A-E Principles of a Trauma-Informed Examination

Many of our patients have experienced trauma. As have many of us. The feeling of overwhelm, fear, powerlessness, perhaps all at the same time in response to an external threat is familiar to so many. This may have been trauma from a one-off terrifying event, it may have been repetitive patterns of terrifying events, or perhaps even a terrifying life and existence stemming as far back as being a growing fetus in utero.

As healthcare professionals, when we meet a patient, any patient, we don’t know what they have experienced or are experiencing. Unless we’re in a fairly high-up leadership position, and probably even then, we don’t often have much control over the context in which we see patients. For example, the Emergency Department will continue to be a busy place with noise, people, drama, sometimes chaos, occasional calm, all outside of our control. However, we do have more power than we think during the actual consultation with our patients. The moments when they are in front of us. 

I hope you find these practical trauma-informed principles really helpful for you to make sure you are doing all you can to create a safe environment, dignifying your patient and giving them control. In a paradoxical way, this is something very much within your control. Just like our A-E assessment of a deteriorating or critically unwell patient, these A-E principles of a trauma-informed examination are designed to help you structure your clinical examination.

A – Ask permission
With anything you do. Ask permission, consider your patient’s capacity, give them time to make an informed decision, perhaps even an exit route. An opportunity to say or signal “no” and have that respected. This matters. We can be very passionate and vocal about how the education system must teach children the concept and importance of consent, particularly regarding sex education. This is what it looks like. Let’s be consistent with adults as well. Despite your role as a doctor, nurse, physio, midwife or any healthcare professional, you’re still likely a stranger. Even if they would have let you perform the examination anyway, the principle of consent is powerful. Their body belongs to them and so we must ask permission and gain informed consent for an examination.

B- Be respectful
An inspiring paramedic once told me that for every single person he goes to see in response to a 999 call, he always wipes his feet by the door before walking inside. Even if the house is a mess, there’s evidence of neglect, poor hygiene and worse, it’s a mark of respect. You are going into their home, their environment. As a ritual, it might also help re-adjust your attitude and approach to someone. I love that.
It’s very common and easy for any of us to make quick judgments about someone’s behaviour, appearance, apparent lifestyle choices, cleanliness, dynamic with you or others, anything. So no matter how a patient presents, without stigma or judgement always consider and do everything you can to maintain a person’s dignity.
For an examination make sure you have minimal exposure necessary. Also, consider who is in the room and who is and should be outside of the room. Bring in your chaperone if you need and safely and routinely remove an accompanying person from the room to examine your patient.

C – Give Control to patient
I work with some amazing obstetricians, doctors who care for women through pregnancy and in safely delivering babies in high-risk pregnancies or emergencies. Part of their role is to perform intimate examinations on the women through pregnancy, and when they’re in labour. They have a brilliant phrase that they say to the women routinely before the examination – “you’re in control. If you want me to stop for whatever reason, I’ll stop.” Sometimes they give an alternative way of saying stop, like “raise your hand” or “tap on the bed”. I now say this with all patients for any intimate examination.

D – Don’t continue if signs of distress
Distress takes many forms and may not be obvious, like crying or evidence of pain. Look for these signs. When people freeze or dissociate they may stop responding to questions or go blank. This is a recognised trauma response, so stop what you’re doing and reassess. Freezing or not responding is not the same thing as giving consent.

E – Explain
What, how, why and how often? For any examination, give clear and transparent explanations for anything you do, even if it’s something you normally wouldn’t. Explain what you’re doing and why, how it might feel, and then listen and acknowledge their concerns, and account for these as far and safely as possible. 

These principles are important for all patients. They may seem obvious, but need to be emphasised, as not only intimate examinations but also simple examinations can elicit trauma responses, even if they are non-threatening to us. 

*************

– To find out more about VITA Training – www.vita-training.com
– To book onto an upcoming Interactive Webinar – https://www.vita-training.com/courses/#book-now
– To arrange a bespoke webinar/seminar/simulation training session for your team contact us – info@vita-training.com

We look forward to hearing from you!