Lessons in trauma-informed care also can beneﬁt refugees, veterans and victims of domestic abuse
By RENEE STOVSKY
Felice Zimmern Stokes, 82, has been a volunteer at Holy Name Medical Center in Teaneck, New Jersey, for 10 years, first working with children in the day care center and now assisting throughout the hospital.
Felice Zimmern Stokes, right, and Deborah Buldo, simulation educator at Holy Name Medical Center in Teaneck, New Jersey, perform in a video simulation of a Holocaust survivor receiving compassionate medical care. Stokes was a toddler when her parents were murdered in Auschwitz. Filling out forms about her family's medical history can make her feel sad and alone.
Jeffrey Rhode/Holy Name
But one of her most important contributions to date may be the part she played in a new interactive, web-based training course, "Helping Survivors of Trauma," that educates health care professionals on how to use a person-centered trauma-informed approach to care when treating Holocaust survivors, refugees, veterans and even victims of domestic abuse. The module was recently developed by Holy Name's Russell Berrie Institute for Simulation Learning in partnership with The Blue Card, a national nonprofit organization dedicated to assisting Holocaust survivors in need.
Stokes is herself a Holocaust survivor. Born in 1939 to a Jewish family in Walldürn, Germany, the infant girl was separated from her parents when they were deported by the Nazis to Camp de Gurs in Béarn, France, near the foothills of the Pyrenees Mountains, in October 1940. Thanks to the efforts of Oeuvre de Secours aux Enfants, a French Jewish humanitarian organization that saved thousands of Jewish refugee children during World War II, she was placed with a Christian family — becoming a "hidden child" — until the war's end.
Roll call at Buchenwald concentration camp, circa 1938-1941. Two prisoners in the foreground support a third man. Physical weakness made prisoners vulnerable to Nazi executions.
"I have no memory of my parents; I just know they were deported and killed at Auschwitz in 1942. But I was reunited with an older sister, who was also hidden, after the Germans surrendered. By then I spoke only French," she says.
The girls lived together in two different orphanages in France, and arrived in Newark, New Jersey, in 1951, where they grew up apart in several different foster homes. Eventually Stokes went to Stern College for Women — part of Yeshiva University. She worked for 40 years as an executive secretary at the Memorial Foundation for Jewish Culture in New York City. She married her late husband, Sherman Stokes, a chemical engineer, in 1980 and moved to Teaneck, where she's lived ever since.
Stokes says she does not suffer many of the scars of trauma that make so many Holocaust survivors, particularly those who survived concentration camps, hesitant to access health care. But she was happy to play the role of patient in the webinar to help educate nurses, doctors and dentists, especially younger ones, in how to promote well-being and avoid re-traumatization of those who were once victimized by the Third Reich.
"So many of the young nurses and medical residents I've met at the hospital know very little about the Holocaust except as a historical note in a book about World War II," she says. "So, the more those who lived through it can still speak up about it, the better."
It's estimated there are currently 80,000 Holocaust survivors — all at least 76 or older — in the United States, and about half of them live in the New York metro area. The Blue Card defines them as anyone who had at least one Jewish grandparent and lived under German occupation from 1933-1945. That includes prisoners in concentration camps, people who lived in ghettos, people who survived in hiding, lived under false identities or escaped to other countries, and those who emigrated later from the former Soviet Union.
More than 30% of Holocaust survivors in the U.S. live in poverty, and many are at higher risk of developing heart disease, cancer, osteoporosis, joint disease and dental problems. Trauma survivors may have more difficulty in performing day-to-day tasks. And psychological scars also have an insidious affect — depression, anxiety, social isolation, nightmares, panic, paranoia, feelings of abandonment and fear of everyday activities, including routine medical visits that trigger past memories of persecution — are prevalent as well.
Time is short
"Time is running short for us to help heal this most vulnerable of groups," says Shari Gold, program manager for grants at The Blue Card, which traces its origins to 1934 Germany, where it provided assistance to Jews fleeing growing persecution there. (Its name came from the stamp and blue card donors received after raising funds for Jews who had lost jobs and businesses.) The organization relocated to New York in 1939 to continue aiding refugees resettling in America. Today it helps survivors in more than 35 states with everything from emergency cash assistance and educational outreach to in-home care services.
The origins of the Holy Name/Blue Card training course can be traced to 2015, when the Jewish Federations of North America received a grant from the U.S. Department of Health and Human Services Administration for Community Living/Administration on Aging to develop innovations in person-centered trauma-informed care for Holocaust survivors. With that, plus additional contributions, the Jewish Federations created the Center for Advancing Holocaust Survivor Care and has since funded more than 400 programs.
In 2018, The Blue Card received a two-year grant from the Jewish Federations to advance person-centered trauma-informed training for medical professionals. With the help of consultants — including Eva Fogelman, a Manhattan-based psychologist, writer and filmmaker who pioneered the treatment of psychological effects of the Holocaust on survivors and their descendants; Dr. Barbara Paris, director of the Department of Medicine, Division of Geriatric Services at Maimonides Medical Center in Brooklyn, New York; and Dr. Rada Sumareva, a periodontist in Cliffside Park, New Jersey, and president of the Russian-American Dental Association — it created and organized presentations for doctors and dentists in the five New York boroughs to improve treatments for this cohort.
"We put together a lot of learning and got a lot of feedback, but we realized it was very labor intensive to organize in-person seminars for very busy people," says Gold. "So, in 2019 we applied for a second grant for $225,000 to translate our presentations into a web-based module."
Holy Name steps up
It was obvious that Holy Name Medical Center would be a terrific partner, says Gold. Based in Bergen County, it serves a large number of Holocaust survivors, particularly Russian Jews. And its institute for simulation learning, which teaches skills to medical professionals, was an appropriate platform to house the training course.
J. Cedar Wang, vice president of nursing at Holy Name, says the medical center is a perfect fit for the patient-centered trauma-informed care training program. "We are known to cater to the Jewish community here out of recognition of our shared Judeo-Christian values," she says. "We have a Sabbath elevator, serve kosher food when requested by patients, and maintain things like a sukkah (a traditional temporary outdoor eating space) during the autumn harvest holiday of Succot."
Even more important, she adds, is that cultural competency and sensitivity are a cornerstone of care at Holy Name. "As compassionate medical providers, it is essential that we are aware and educated to avoid unintentional reinjury by instilling a sense of well-being and promoting healing in our patients," she says.
To help implement the module, Holy Name donated professional expertise to videotape interviewees, create and record simulated scenarios and incorporate historical photos. It also provided IT support. Despite delays due to the COVID-19 pandemic, "Helping Survivors of Trauma" was completed last spring and has been available free and online since May. (To view the webinar, go to HelpingSurvivorsOfTrauma.org.) An estimated 500 health care professionals already have accessed the program, which involves watching videos and answering interactive questions. It takes 30-45 minutes to complete, and doctors, nurses and dentists can receive continuing education credits for the webinar.
Sue McClain, a registered nurse at Naples Community Hospital in Florida, recently viewed the module and says she found it "very engaging."
"My biggest takeaway is that the patient-centered trauma-informed approach to care can be helpful for all patients. Instead of just asking them to sign consent forms for treatment, maybe we should routinely ask permission as well," she says. "Many patients, regardless of background, are hesitant about everything from a routine blood draw to an EKG or an injection; we've seen this most recently with COVID-19 vaccinations."
Stokes, who portrays an elderly patient prepping for an MRI in the program, says her acting debut did bring up an uncomfortable feeling she harbors as a Holocaust survivor.
"I don't hesitate to make an appointment to see a doctor, and I don't fear routine procedures, but I realized that filling out forms about my family's medical history or identifying next of kin can make me very sad," she says. "I feel so alone at those times."
Compassionate care of trauma survivors requires attention to sensory stimuli
When you are a victim of trauma, any sensory-related stimuli — smell, touch, taste, sound — can spark re-traumatization. And for Holocaust victims, routine activities in a health care setting can set off flashbacks, irrational fears, sleep disturbances and more, according to "Helping Survivors of Trauma," the person-centered trauma-informed care webinar for health care providers produced by Holy Name Medical Center in conjunction with The Blue Card.
- Because Nazi doctors examined and then selected sick concentration camp inmates to be killed if they were unable to work, a Holocaust survivor might associate a routine checkup with serious illness and death.
- Filling out intake paperwork can cause extreme anxiety. Many Jewish children sent by their parents into hiding do not have a birth certificate. Others are unsure of their exact ages; in order to survive in concentration camps, they lied about how old they were to qualify as slave laborers rather than be murdered because they were too young to work.
- Being asked to undress and put on a hospital gown can be a reminder of concentration camp experiences. Survivors know that those who were selected to die were stripped of their clothing before being forced into gas chambers; those who were selected to work were forced to wear prisoners' uniforms.
- Health care providers in white coats who examine and treat patients without consent or adequate explanations can unleash memories of painful medical procedures that Holocaust captives
experienced — the extraction of gold-filled teeth without anesthesia, injections of unknown substances, and horrific "twins" experiments.
- Loud noises from a dental drill, a dropped metal object or the banging of an MRI machine can cause extreme overreactions.
- Even receiving a hospital meal on a tray can bring memories of starvation.
Safety, courtesy, trust
Now used to inform holistic care in many medical specialties, patient-centered trauma-informed care recognizes that mental health impacts physical health and vice versa. Practitioners of the approach promote the dignity of trauma victims by incorporating knowledge about the role of trauma in patients' lives.
The approach emphasizes:
- Safety. That includes providing well-lit spaces in health facilities, even in parking garages, and easy access to exam rooms and exits. Calm environments promote feelings of well-being. Scheduling appointments for trauma victims on less busy days or times and moving patients to quieter areas can be beneficial.
- Trustworthiness. Make sure all
communication — starting with receptionists on up through the physicians — is respectful and compassionate. All medical staff and support people should be trained in the principles of the approach and aware if a patient is a trauma survivor.
- Collaboration. Patients should have a role in planning and evaluating treatments and given choices if possible. Doctors and nurses should include not just family members but also patients —
even those suffering from age-related
dementia — in conversations. Engagement, not compliance, is the goal.
- Empowerment. Clinicians should ask the patient's permission before beginning any exam or treatment, and always provide explanations before procedures.
- Sensitivity. Providers should be aware of cultural, gender and historical issues trauma victims may have. Questions about age, date of birth or family medical history can cause anxiety in Holocaust survivors separated from their families as very young children.
— RENEE STOVSKY
Copyright © 2021 by the Catholic Health Association
of the United States
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