Hello Incubator gang! We welcome this week the amazing Mary Coughlin who introduces us to trauma informed care in the NICU.

Short Bio: Mary E. Coughlin, MS, NNP, RNC-E, is a global leader in neonatal nursing and has pioneered the concept of trauma-informed, age-appropriate care as a biologically relevant paradigm for hospitalized infants, families, and professionals.

A seasoned staff nurse, charge nurse, neonatal nurse practitioner, administrator, educator, coach and mentor, Ms. Coughlin has over 35 years of nursing experience beginning with her 7 years of active duty in the U.S. Air Force Nurse Corp and culminating with her current role as president and founder of Caring Essentials Collaborative.

https://www.caringessentials.net/

The transcript of today's episode can be found below 👇

SUMMARY KEYWORDS

baby, trauma, nicu, care, experience, person, talk, feel, nurses, individual, clinicians, human, family, happen, colleagues, started, premature, people, nursing, work

SPEAKERS

Daphna, Ben, Mary Coughlin

Daphna 00:00

Ben 00:39

Welcome Hello, everybody. Welcome back to the podcast Daphna. What's up?

Daphna 00:49

Well, it's been a busy week for us. We are recording a lot. Speak. I feel like I've seen you every single day. But I'm especially excited about our our guests today. What's new with you?

Ben 01:01

Not much. I mean, I actually was not very familiar with the work of our guests. And you bringing her up her name, has allowed me to delve into some of her talks, some of her resources and it is fascinating. So again, Daphna, you have this this knack for exposing us to very, very cool guests and core topics. So thank you for that.

Daphna 01:24

No, it's It's my pleasure. Well, let's just get started I'm, it's my really a pleasure and an honor to introduce Mary Coughlin a seasoned staff nurse. She's been a charge nurse and neonatal nurse practitioner, Administrator, educator, coach and mentor. She has over 35 years of nursing experience, and she even started out her nursing career with seven years of active duty in the US Air Force. But we have her on today specifically because Mary has pioneered the concept of trauma informed age appropriate care as a relevant paradigm for hospitalized infants and their families. She's a published author with credits that include the seminal paper introducing the concept of core measures for developmentally supportive care, the 2011 clinical practice guidelines for age appropriate care, the premature and critically ill hospitalized infant for Nan, the National Association of neonatal nurses, transformative nurses and then NICU trauma for age appropriate care first and second editions and trauma informed care clinic use evidence based practice guidelines for transdisciplinary neonatal clinicians, again, endorsed by Nan. She's recognized by the National Association of Neonatal Therapists and the Council for international neonatal nurses as the definitive resource for evidence based best practices and neuroprotective developmentally supportive care. She currently has a role as the president of caring essentials. And Mary works continuous continuously through caring essentials to educate NICU clinicians to transform the experience of care for the hospitalized infant and family in crisis. And Mary, thank you so much for being with us today.

Mary Coughlin 03:04

Thank you so very much for this opportunity. I'm really, really honored and excited.

Daphna 03:10

Well, I you know, Ben, Ben always says I'm starstruck. So I'll admit to you that this is a starstruck moment for me. So when I was in training, I knew that I had this variety of passions for different parts of care. neurodevelopment and palliative care and getting families involved in my research was in kangaroo care. And everybody would say to me, like, but what's, what are you doing? Like, what's your thing? Right? And it was not until I heard you speak as a resident, when I said, Well, my my interest is in trauma informed care, it really is made up of all of these components of care. And so you set the trajectory really for what how I work. So admittedly, I'm starstruck today.

Mary Coughlin 03:59

Oh, my gosh, I am so wicked honored by that those are incredibly kind words.

Daphna 04:05

Well, to me, again, like I said, it's set my trajectory, but I think we will have listeners who may be this term of trauma informed care is still new, or they've heard it in different populations, you know, adults and children and, and so maybe you can just give us in your own words, you know, what is trauma informed care mean, and how can we, you know, use it specifically for neonates?

Mary Coughlin 04:34

Yep. Well, if and for anybody who's never heard this term before, I was in the same boat, you know, I mean, eight years ago, I didn't know squat about this concept. And it wasn't until I had this very unique clinical experience, which is gonna sound kind of bizarre, but I was asked to step in as an interim nurse manager on an inpatient adolescent psych unit. Why you might ask It's because these crazy adult clinician said, Oh, Mary has pediatric experience, right? No, I don't know, I don't. I'm a NICU nurse. But I for them, yeah, it was a kid as a kid, right? You know? Yeah. Yeah. And so, you know, that was when I was first exposed to it. And so I can really understand why a lot of my colleagues get a little kind of uncomfortable with the language, because I think many of us in the absence of understanding anything about this work. If you're like me, you think of trauma as like a motor vehicle accident, right, or a gunshot wound or some kind of event like that, and not really, the result of some kind of adverse experience that not necessarily had physical implications, but quite often has psychosocial and emotional, and maybe even spiritual implications, you know, for for developing individual. So I think when I first was exposed to this, you know, so this is an inpatient adolescent psych unit, and trauma informed care at that time, had like, it had been around for like 40 years in behavioral and mental health. And so, you know, trying to fit in trying to do the right thing guided by these amazing mentors that were clinical specialists in psychiatry, psychiatry, and were helping me understand that the children that we were caring for in this unit, which was a closed locked unit, had early life adversity, had trauma in their early life. And that has resulted in a myriad of different, you know, physiologic manifestations, but a lot of behavioral manifestations that required intensive care. And I was thinking, well, Gee, whiz, I love intensive care, right? I'm over get adrenaline junkie. But this was intensive care. On a completely different level. This was internal intensive care, right? When you walk into the NICU, you know who this person is in the unit. But when I walked on this floor, I had no idea. They were all critically ill, but in a way that was really new to me. But, you know, no less important, right? I mean, it was just, you know, so I, I started diving into the literature to really try and understand what is this? What is this thing of trauma? And what is this idea of trauma informed care, and kind of my short takeaway from what I gathered from that experience was that trauma informed care was an approach that you adopted, when you were interacting with folks that had a trauma history. So I might one of my colleagues, a clinic nurse, came into clinical psych specialist, she would always have me turn sideways, and she would never let me wear my lab coat, I love my lab coat, you know, I can put tons of stuff in the pockets, you know, and it makes me feel cool and important. But when I would walk onto that floor, you know, you can't wear that you can wear you can't wear the coat, take off the stethoscope, you have nobody needs their vital signs checked here. It's a completely different environment. And I remember the first time I had to take the coat off, and I really, I felt wicked vulnerable, because I thought, I don't know how to engage with these critically ill children. I just felt so ill prepared. And, and what she taught me was this concept of the therapeutic value that me just as like a human being brought into that space. That scared the bejesus out of me, because I had never thought about that, right? I mean, I was just, you know, always about the doing, you know, let me put a PICC line and let me do some vital signs, let me do you know, some whatever suctioning you know, that kind of stuff, but you want me to just be me? Well, gee, willikers I haven't thought about who I am in that context. In probably forever to be perfectly honest with you. But um, but that was really kind of how she primed me to really understand the concept in that environment. And and that really struck a chord with me and I started again, us reading and voraciously. I was blogging about this, and just really, I couldn't get enough of it, because it just hit me that I have these guys here. Obviously, critically ill children developing humans have had these adverse experiences. Oh, the NICU, all of these little people, right, that are suffering profound adversity, you know, I mean, yes, life threatening illness, you know, right off the bat is definitely traumatic. But what about all of those other things that these individuals aren't able to experience because of their life threatening situation, like the proximity, the continuous proximity and presence of their loving parent, you know, being able to be sung to sleep being held, not having painful experiences every two to four hours. You know, the sleep disruptions, all of these other kinds of things. And so I shifted from this understanding of trauma informed care and behavioral health as kind of a like, a responsive strategy. Versus when I started thinking of it in the NICU, it felt actually like it had the potential to be a preventative strategy, that in understanding how trauma changes the biology of humans and a people, right? What if we could mitigate that trauma, by our understanding of that biology and psychology and stuff like that, maybe we could actually cultivate resilience for these individuals. And, you know, it started out an obsession about the baby's with a nod to the family. And then it just kind of was like, wait a minute, I can't be nodding to the family, they're falling apart at the seams as well. And then as I really felt, you know, like, Okay, I got a handle on this, then I started thinking about the clinicians, and, you know, all of the literature, at least in the nursing literature, that talks about bearing witness, and how bearing witness to the suffering of others, actually takes a toll on us as well. So, yeah, ya

Daphna 11:12

know, and I have a bunch of follow up questions, you, I think you've covered the spectrum. So we're gonna have to break that down. But I think, at the core, one of my favorite live, lectures, workshops, and is watching you kind of what I will just call it, you may have a name for it, giving the like, premium experience demonstration. Oh, and so I wonder for, you know, this is an audio podcast, our listeners are driving, they're doing their dishes, they're going for a walk, and maybe you can walk us through that as if we were live, and so that, so that they can, you know, every time I've seen that done, I can hear people walking away saying, Well, gee, I never thought about that. And so I think I'm hoping I'm asking you to put you on the spot to see if you can we replicate that for our listeners just a little bit?

Mary Coughlin 12:10

Sure. Sure. Well, I think the example that you're talking about is, you know, I think of when I was a bedside nurse, you know, and I came into the unit, go down and get my assignment. And, you know, okay, I've got these three babies, for example. And then you know, go go to my assignment. And in the NICU, as a nurse, all the babies are on a schedule, right. And, you know, most of my assignments would be 811 to five kids or on an 811 to five, and we would use the expression that do up, that was the time that I had to do up the patient do up the baby. And, and, you know, you're very, you know, because of the mindset because of the way we get a culture into NICU nursing. It's very task driven. And so it's all about you know, alright, it's eight o'clock. Time for me to do Yeah. So I would belly on up to the incubator, right, pop open the doors, reach in flip strip, you know, I'm doing you up, I'm suctioning you I'm changing your diaper. I'm doing all of these kinds of things. Quite oftentimes, the baby would be, you know, maybe like expressing their dissatisfaction with the experience that that's happening, right? throwing their arms out, maybe having some D sets and stuff like that. And I would speak very reassuringly, very pragmatically, hang in there, I'm almost done, you know, blah, blah, blah, whatever I have to say, and then I would flip you into a new position, because I want it to be developmentally supportive. So I'd flip you into a new position. And then I just, you know, lay down the blankets, tuck it and you know, make it all nice and smooth. And, you know, if you had any toys or something, rearrange it, because I know if you look good, you feel good. And I certainly feel good. If you look good, you know, and I want all my colleagues to say that Mary makes a mean bed, isn't that great? You know, and then I would move on to the next person. And and this always would happen, you know, I go ahead, same routine, open the doors reaching flipping strip, and then what would happen is Baby number one would do something wicked annoying, like D sad or have a Brady or some really obnoxious, physiologic, you know, response. And I'd be thinking, What is your problem? You know, because of course, I have my hands on the other person, so I can't really run over. I'm sure I'm, you know, pissing off somebody in the room, you know, because now the alarms are going. And I'm thinking, you know, you're just you're messing up my groovier buddy, not realizing that this physiologic decompensation that that little person is having isn't just because, you know, she's got a bee in her bonnet, you know, and just wants to piss me off. It's because I have completely pulled the rug out from underneath this person. And not, you know, being responsive not understanding what this experience was feeling like for her. If I hope that's probably not the best English stated sentence, but um, is that the phrase that you're referring to? Definitely.

Daphna 14:52

Yeah, I think you do such a nice job of even in this scenario describing our or inability to read infant cues. And it's not just about feeding. It's it's about every interaction that we have with babies.

Mary Coughlin 15:10

Yeah, yeah, you're absolutely right. And I think we, we get so compartmentalized, and this is me really kind of deconstructing my own nursing practice, you know, my past nursing practice, to really realize that these are people, they're expressing their experience, right their feelings in any given moment. And it's really challenging, right for me to, and I think other people, but I can just I know, for sure, it was really challenging for me to interpret what was happening, because oftentimes these people, due to a myriad of reasons, right, I mean, you're ridiculously immature, and you don't have the capacity to make these facial expressions, right. Or maybe you're heavily sedated, or you're, you know, you've got some kind of meds on board. I didn't really appreciate that just moving your arm was It was an extraordinary feat, you know, when you're only maybe 2526 weeks gestation, just that anti gravity movement. And then and now your arm is stuck in some crazy position. And I'm thinking you're just a knucklehead, because why would you do that? Not really understanding, right? Like the full breadth of the human experience of this person, in this new environment, not expecting it, you know, supposed to be in this watery, you know, cool milieu where they can move and you know, not feel any gravity not feel any distress or stress. And now you're here, and nobody really gets what your issue is. I'm all over your disease. I got it nailed. But your humanity? You know what? I didn't have that class? I don't I don't know what that looks like, when you're critically ill and immature. And, you know, and that sort of thing.

Ben 16:54

That thank you this is this is so great. The question, I guess that that I wanted to, to ask you want to talk to you about, obviously, is this idea that is very modern, and very, very much a grown up idea of babies having the ability to experience stress. And, and obviously, there's there's obvious stressors in the NICU. So I'm not going to talk about a baby that needs to have a line placed or peripheral IV plays, because obviously, this is a stressful procedure. But you're often referring to a very toxic and toxic, stressful environment for the baby, that doesn't always necessarily involve painful procedures. You're not just talking about these instances. And I was wondering if you could break down for us? What does it mean for a baby that is preterm in the NICU to be to be stressed, without being exposed to a painful procedure? unnecessarily?

Mary Coughlin 17:53

Yeah. Yeah, brilliant question. The number one traumatic experience enjoyed by newborns across all mammalian species is maternal separation, right there, that is a catastrophic event for this individual. And again, if you think back to their inter uterine experience, it's like total surround sound mom, right? It's smell, taste sound of their maternal maternal presence. And then you have this delivery. That is obviously, you know, it's it's a critical event. And so the, this little person is now swept away. So their full sensory experience of safety and comfort and connectedness is taken away from them. And that is absolutely catastrophic for these individuals. There was a really cool recent paper written by this guy, lammer tank, I think it I might be mispronouncing his name a little bit, but he actually talks about the fetal biology of the stress systems. And how, you know, I mean, there's, there's a lot that this individual, but I'm sorry, there's a lot of mechanics that are laid down, that can, you know, that are available to this individual from a physiologic perspective. And so that initial experience, activates that HPA stress response immediately. And then, if it you know, obviously, it goes on unabated, then this person has experienced that chronic stress, you know, and I think the thing that was, like, a big aha, for me was realizing that babies don't like, they don't get, like, you know, what is it like the impermanence of things, you know, it's not like, Oh, your mom's going to come this evening. So everything's gonna be fine. Right? to them. It's just this incredibly protracted period of unknown newness, you know, of fear of isolation that the person is experiencing, you know, we know this with babies, right? The peekaboo stuff, like, you know, I mean, but just think of this as like, a horrible, you know, experiment of that, you know, that they just don't have that sense. So, superimposed on that is the whole sleep thing, right? I mean, the more immature you are, the more sleep you know, time you spend in sleep. But if you're in a NICU, guess what? You know, nobody's paying any attention to that. And was it leave Ayers levy I forget did this really cool paper that talked about how the bulk of care is provided, you know, when the baby is asleep, and that they have these respiratory events as a consequence of the disruption of their sleep. So sleep fragmentation, right or, and sleep deprivation also, as a consequence, that you're not even thinking about as being traumatic. But it absolutely is, and it's deranging how their sleep architecture and the respiratory architecture is actually developing as a consequence. And then I think about like postural stuff, right, and I kind of mentioned a little bit about the gravity. And who thinks about that, right? Nobody thinks about that. But for this little individual, and again, I don't know what it actually feels like, because I've never been in that state. But I can imagine, you know, if I, when I used to do live classes, I would have people stand up, and just put their arm out in front of me, in front of them, right. And I would just keep talking and talking and talking. And after a while your arm does get kind of tired, because you do start to experience gravity on your arm. And you know, it helps people just kind of connect experientially, that might be just a fraction of what these little individuals feel, you know. So it's all of these abnormal, just day to day experiences, minute to minute experiences, that can also be experienced as trauma. And it's an individual experience, too. So it's not like one size fits all, what's traumatic for, you know, the baby over here, may not feel the same for this other person. But because we have no way of knowing, I think we have to err on the side of caution. You know, and say we, you know, we have a gestalt that this is what the biology is telling us, we probably should just treat everybody a little bit more gently right and a little with a little bit more insight. Did that answer your question?

Ben 22:03

It did. It did. And, and, and I guess, my, my next, my follow up question is, is we have these babies who are subjected, not always, voluntarily to these to these stressful experiences early on. And I was wondering if you could talk about some of so what are the consequences of that? Right? I mean, we do have, we do have principals in neonatology that say that baby are very adaptable, they're their brains are plastic they can overcome and they're very resilient. And so young could be tempted to think, okay, big deal. So they'll they're so small, maybe they won't will they even remember it? I'm wondering if, if there's any evidence that shows how these early experiences really translate into significant findings down the road? Like months? years? Yeah.

Mary Coughlin 22:54

Yeah. So yes. And in the fact that they don't remember it, it doesn't matter, again, because it really understanding the biology of trauma. It really it gets into your cells, you know, and a lot of the folks that have done extensive work in this, like, Vander Kolk, and, Oh, fudge, like Porges is it does work in this field. But there's just all of these folks that their names are escaping me right now. So I'm embarrassed, but tons of folks that really helped us understand the cellular nature of the trauma experience. So the memory is irrelevant, except for the point that for people that experienced trauma during pre verbal periods, one of the challenges that they have is, is the metabolizing, right of the metabolizing, the trauma experience, because they're unable to articulate it, you know, really talk about it. And so what I've had experience with it actually was on that adolescent psych floor. We had these therapists come in from Lesley College, and they are our arts therapists, but trained in Psych so that you can actually use other creative avenues to help people release the trauma that they've experienced through nonverbal ways, which is really, really cool. But that's a bit of a digression. When you're looking at the outcomes, right, short term and long term outcomes, what we see is that these individuals kind of coming right out of the chute, they have a shortened lifespan. There's some beautiful research that is, you know, really given us some solid understandings of the connection between morbidity and mortality as a consequence of prematurity and they actually they like hot off the press 2021 and I was just doing a talk about this and that's why I'm kind of excited to share with you because it's really impactful stuff. The and of course, I'm trying to think of the author's name but you guys excuse me if I can't remember that right. But most of the Crump Krump 2021 and resumes. So reason the reason these paper they looked at over 6 million Former premature people across, I think it was like all the Nordic countries. And what they found was that they were super high risk for cardiovascular disease, metabolic syndrome. Oh gee has diabetes, and it's probably an Amaya metabolic switch situation, but more importantly, psychopathology, and so high high risk for depression, anxiety, and although all of those other diseases that I mentioned, right cardiovascular disease, metabolic syndrome, and stuff like along those lines, non communicable diseases, which is definitely linked it to a higher mortality, for these premature people, the, the leading cause for mortality for these individuals is suicide, and accidents. So, and a lot of these suicides are happening during adolescence. And so if you think about, you know, just, you know, the burst of development, you know, that happens, you know, across the continuum, and that these kids in adolescence, really, they don't have a way of processing these trauma memories, they're suffering from anxiety, they're suffering from depression, you know, you can, you can kind of see the connection. And that was really impactful for me to just say, holy moly, we got to get on top of like, you know, the Empire State Building and scream this across the globe, that we need to look at this work differently. You know, that, yes, you know, they've got these life threatening illnesses, and we're awesome at doing, you know, care for these, you know, specific symptoms and diagnosis. But the human piece is really kind of falling away. And we're not tuning in, I think we felt like that there was so much of a connection. Well, I'm sorry, you're premature, but you know, you had hypoxia, you had these perfusion challenges, you had lots of A's and B's. So your brain didn't develop as great as it should have been, could have, that I'm absolutely convinced that that is a contributing factor. But it's not a linear phenomenon. It's the wholeness, that we're missing, right? It's that that feeling of safety, security and connectedness that we're missing out on, and it doesn't have to happen, either. Or I don't know if you guys have had these experiences, but I remember, you know, people would kind of really get annoyed with me, because I can be a little bit annoying, pushing developmentally supportive care. But they'll, you know, look at me, like, you know, I'm trying to save a life. You know, hey, yeah, that's awesome. I think it's good to save lives. But I think it's not to save life for the sake of saving a life, but to save a life so that it can thrive and flourish. And if you want to make sure that that individual can not only survive, but thrive and flourish, then you need to be responsive to the human dimensions of this, this individual. You know,

Ben 27:44

I think this is yeah, I think this is a very interesting point. Number one, it's difficult to follow up your answers, because there's so many things that I want to talk about it. But there's this I mean, what you were talking about earlier in your response, the this idea that the changes yourself out, I want to recommend the book you're probably familiar with the Body Keeps the Score. Yes. Yeah, by Dr. Vander Kolk. And this is exactly what you're saying where even certain things you may not perceive your body somehow has registered these these, these emotions and these trauma. What I think is interesting, and maybe you can talk about that is, I guess one of the lucky things about not being so far out of my training is that I remember my pediatrics training. And there's a lot of things that you're talking about now, which are completely obvious when it comes to the etheric world, right. I mean, just basic stuff, you would never walk into a room see your child having lunch and say I'm interrupting your lunch. And we're going to do now this this physical exam stop eating right, automatic 99% of pediatrician will be come back would never perform. I mean, that was I was I was trained by Dr. Daniel Rauch, who was in Boston and who was very, very strict about those things, you would never perform a painful procedure in the baby's bed or your child's bed, you would move them to a procedure room so that they could feel the sense of safety in their own bed. So that and so, I mean, again, we could go on and on and these are these are not revolutionary ideas, these have been established and somehow you crossed into neonatology and that all that stuff goes out the window. And, and I am wondering why. I mean, do you guys guess? Definitely. I'm asking you as well. Do you guys have any idea why that is?

Daphna 29:27

No, I think the point well, and I defer to Mary but the pendulum has swung so widely to where, you know, when we when neonatology was just starting out. I mean, we didn't think and there are still people came up on Twitter this week. There's still people who think that babies premature babies don't feel pain or they don't. They don't feel anxiety. They don't feel these emotions. When there's plenty of evidence, you know, just like you said, if we treat them like people and we want Watch what they're doing. They're telling us they're communicating with us. And we're ignoring their cues. They're giving us evidence that they have those sensations. And so I think the pendulum is coming back. But we, we, we've are so far gone. I think it's hard for us to redirect our care. The thing I say on rounds every single day is how many times are we checking this kid's blood sugar? And they're like, Well, we're still, we're doing a Q 12. And I said, Well, how often How long have you been doing a Q 12? For I don't know, a month, and you're like, you would never do to pediatric p right. Now. We that's the first thing that should, you know, we just get rid of that's an actual. Exactly. So I'd love to hear your

Mary Coughlin 30:42

thoughts. Well, I think, you know, what happened in the ontology was, it was just so it was so super intensive. It was so novel, and I think we still don't really understand all the depth and breadth of the humanity of a baby, right? I mean, even healthy babies, you know, we tend to minimize their experience, you know, my grandson, you know, like, he goes and has vaccinations and it's like, Oh, you'll be fine. You know, having these two grown people hold him down. So you can you no jab that he'll be fine. He'll we'll forget about it. It. Does that mean, it's okay to be inhumane? Is that like the carte blanche, you know, kind of approach to this? So, I think, and I think we've just gotten locked in we've isolated ourselves from pediatrics. I mean, I said at the very beginning, right, the, the nurses at the hospital, like, Oh, she's got pediatric experience. I'm like, No, I don't. And I and I really did not believe I did have pediatric experience, because neonatology is so not like, peds. Right. And so I think that's also, you know, a gap that really needs to be bridged, we, you know, what is it about being immature? And I think it's because these little people, they don't look like a traditional baby, right? They don't, we have this different understanding. And for some reason, we feel like we have to do all of these studies and all of this research, which I love studies and research, but like, do I really need to, like prove that you're human? You You came out of this woman's body, I'm assuming, you know, you're not a cat. I mean, I'm assuming that you're human. So and, you know, many people treat their pets better than they, you know, will treat a premature person. So it's really about changing it. And I do want it Ben, if you don't mind, I just wanted to make one comment. When you said about in peds, when they take the baby, the child to another room, right to the treatment room to other procedure, to have that same to be of safety in their bed is so wicked important. And, and for my NICU nursing colleagues, I've really tried to help them understand that. Obviously, we can't do that, you know, for a variety of safety reasons and stuff like that in the NICU. But what if we could just create these sacred spaces, right, these safe spaces, where if we can create a more consistent approach to the care that we provide these individuals with, right, and frame care encounters, right? So instead of me just showing up popping in, you know, flipping in stripping you that there is a routine, or maybe even a ritual around the engagement, right? Like, I can pair through the incubator and see like, okay, his eyes are open, I think we're good, you know, I'm gonna go ahead and engage with a patient. And I say, Hey, Joey, or whoever you are, you know, nice to see you. And I bring my hands in and slowly, you know, and put my hands you know, in non vulnerable locations on the baby and just kind of do a greeting, kind of, like I would do in a, in a grownups room, you know, hey, how you doing, I don't walk in and just pull the covers down and strip you, you know, kind of a thing. So you know, kind of do these little things, then, you know, progress to the care encounter, whatever the heck it is, using the baby's response to the experience to guide me, will it take longer, yes, but you know, what won't happen, I won't be having all those D sets and Brady's after the event. But before you finish the care experience, then do the same thing, frame it, close it out, put your hands back on that space and just say, hey, you know, see you in three, or, you know what, you know, I'll be checking on yours or something like that. But obviously, it can't just be me doing that, like in a, you know, Nicu where there's, like 200 staff, it would have to really be an adoption, right, a true paradigm shift, where we're creating these experiences. But in that sense, I think we could create a version of that sense of sanctity, you know, you know, now my, my time is not is mine now, I'm in a safe space now, because of these experiences that I've had, you know, that pattern recognition kind of thing.

Ben 34:45

I wanted to ask you a follow up question to that because I doubt that anybody listening to our discussion at this point will say I completely disagree. I think this is such a such inhumane and and noble cause that I think we're all on the same page. Now, to make things practical, I am putting myself in the shoes of, of the nurses and the physicians but the nurses specifically because with COVID, everybody I spoke to every unit is is stripped to the bone. There's shortages as unprecedented shortages of nurses of respiratory therapists. And it's putting a load on our nurses. That is tremendous where our nurses are covering more patients than the than they were supposed to or ever covered. A follow some of my former institutions on Twitter, Instagram, and like you could sometimes see the messages of nurses saying, hey, like we're desperately short tonight, like if anybody can come in. And and it's and it's very scary, obviously. But when we put this in the context of what we're discussing in terms of trauma informed care, it feels like it's it's resource intensive from the standpoint of time. And and the question is, how do we, and I don't think that I don't think that when we want to do more things on top of what we're already doing, we're being very efficient, I think, it probably means that we have to deconstruct the way we deliver care, as you were just mentioning, and rebuilding a framework that makes sense where ER nurse would be able to do all these things within the shift that is assigned to her or him. And what does that look like specifically?

Mary Coughlin 36:22

Yeah, excellent point. And a lot of folks, you know, that hear this, it just like you said, they're like, Okay, oh, gosh, I want to start now, what am I going to do? And it's not like you can, it'll work that way, you know, it's, it's taking that bigger step back, looking at the system, because it took a village to create this situation that we're in right now. It's gonna take a village and time to deconstruct it and rebuild it. And so kind of just as a starting point, for me being trauma informed as a first step, it's not doing more things. It's being showing up differently, right? It begins with who I am, and how I'm going to engage with that person. And then working out all of those details together over time, because ultimately, I you know, I don't know if folks are familiar with the five care model, that TRICARE family integrated care model, where the family is really that primary care provider, and I know that their work

Ben 37:22

with Believe me, I'm familiar with bikeerg.

Mary Coughlin 37:26

All right. I think you know, I mean, obviously, there are challenges to that. I mean, there's challenges to everything. But you know, I was kind of trying to get to that understanding of the gold standard of that person that's going to be delivering the infant care, not the medical care, not the nursing care, but the infant care is the parent, and, and boy, have we like screwed things up with the COVID stuff in that and, you know, I really have to Well, I mean, it was not the right thing, you know, limiting parent presence was not the right thing. There are going to, there's going to be a horrible follow up for these families, these infants, and it's certainly impacting the clinicians as well, you know, so, I mean, I get the intention, you know, the mindset, but I don't think people really thought it through. But um, you know, to start out in and beginning this transformation, is, is really about for me, taking that journey within. So how do I connect with this baby with this family in crisis? How do I really empathize authentically, with what they might be experiencing? And I know some people say, Well, I've never had a premature baby, it's like I, you know, I don't think you have to have a premature baby, to be able to empathize with what it might feel like to have a loved one in a hospital setting or to have a baby, you know, maybe you had your baby, imagine your baby, you don't go to the pediatric emergency room, right? And drop your baby off and then drive home and say, Call me when you want me to pick up. Joey right. And that just never happens. But that's what we do in the NICU. So it's, you know, kind of taking a step back, taking stock in your own story, your own experiences with possibly trauma, early life adversity, isolation, pain, the struggles, but also the triumphs, you know, really connecting with that. So that you can show up to these horrific situations. As a loving, compassionate human being right? You, you can't give what you don't have. And I, as a clinician, I want my legacy to be more than she's really good putting in PICC lines. You know, boy, she can intubate anybody, you know, I mean, that that's cool. And my ego loves to hear that stuff. But I don't want that to be my legacy right now.

Daphna 39:51

Yeah. Yeah. I think you bring up this such an important important top topic about it's really just about connectedness, you know, it's why so many of us went into medicine. But for some reason, as neonatal providers, we feel like we can't do that with the patient. And, you know, we on our, on our podcast, and one of our initiatives is really to talk about, you know, burnout in moral injury in providers. And, and what we're finding, and what research is showing is really, it's kind of that lack of connectedness that leads to burnout. And so, I, you mentioned this earlier, but I, you know, I, it brings me so much joy when I can hold my patients read my patients when I talk to them and sing to them, and I can see them engaging back with me. And so I wonder, how may, how can we influence clinicians at the bedside to say, this isn't just for the baby, right? It's for you, too. And I wonder how bringing that connectedness and seeing that even the 25, weaker, the 24 to 23 weaker as another human to connect with can change our own trajectory and burnout.

Mary Coughlin 41:10

Well, you know, when you had mentioned earlier that you're doing studies in palliative care, I don't know if you've seen anything written by Joan Halifax. So yeah, so and this is what I share this with my NICU colleagues, because I think it's so easy right? To get sucked into the vortex of busy frenetic, crazy energy. A lot of it is real, you know, so how do you calm yourself to be in a place that you can be authentically available to other and then when you are that other person, baby parent colleague, you can feel that right? And then they're available for you. She she has this really cool little exercise, the grace acronym. And so I tell my nursing colleagues, and, you know, physicians, too, can do this, too. It's not just a nursing thing that, you know, before you belly on up to the incubator, you know, give yourself a little, you know, a sacred moment, a safe moment, whatever you want term feels comfortable for you and just practice this grace acronym. It might it won't take long. So the G, it stands for gather your attention. So just stop, right and then our recall your intention. And if you didn't set one, make one right then and there, you know, whatever, whatever feels right in the moment, and your wisdom will tell you right, it'll just sneak right up and tell whisper in your ear. A attune attune to the situation attuned to how you're feeling is your heartbeat, you know, like a maniac. And are you all crazy? Take a nice deep breath, and then look at the baby. does the baby look like they're sound asleep? Are you seeing some eyeballs moving behind the lids, maybe you should go do somebody else up or get yourself a cup of coffee, write a tune. And the sea is kind of like what I just said, but consider your options based on your attunement. And then you know, whatever your option is, if your option is to, you know, engage, then do that right, the E engage with the patient and then end right and that's that framing idea. And I know there are some other strategies out there little acronyms but I think taking those little moments for yourself, really help you reconnect with your own humanity which is that's the thing that opens the door for you to connect with another person's humaneness right humanity.

Ben 43:36

So I wanted to give some props to one of our future guests, Rick guidotti which will have on which we've recorded and his episode will be answered. But he has this great saying that touches on what you're both are saying, which is, change how you see and see how you change. And it's this symmetry of that of that mantra and what it means that when you when you change your perspective, you by your intrinsically will change yourself is so powerful, and it applies exactly to what you guys are saying. So this is really cool. I wanted to before we before we start running low on time, I wanted to talk to you about this because when I first got into neonatology, I saw a lot of add hyperactivity and some of the I've always been very passionate about long term follow up. And this is something you see frequently. And my initial thought was, oh, super simple. Because of the caffeine we give these calf these kids caffeine so much. That's why they're just hype. They're just hyper and then as I was digging through the data, really there's no association between the development of attention deficits or hyperactivity and caffeine. And then listening to some of your of your talks. You do mentioned the this idea that, well, these pathologies in early childhood could be the result of PTSD and that was very Interesting to me a bit a bit mind blowing. And I'm wondering if you can talk more about that to our audience?

Mary Coughlin 45:05

Yeah, sure. Well, I think where I kind of came to that, and I think I saw a reference to that at some point, and then it really kind of like tried to backpedal and figure out okay, so how does that work? Biologically? When you think about like the polyvagal theory, Are you guys familiar with the polyvagal? Theory? It's this wicked cool theory, by this guy, Steven Porges, who actually started out in pediatrics, you know, looking at heart rate variability and stuff like that he was really interested in vagal tone, how is the the vagus nerve connecting with the autonomic nervous system? And how is that translating into the lived experience of the person kind of, and so he, he talks about three levels to the brain, okay? And I'm super, super simplifying this, and he's the guy to talk to you, right? But, you know, he talks about, like, you know, first at the level of the brainstem, right? Your, your body at that level of the brainstem, it's all about survival. And so, you're continuously on an unconscious level, surveying the environment, am I safe? Or am I in trouble, right? It's safety, versus, you know, survival. And by being in threat, whatever. And this just happens all the time. Like, I actually had a little bit of this before I came on this call, you know, I was like, a little bit nervous, you know, that's my anxiety kind of heightened up a little bit. And so that, you know, once you decide, okay, um, they're not going to kill me, I'm safe. Okay. Then the next the next stage, and this all happens, like instantaneously, right? But the next stage is at the Olympic level. Am I Am I loved, right? Am I you know, do these people care about me? And think about this from a baby perspective, right? It's survival. And then am I loved. And then once those two are, like, checked off, we're good. It's my neocortex is then open to learn and explore, and do all of those cool things. So let's go to the premature person who's now a toddler. If all of my experiences for, I don't know, 18 months, well, no, we won't say that. Because then they're not in the hospital for 18 months, we'll say, I don't know. 130 days, right? Just get guessing. Right? If for 130 days, all of my experiences have made me feel terrified. I never knew when the other shades gonna fall. Yep. isolated. I don't even know what love is, all the touch I get is painful or scary or threatening all of that kind of stuff. Then my brain gets wired to, you know, to walk through the world defensively. And and hyper vigilant. That's the other one, right? We, you know, these little people because of the terror and the fear that they experience in the inconsistent chaos, wicked, awesome word, the chaos that they experience. They learn to be hyper vigilant, because you just don't know when something's going to happen. And that translates into that hyperactivity, right, that I'm always I'm always moving. And there's lots of you know, other authors have written really cool things to help us better understand that phenomenon that's based off of that polyvagal theory. And so it is it's a consequence of the trauma that they experienced. And they're learning how to walk through the world to stay alive. And that's what happened. And then it goes into Oppositional Defiant Disorder and all these other or super withdrawn, right, they go that track, and then they have the anxiety and then translates into the depression. Is that helpful?

Ben 48:30

Yes, yes, definitely.

Daphna 48:32

Yeah. One, I think I mean, that's just rolls right into my next question, when we talk about hyper vigilance and our memories of trauma. And you mentioned how we can use a trauma informed lens to work with parents. So I'm hopefully you'll talk a little bit about that, too. Yeah.

Mary Coughlin 48:52

And so again, from a parent perspective, and I think one of the biggest challenges we have with parents is that we don't call it what it is, right? We don't call what we don't call the experience traumatic. So families come in, they're in the throes of trauma. They're freaking out. They're overwhelmed. And we're just like, okay, here, this is, you know, this is the thermometer, this is hot water. This is this, this is that, you know, you just stand here and we'll show you all of these things that we're doing and stuff. And meanwhile, they're just internally just steeped in overwhelm, right? Steeped in I am freaking out what is happening to me, and they're trying to figure out how to cope with that situation. But they may not say anything, or they may be surly. They may be nasty. They may be you know, difficult. And and we don't know, I don't know what your story is. I just know that I've got your little person here and I'm trying to keep them alive. So just show up, pump your brass, and we'll all be good and happy and everything will be fine. And we don't help them process their own experience because again, And because we as NICU clinicians haven't really been introduced that this environment, this is a trauma Ward, this is traumatic stuff is happening. And so we actually I got to do this really cool work with them. Two colleagues of mine, Marilyn Sanders and Neonatologist at UConn, you know, a children's hospital in Connecticut. And Amy got a PhD nurse researcher out of URI wrote in Rhode Island, and we did this, we call it focus group thing to try and understand, like why clinicians were how clinicians feel about this language of trauma and stuff like that real, you know, kind of getting that, that piece of it so that I didn't want to be traumatizing my colleagues and like shoving this information down their throats, I wanted to understand where they're coming from. So that we can then introduce this idea and have them engage with an open heart and open mind about, you know, trauma and trauma informed care. And you can see there, they're just loving, compassionate people. And the word trauma is scary. So I don't want to call this a traumatic experience, and scare the parent. But but then you have to help them understand like, I don't want to scare them, either. They're already scared, they're already freaking out. And they don't have the language to to define their experience. So if we can say, this is a traumatic experience, what you're going through right now is trauma, then it then it's like, Oh, I thought I was just literally losing my mind. And, and you might be having elements of that. But now you can understand the why of it. Because it is a traumatizing situation. And any other human in a similar situation would be freaking out as well, because that's what trauma does. It freaks you out. Right? And then we don't do it to ourselves, you know, you know, you see nurses burnout, compassion, fatigue, because they include physicians as well, right? Because we've been taught to distance ourselves, you know, don't get personal, don't get involved, you know, don't connect. And it's that lack of connection that actually increases your vulnerability for burnout. It's so it just, you know, we've got it all backwards.

Daphna 52:03

Totally agree. Totally agree. You know, we I'm part of the AAP, T kin webinar series about targeting family, specifically, you know, maternal mental health in the NICU. And we were interviewing one of our parents on the webinar, and she said, one of the best things somebody ever did for me was just asked me how I was doing, you know, so many times we're afraid to ask parents, because what if they tell us something that we can't handle for them? Right? Yeah. So we'd rather just not ask. And that was, you know, even though this is something I care very much about hearing her say, like, just ask, just ask me, Do you see me as a person? That's also struggling. So I think that's definitely kind of what you're speaking to.

Mary Coughlin 52:52

Yeah, yeah, it really is. It's just getting out of our own way. And being, you know, that loving, compassionate person that went into this work in the first place, it's a calling, you know, and we went, we came into it, to heal the hurts of others. And, and, and there's a lot of hurt, that's going unaddressed. And because we're afraid and we think we're not supposed to do this, and we don't want to cry in front of our patients or VC. Like somehow, if I'm emotional, that detracts from my intelligence. Does it rarely, you know, I mean, I can actually be loving and kind and compassionate, and be really, really smart and technically proficient and all those other cool things, you know. So,

Daphna 53:35

yeah, amazing, amazing. You've given us, I think, some real concrete things for people to just take back, you know, to their units, especially with the grace acronym and centering yourself before interacting with babies, looking for their cues, talking to families. So I think that's a good start. But maybe tell us a little bit more about if, if people really want to invest in changing their practice. How can they do that?

Mary Coughlin 54:03

Well, I mean, I think, you know, reach out to me, you know, my team and I, we've just done, finished of developing and evaluating our pilot program of a trauma informed professional assessment based Certificate Program. The program, it's, it's a blend of self paced online modules, and then live virtual sessions, masterclasses and mastermind sessions. And the intention of the program is, as kind of I've been alluding to throughout this whole session, it's really about discovering yourself, right, unbundling your own story and your connection to what had been identified as eight attributes of a trauma informed professional. These attributes were identified by an international interdisciplinary group of neonatal experts. And we decided to go with an assessment based certificate program versus an examination, you know, a, you know, a traditional sort of vacation because we felt like there's a kajillion wicked smart people out there. And, you know, I know alphabet soup is really awesome, I love it myself. But just because you've got those extra letters doesn't really mean that you're going to do anything differently. And because it's hard, it's hard to go against the system, right? It's hard to stand up and step out of line. And so we we went this path, because we really wanted folks who go through the program to be able to walk the talk, to actually become that leader for transformation. If you want to transform cultures, it begins with personal transformation, right? You just, it doesn't just happen. It's not. It's not a recipe. It's a, it's a journey and a process. And so I'd love for folks to, you know, reach out and I can share more details about it. It has been endorsed by NID, Cap Federation International, the National Association of neonatal nurses, the Council of international neonatal nurses, and just recently the National Association of perinatal social workers. So it feels like it's really being recognized. And I don't know if you guys have seen the hot off the press, sort of kind of August 2021, the American Academy of Pediatrics issued a clinical report, talking about trauma informed care, and a policy statement, recommended trauma informed care for Child Health Services. And I had the amazing privilege to actually speak with one of the lead authors, Dr. forky, who's out of UMass Wista, here in Massachusetts, and talked about, you know, the work that I'm doing, and how I feel it really aligns with what the academy is really putting forth. And she shared with me that the agenda for the next presidential period, and you know, of how the academy rolls was mental health, mental health and trauma informed care. So that just felt really exciting. And validating, I think we're in a in a time that is, you know, it, we're ready for transformation on so many different levels. I mean, COVID has revealed so many gaps in our system and in our, our humanity, really, I know, that might sound kind of strong, but I feel that it's really opened up our eyes to recognizing that we have an opportunity to be more loving, compassionate and kind to those that we've served. It's it's a biological necessity. It's not just, you know, frosting on the cake.

Daphna 57:24

That's right. I totally, totally agree. Mary, I, I'm going to ask one more question. And then I'll let Ben close out the show. I'm sure I can tell he has another question. But so I wonder when you enter the unit, and you find yourself, like we all have in like, what is obviously a chaotic situation? How do you like keep from pulling your hair out? And, you know, stomping your feet and saying like, what do you guys do? You know, how, how can we talk to our colleagues and provide feedback that is constructive, but not off putting, you know, in real time.

Mary Coughlin 58:06

I mean, in real time, it is hard, and it is and you do have to be gentle and loving. And I think what I do is I ground myself in the firm belief that everyone is doing the best they can, that everyone is doing what they think is the right thing to do. And when you address opportunities for improvement or change from that core belief, authentically, right? Then people kind of, you know, are more receptive, their first response, their first reaction, like if I go up and say, Hey, how you doing? You know, it feels kind of loud over here, are you are you? Are you doing? Okay? You know, if, you know, do you need some help? You know, why are you up here in high G, kind of a thing, you know, so if I can kind of like respond to where they are, everything pivots off of where they are, they're not talking loudly, because they want to cause you know, hearing impairment to the baby or freak the baby out. It's something's happening with them. So I think to be trauma informed is to meet people where they are and honor that you seem really freaked out right now. Do you want to get a cup of tea? Can I take over your assignment, so you can go and decompress? You know, it's that place instead of saying, You're doing this wrong. And I, you know, let me show you how it needs to be done. It's, it's really, if you really going to be trauma informed, it's to recognize that everybody is feeling it. And to start there, right? My mother in law has this saying and I'll stop talking in inches is cinch a yard is too hard. I think another wiser person probably started that, but she takes credit for it. So I have to, you know, wrap it, you know, so it's those small steps. And then that person sees, I think definitely cares about me, right? You know, that was really kind of her and one act of kindness. It's that domino effect

Daphna 59:59

that gets Another Yeah, that's right.

Ben 1:00:01

Thank you for everything you've shared. It's, it's it's so, so dense and so good. I wanted to ask you, I wanted to close the show maybe with a very practical question where, for the people listening, who are motivated and who are going to take on the mantle of trauma informed care? What are some of the immediate responses from the patient from the unit that could create a short positive feedback loop that people could look for, to feel like what they're doing? I mean, sometimes, sometimes we need this feedback of saying, Well, this is this is working, I'm doing a good job. I feel like, because we've been talking about trauma informed care, and the very long term ramification it has, I'm wondering if you had anything to say about some of the immediate short term things that you will see at the bedside that could reinforce the behavior we're trying to promote?

Mary Coughlin 1:00:53

I mean, right off the top of my head, you'd see fewer A's and B's, right, you'd see fewer, fewer spit ups, you know, when the baby, when you're feeding the baby, you would, you would feel a different energy in this space, if the parents feel that they're more empowered, to really be that loving support for their baby, right, driving the care of their baby would have that different energy. So I think if you can, if that's what excites you, then that's what you can look forward to in the short term, and what it feels like for me, you know, because I don't know, I mean, everyone has their own experiences. But for me, when I started to really understand this and bring this to my clinical practice, I knew what it was right, I knew that it was my kindness, I knew that it was my patients. And I knew that that was triggering these experiences. So it was it went full circle, right? So if I can be kind and compassionate and patient with this baby with this family, you know, sit down with them and have that conversation and watch their face relax, or their tears may either flow because that is important. Or maybe or maybe a beige, then that fills my cup up. Because I was the agent of that, that healing moment that healing. The second you know, whatever it was. So it's it's, it's, it's those small things that you can find joy in that remind you of why you you were called to this work in the first place. Right. Yeah, no

Daphna 1:02:25

worse. So Mary, we're so grateful for your time. We are hoping to to this is the start of our new year. So we're hoping maybe everybody will set an intention, not a resolution, but at least an intention to make a little bit of change, like you said, those moments each day to make a difference. So thank you for sharing those opportunities with thank you so very much. This

Mary Coughlin 1:02:51

was awesome. I really appreciate it.

Ben 1:02:53

It was fun. And that hour did fly by as expected. So much.

Mary Coughlin 1:02:59

Thank you most welcome, guys.

Ben 1:03:01

Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address the queue podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikhil spelled Dr. NICU, and Dafna is at Dr. Dafna. MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you