medical procedures, we're now going to shift into that piece. Just to point out, this is actually a play hospital that was in my office when I worked in the PICU, and so that's the actual toy set that I played with the patients to help them, well, patients and siblings, cousins, friends, to help them process what's happening. As we talked about with the definition of emotional safety, it's so important to really plan ahead of time. So we know that most of the medical procedures that we're going to do are going to cause some amount of pain, and there's no reason to wait until the child is expressing pain to then stop and say, should we maybe medicate? We know that needle pokes, although as adults, if you're not needle phobic, they're not that big of a deal, but we know that needle procedures are rated as the most painful and frightening experiences that children have in the medical environment, and those are kids who had had surgery and kids who had gone through cancer treatments. They still rated pokes as the most painful and scary part of their process. So it's not the big things that we think of always. It's those IV starts, those lab draws, so coming up with a plan, using numbing, some sort of numbing agent if we're going to do a needle procedure, going ahead and having a plan A and plan B for that ortho reduction. We know that it's going to hurt reducing that fracture, and we don't know how well the child is going to cope with our first plan of action, so let's go ahead and have plan B ready in the room so that we don't have to stop and decide, are we going to let go of the arm, go get the med, wait, come back, and do it again, or can we have it on hand so we can go through it right away? We also, again, want to address that fear, so helping them understand in an age-appropriate way what's happening, using first event sequences. First, I'm going to tie this rubber band around your arm. It's going to squeeze, and then I'm going to clean your arm with some cold soap, and then I'm going to count to three, one, two, three, and you'll feel a poke, and that poke feeling will last for about 20 seconds, and then helping them with expectations. Your job is to hold very still. Your job is to hold, take a slow, deep breath, you know, stating it in the positive, not negative, and then helping with coping. You can watch. You can look away. You can squeeze a ball or dab tan, giving them options, so along those lines of language, we want to make sure that we're using softer words, that it's not about lying or tricking them, but it is about, you know, if we say I'm going to use this needle to draw your blood, you're going to have a much different reaction then. I need to put this little straw into your vein in your arm so that we can get you medicine, and the straw needs a helper to get into that vein. So you're going to feel a quick poke, and then I'm going to push a button. Once the poke is done, that poke leaves your body, and just the straw stays there. So it's helping them understand the why, what to expect, the order, and then helping them come up with a plan for coping. We also, another way that really helps decrease the stress for kids is comfort positioning. So what we often do when we're working with pediatrics is they're small. It's easy to hold them still so that we can get whatever procedure done. Just because they're smaller, though, and they can be handled in that way doesn't mean that that's the best way. We know that one of the things that can lead to post-traumatic stress disorder is a loss of bodily autonomy immediately following the incident. This is for adults as well. And so we want to give as many choices and ways for that bodily autonomy to stay intact while we're safely caring for them. With pediatrics, that's comfort positioning. So that's having the caregiver, or sometimes it can be a team member. I've stepped in and done that for kids if they asked me to, if the parents couldn't do it and the child asked me to. But usually it's going to be their trusted adult that's with them to hug them in a way that we are minimizing their ability to move around while also helping them feel supported and not feeling physically restrained and held down by adults. So you think about adult scary movies and some themes that we see about like alien invasions or abductions or these different types of scary events is that you are being held either physically or chemically still and that people are over you and that things are being done to your body that are painful or terrifying and that you do not have the ability to stop that from happening. And that in essence is what we're doing to children all the time when we're caring for them in the medical environment. And it doesn't have to be that terrifying. So kids cope better when they are sitting up versus when they're laying flat. There's a vulnerability to laying flat that I think all people react to, children, especially young children, even more so. So it's a kind of a double whammy for infants and toddlers when they're in that separation anxiety state where they're being comfortably held by the parent and you remove them and then you lay them flat and then you hold them down. So now you have a child who's screaming and sweating and flailing and it takes multiple team members to hold them still and we haven't even started the procedure yet. And what happens with these pictures is you can see the parents is holding in a safe way. So with infants that can be that they're swaddled and being held so that they can't flail and just their one arm is exposed and the parent is holding them and they're sucking on sucrose or they're being breastfed while they're having like a needle procedure if it's safe. With older kids, as you can see on the left, what's important that he's chest to back with his mom, her legs are actually kind of crossed over his. So if he starts to want to kick, she just closes her legs and he has no momentum to do that. You can also see that her arm, her right arm is over his arm. So he doesn't have free access for his arm because you know what he'll do as soon as you go with that poke, he's going to reach for that needle. So she's holding his hand and then she has her arm securing his arm. And then you have in these pictures a child specialist but you could have a team member or another parent who's providing distraction and pulling his view away from what's happening. When we're providing that distraction, we've talked about this giving them a job to do, telling them what to expect, engaging parents. One really important piece is to only have one person speaking at a time. What we tend to do, especially if the child is showing their anxiety, they're crying, they're starting to go, I don't want it, I don't want it, is that we all try to comfort that child. And so we end up having three or four people that are like, it's okay, honey, it'll be fast, we'll be over quick. I'm here, look at the light, look at this, you're okay. And so then it has the opposite effect of what we're intending. It's creating chaos and loudness in this environment instead of it being calm and quiet. So identify that one person who's going to coach the child, whether it's parents, a nurse, a tech, a child life specialist, one person is going to engage with that child and help them with the focus and everybody else can focus on their role. Similarly, what studies have found is that saying it's okay has a paradoxical effect. It actually makes adults as well and children, it increases the anxiety. And so it's such a common phrase and I've caught myself saying it as well. But knowing that when everything really is okay, we're not repeatedly saying it's okay. So it heightens their alert that like, whoa, it's not okay, they're all telling me it's okay. So avoid saying that, having one person focus on them and again, giving them, you know, do you want me to tell you what's happening as it happens? Or do you want to just focus on this light spinner? Do you want me to count to three before you feel the poke? Or do you want me just to do it? Remember that belly breathing we practiced? Remember squeezing dad's hand? So there's other ways that we could provide that comfort without saying it's okay. Looking at some easy distraction kits that you all can create for your environments. There's a lot of little things that you could put on your badge that, you know, like key chains or in your pocket. So if we have any EMT first responders on the call that there are ways that you can have small items accessible to you. Little iSpy cards are great for, you know, depending on the in-depth of the iSpy for kids that are like four and up. Push button books where they push it and it sings a song or anything that has cause and effect is really helpful because they're focusing. Sometimes just the passive, having an iPad or a phone to look at, it helps. But some kids really need something active to engage with. So having both options. The key really is that it's, you're having the engaging and passive distraction and that it can be wiped down and reused. Because I don't think any of us have the budget to have single use items. We do use stress balls as single use items, of course, but most of the things that we use can be wiped down. Another important component is communication. So going back to the idea of being intentional and planning is making sure that we're really thinking about the words we're choosing. And when we're speaking to families, how we're speaking to families, instead of it being more like, I have five minutes. I'm going to go in the room and talk about this right now. And then seeing the negative impact of that. And then it's so much harder to go back and fix it and repair that damage. When we're giving life-sensitive or life-changing or sensitive news, this is really important. We want to make sure that patients are not overhearing big information with handoff or during times of getting consent. So I've heard a child be told during consent for surgery when they came straight off of the helipad that they are likely paralyzed. That's not information that they needed in that moment as they have barely even settled into the room and are about to be rushed off to the OR. Or I've seen during handoff in the ED from EMT to the ED team where they say, this is the sole survivor of X, Y, or Z. Or multiple fatalities. Parents DOA, those types of things. And there's an assumption that maybe the kids aren't listening or don't understand. But absolutely, we want to make sure that that information is getting from those team members. Absolutely, that's a part of what we need to know. You all need to know that information. But can it be said in a quieter way to the key people instead of out in front of everybody? And can we make sure that somebody is distracting the child while those conversations are happening? And the timing. We don't want to get kids big news. We don't want to tell them about a fatality or paralysis or amputation or even a life-threatening, you know, a really scary surgery that they're going to have. We don't want to tell them all of that right before they're going to bed. We don't want to give them big news right before they're about to be sedated. We want them to have their support systems there to be told in a way that they can understand and to give them the space and time to absorb it, to ask questions and to express themselves. And if they're intubated and awake, or they are about to rush to the OR, or it's 10 o'clock at night, we will hold off on giving them information until they can process it and ask questions and engage with us. When there are fatalities and we, you know, of course, you go through HIPAA. If there's multiple kids are coming into the ED from the same event, you know, we're looking at HIPAA. We're looking at those parents saying it's okay to tell. But oftentimes there's some, when we're talking about somebody who died and they are not a patient here, guiding the family and how to do that, engaging social work, spiritual care, chaplain, I mean, child life, psychology, if this is like a rehab patient or a longer term patient, they're seeing psychology. And then being really clear and concrete about the person's body stopped working. Everybody tried everything they could to fix it, but they were hurt too badly. And their heart stopped beating and their brain stopped thinking and their body died. Now, I know that that is really sounds harsh and insensitive. I always prep parents before I help them give this information to kids to say just that. I know this sounds insensitive. And I know this was your other child we're talking about or your sister or whomever. And I don't mean to be insensitive. It's just that children understand death in a concrete way. And if we say that they're asleep or they went away or they passed away or they're no longer with us, that just causes confusion. So this is how we explain it to them. And then as you're helping them process their grief moving forward, of course, you'll add in your belief system to support that. When questions can't be answered in the moment. So we talked about that a minute ago about if they're about to go to sleep, if they have a brain injury, if they're unable to communicate in some way, we may not have permission to share the information yet. We may not have next of kin available here yet. So there's a lot of reasons why we can't always answer the questions when they say things like, where's my mommy? And we know, or we believe that mom has died or they might be asking, am I ever gonna walk again? Or questions along that. And we wanna be really mindful of how we answer it. So the first thing we wanna do is just validate. I know it's really hard to not know what's happening with your mom right now. I don't have all of the answers. I'm here taking care of you. And there's a lot of people who are trying to figure out exactly what happened to your mom. When we know more information, I promise you that we will talk to you about it. Right now, I need to focus on helping your body and figuring out where you're hurt so we could help you to get better. So that means we're going to go take pictures of your body and then you shift into what's happening right now. I will say in all of my years, I never had a child fight back about this and demand to know. So that tells me that they weren't probably ready to know. Older kids, especially if they saw their loved ones at the scene have a feeling that they died but aren't ready to hear that yet. So just staying in this space. What we don't want is people that we are uncomfortable with them being in that space of not knowing. And I've seen staff panic and say, I'm just going to tell them they deserve to know that their brother died. They deserve to be told in the right way at the right time with the right support. And the last piece we'll go through really quickly is just being aware of our environment. Knowing that while this is a healing environment, it also can have trauma reminders and the way we care for and talk to and around patients can be sort of re-triggering as far as their events. So we want to make things, their environment soft and we want to protect them when we can. So avoiding having medical conversations in the room or talking about what happened in the room. If they are constantly being overhearing like skier versus tree, multiple fractures, blah, blah, blah. Every time we do that, their mind is going right back to that trauma. So stepping out of the room to have those types of conversations, encouraging parents to have a family member be the one that is sharing the story and telling the appropriate people and not to have everybody calling the mom and dad bedside or the parent caregiver bedside. Also saying like, I know you want to talk to your sister and you're going through your own trauma, but let's have those conversations out of the room. We can find a private space for you to talk to your family member so your child isn't hearing this over and over again. And also being aware, like we have dogs at our hospital. We have volunteer dogs and we have child life specialists have working dogs. So if there's like, if it's a dog bite of being mindful and putting up signs, if the story is on the news, being aware of trying to limiting their access to TV and internet, it can take some creative planning to block those things until you're ready to tell the child that it's on the news and let them decide if they want to watch with loved ones if they're older, but really making sure we're minimizing that. And also the items and movies and things that we bring into the room. You know, if they were in a car accident, we don't want to maybe watch a racing movie or if they were in a fire, superhero movies have lots of explosions. So just being mindful of those things and reducing that when possible. There are some resources that I have on here that you're all welcome to look at that we've used. The Simply Saying is an app that helps use child-friendly language explain medical experiences. NCTSN has amazing resources specifically for healthcare providers on how to provide trauma-informed care to your patients. Healthcare Toolbox has, again, team member information about how to keep in mind the emotional impact of what's happening with your patients while you're caring for them. And this is a training kit that I created in collaboration with the Colorado Department of Public Health and Environment. And it's an in-depth training about everything that we've talked about. Trauma responses and how to provide care bedside. And they have downloadable printable cards that you could put on a ring or put in your pocket that have each age and the weight of that age group and coping in case you don't know how old the child is. And then EmotionalSafety.org has the white paper that I wrote. And other resources around emotional safe care. Okay, so that is the end of the presentation part. And I am happy to take questions or comments. Missy, I can't hear you. Can you hear me now? Sorry. Yes. You think I'd get all this down by now. So, great presentation. I see Christy posted in the resources for everything. So, the one question that I have actually is I know that, you know, when... So, nurse background, you're doing child life. We walk into patients' rooms and, you know, we might have fun scrubs on or fun clothes that are really that pediatric oriented. Do you chat with providers? And especially since, you know, we do have hospitals that are not freestanding children. Do you chat with your providers kind of about that white coat syndrome? Saying like, you know, when you go in and see these kids, because there is fear, right? It works in the adult side as well as the pediatric. You see that white coat and you kind of instantly go to a level 10, right? So, do you chat with your providers about, you know, how they approach? And because the parents is a lot, right? I mean, I can walk in with a scrub top and I look fun, but the minute I put on... But then you're doing a BCUG and yeah, like it's really more about what you're doing and how you're doing it. Absolutely, the white coat syndrome, we definitely have had patients that had such a strong phobia and that was a trigger, but also it could be the gloves are a trigger. So, and you can't avoid that. So, the best way is to really talk about you doing all of this, engaging with the child, being respectful, being developmentally appropriate, absolutely planning for pain and fear when you were caring for them. And hopefully that decreases. We don't really want there to be good people and bad people. And we're all caring for the child in the best way that we can. So, certainly if they have a specific phobia about the white coat, which is rare, but happens, then we'll say like, you know, maybe don't wear that. But it's really more about engaging and letting them know, I'm just here to talk to your mom and dad. You can keep watching TV, I'm not gonna touch you. Or I'm just gonna listen to your heart, but then I'm gonna talk to mom and dad. There's no pokes. So, it's really just making yourself meet them more where they are and help that environment be less scary. Thank you. Let's see. So, lots of comments. Everybody really loved your presentation. Great information. Thank you. Both the adult and the pediatric world. Most all of this is applicable for, I mean, really like comfort positioning is not really applicable for adults. But if you can let that adult sit up instead of lay down, that decreases that vulnerability piece. But most everything, prepping them, remembering that even if we're adults and we're in medical care, when we're in that trauma brain, we don't understand and process information as well. So, using simple language is always better than assuming that somebody can understand. So, really everything is applicable for adults too, for the most part. Well, thank you so much. And thank you to our audience for joining today. This is great information. I definitely know I'll be utilizing some of these resources over at my hospital. And if we have no further questions, you will be getting your survey for your CMEs and the resources will be available. So, thank you very much.

trauma-informed care

pediatric trauma

emotional safety

child life specialist

patient care

traumatic stress

healthcare strategies

family involvement

pediatric patients