This EMT integrates ACEs, offers emotional first aid

chiavetta

Peter Chiavetta and the handouts he gives patients

One day, when Peter Chiavetta was just out of college, he was driving down a road in Eden, NY. Before he could even give the slightest conscious thought to his actions, he swerved off the road onto the shoulder. The car that was heading straight at Chiavetta slammed into the vehicle behind him.

“I thought I was a good prepared citizen,” recalls Chiavetta. “I had road flares and a two-pound fire extinguisher in the trunk of my car. I’m standing in the middle of the road with my little fire extinguisher, while on the ground the two passengers in the car behind me had been ejected and were lying motionless. Out of nowhere a man appeared with a first-aid kit and tried to help one of the victims. The driver — covered with blood and his knees are chopped down to bone — was calling out to me for help. I had no idea how to help him.”

He vowed never to be unprepared again. He became a volunteer emergency medical technician with the Farnham Volunteer Fire Department and answers calls in a 50-square-mile area.

Forty years and hundreds of calls go by. It’s 2015. Chiavetta – who’s now chief of the fire department while running Chiavetta’s Catering Service, a family barbecue catering business that serves 20,000 people a week during the summer in Brant and Lockport, NY — is thinking about letting his EMT certificate expire. The last two years have taken an emotional toll. He’s attended his first infant fatality. A friend’s son dies of an overdose. He responds to a call where a child was murdered by its mother’s boyfriend.

Then two things happen: A couple of days after he handles a call where a young girl has attempted suicide, Chiavetta, a self-described TEDTalkster, watches a talk by pediatrician Nadine Burke Harris. She explains how the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) has completely changed her approach to treating kids, and why she thinks everyone should know about it. Adverse childhood experiences (ACEs), she says, contribute to most of our major chronic health, mental health, economic health and social health issues.

The ACE Study, she explains, measured five types of abuse and neglect: physical, verbal and sexual abuse; physical and emotional neglect. And five types of family dysfunction: a family member with mental illness, or who has been incarcerated, or is abusing alcohol or other drugs; witnessing a mother being abused; losing a parent to divorce or separation. (Of course, there are other types of childhood trauma, and subsequent ACE surveys include other types of trauma. These include racism, bullying, witnessing a sibling being abused, witnessing violence outside the home, living in an unsafe neighborhood, experiences unique to being an immigrant (such as losing a parent to deportation), and involvement with the foster care system.)

 The higher a person’s ACE score, she says, the greater the risk of chronic disease and mental illness. For example, compared with someone who has an ACE score of zero, a person with an ACE score of 4 is 12 times more likely to attempt suicide, seven times more likely to become an alcoholic, and twice as likely to have heart disease. People with a score of 6 or higher have shorter lifespans – 20 years shorter.

And it doesn’t matter what the types of ACEs are. An ACE score of 4 that includes divorce, physical abuse, an incarcerated family member and a depressed family member can result in the same damage as an ACE score of 4 that includes living with an alcoholic, verbal abuse, emotional neglect and physical neglect. (For more information about ACEs science, go to ACEs 101.)

“The part that got me was this,” says Chiavetta:

“…one of the things that they teach you in public health school,” Burke Harris explains, “is that if you’re a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics, or you can walk over and say, ‘What the hell is in this well?’ “

“It clicked right there,” says Chiavetta. Many of the people he helps on his EMT calls overdose, attempt suicide, are injured in fights, and suffer from chronic diseases, mostly because of their childhood trauma. Maybe if they knew about their ACEs, he thinks, it would help them understand their lives, give them hope that they weren’t born bad, that what happened to them when they were kids wasn’t their fault, that they coped appropriately by smoking or drinking or overeating because that’s all that was offered or available to them, and, most important, with help, they could change.

He prints up the 10-question ACE survey and tucks it into a transparent plastic cover. A couple of weeks later, he has his first opportunity to include ACEs in his assessment. Chiavetta is called to a house to help a 24-year-old man whose brother had put him in a severe headlock. However unlikely, the man thinks he might have a concussion, but he’s also extremely anxious. As Chiavetta guides him into the ambulance, the young man tells Chiavetta that he’s just seen his father punch his sister-in-law in her face. “You’re just a hypochondriac!” the man’s brother yells at him.

During the ride to the ER, Chiavetta asks the man: “Do you want to participate in the ‘Adverse Childhood Experience’ survey? If so, I don’t want to know which questions you say ‘yes” to, just how many.”

The young man reads through the survey and tells Chiavetta that he scores a 5. “He repeated the number ‘3’ two or three times,” says Chiavetta. “I reminded him I did not want to know which questions he answered ‘yes’ to. No. 3 is ‘Did an adult at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way?’ ”

Chiavetta tells the young man that if he thinks any of those five experiences are affecting his life, that he should follow up with a therapist. The EMT doesn’t know if the young man did, but the experience helps him realized that integrating ACEs questions is “no different than any other crisis intervention that we do.”

“We score our patients on AVPU, CUPS, the Cincinnati Stroke Scale, DECAP-BTLS and PMS,” explains Chiavetta. “Why not ACEs?”

(AVPU measures level of consciousness: “Alert, Voice, Pain, Unresponsive”. CUPS measures stability: Critical, Unstable, Potentially Unstable and Stable. In the Cincinnati Stroke Scale the patient is asked to smile (one side may droop), extend their arms and close their eyes while the EMT watches for arm drift. The patient is also checked for slurred speech. DECAP-BTLS assesses: Deformities, Contusions, Abrasions, Punctures, Penetrations, Burns, Bleeding, Tenderness, Lacerations, Swelling. The PMS tests extremities for  Pulse and Motor Sensation.)

So, Chiavetta decides not to let his EMT certificate expire, and he proceeds to learn everything he can about ACEs. He finds the NEAR@Home Toolkit, which was developed to administer ACEs in home visiting, and calls Quen Zorrah, one of the 60 people who developed the toolkit and is a pioneer in integrating ACEs into public health clinics. Zorrah likes his approach and encourages him. “She’s been a big help,” says Chiavetta.

Zorrah suggests that before he administers the ACE questions, Chiavetta warn patients that they might have an emotional response to the questions. She advises him to use wording such as: “I know you’re having a tough struggle. Thank you for answering these questions, and for being so brave.”

And then she tells him: “If you’re not blurring the boundaries, you’re not doing enough for your patient.”

“I needed that validation,” says Chiavetta. “I don’t get that locally.”

With that encouragement, he decides to incorporate ACEs into his assessment. He calls it emotional first aid.

Since May 2015, he’s used the ACE survey to administer emotional first aid for 14 other people. They all had high ACE scores.

When he asks someone if they want to participate in the ACE survey, explains Chiavetta, and they say, “Ya, why not?”, “I get the impression things can’t be any worse. Once they agree, I informed them of the sensitivity of the questions and that they can quit the survey at any time. If they give me time, I normalize the survey with its origin and how common ACEs are. There are times I can’t even get the whole spiel out. They grab my laminated sheet and they are on their way.”

Besides administering the 10-question ACE survey, he gives them a copy of the 10 questions and a resilience survey (the same found on Got Your ACE Score?), a parent handout, and a sheet of thoughts that express what they are likely to decide about themselves from the perspective of a traumatized child’s limited experience of the world, Chiavetta says. These include “I am weak. I don’t deserve love. I am a bad person. I am terrible. I cannot trust myself. I deserve to miserable.”

“If you believe these, you’re taking career advice from a child,” Chiavetta tells them, “and you’re an adult.”

He’s added one more tool to his emotional first aid toolkit that he had occasion to use recently. The boyfriend of a 19-year-old woman called the local sheriff because she threatened to injure herself. The sheriff asked Chiavetta to stand by, they did an evaluation, determined that the woman probably wouldn’t hurt herself, and left.

Chiavetta decides it might be a good idea – and opportunity — to ask the woman if she would like to take ACE survey. “Why not?” she says. She starts taking the survey, and at question No. 3, Chiavetta notices that she tears up. She tells him she can’t continue. At that point, it’s not practical – or ethical – to leave her, so Chiavetta follows this protocol:

WHAT HAPPENS IF PATIENT STARTS SURVEY THEN REFUSES.

  • Patient starts survey and the triggers and stops.
  • Administer emotional first aid and tell patient: “You are not alone. Others have suffered the same experience. None of it is your fault. You should of been cared for, protected and loved. “
  • Maintain eye contact.
  • Tell them 60% of all people score at least one on ACE survey
  • Make sure you pause and allow the patient to feel what you are saying.
  • Ask the survey’s simple questions: Are your mom and dad divorced? Is there drug or alcohol use in the household? Did anyone in your family go to prison?
  • If you start getting yes to these questions, stop questioning. Reassure and repeat “You are not alone…”.
  • Explain that all their behavior has originated from their ACEs experience. Carry the narrative forward about where they are now and why. (This may be your past. It does not have to be your future. None of your behavior was your fault as a child.)
  • Explain how one behavior will escalate to other dysfunctional behaviors.
  • Ask if they smoke. Bring them back to that first cigarette. As them: Didn’t it make you feel good? They will more than likely say yes. Explain to them that nicotine is an antidepressant and reduces anxiety. That they just started their self-medicating. This will make your information more believable.
  • Explain ACEs, the neurobiology and epigenetics of toxic stress, and resilience.
  • Assure them they are on their way to healing and that because of this intervention they are almost there.
  • Give referral to a counselor.
  • Hugs when appropriate.

“When she triggered and refused to continue,” recalls Chiavetta, “I thought ‘Oh shit. My first no.’ I rebounded and delivered the above on the fly. You could see her hope and resilience begin. Her face glowed. I could feel the wave of relief of the message I gave her. She was excited to say the least. We hugged three different times. She is going to be on the way to recovery. It was beautiful.”

Although 15 people isn’t a lot, it’s a start, says Chiavetta. “It’s worked every time so far,” by improving their demeanor and removing their anxiety or sadness for those few moments, and given them a different perspective on their childhoods. “This is what’s going to heal the nation,” he says.

It’s also a start because the rest of the community has not embraced ACEs yet. Chiavetta would like hospital emergency rooms to be educated in ACEs science, and provide trauma-informed care to patients. He thinks that when more people, organizations and systems learn about ACEs, then the patients he helps who have never heard about ACEs will be more likely to follow up with going to counseling or getting other help. Over the last year, he’s run into several patients to whom he administered emotional first aid who haven’t changed anything in their lives.

ACEs in your faces

Chiavetta doesn’t just educate patients about ACEs. He’s lobbied local high schools to show Paper Tigers, a documentary directed by James Redford and produced by Redford and Karen Pritzker about a high school in Walla Walla, WA, that integrated trauma-informed and resilience-building practices based on ACEs science. He’s given talks. He’s joined the local Trauma-Informed Community Initiative of Western New York, and has encouraged them to launch a billboard campaign similar to one in Montana. He’s talked with people in other communities that have started ACEs initiatives.

“I had to go for a cortisone injection. I introduced the doc to ACEs,” says Chiavetta. “I gave him my handout and told him: ‘This is why middle-class white America is overdosing.’”

On the rare occasion he takes an order at one of his take-out restaurants, he sometimes starts a conversation and finds himself asking the customer: “Have you heard about ACEs?”

“Somehow, I really am not conscious of how the conversation shifts to ACEs,” he says.

Recently, he was at a party that his niece was giving. About 30 people were there. “My niece had remarried,” Chiavetta says. “She has a young daughter. I wanted to talk with new husband, make sure he knew his boundaries. I started telling him about ACEs. I told him that one out of four women at this party had been sexually abused. And one out of five males. He proceeded to state his level of understanding about statistics and said they did not pertain to a family birthday party. A guy next to me piped up, and said: ‘When I was 14 my uncle made me touch his penis. He tried to bribe me to keep me quiet. I told my father, and my father beat him up.’

And he washed his narrative down with his beer.”

He would like to teach other EMTs about this, but thinks he needs more experience before he can offer a well-informed set of practices, and he thinks that emergency room personnel need to be trained for patients to receive the care they need.

His daughter accuses him of being “ACEs in your faces”. He admits that for a while wanted to be the first to tell everybody, but now he’s “finally calmed down about it,” he says. “It’s the competitive thing, you know. It’s tough managing myself. Even though there’s just one voice in my head, it’s got a lot of personality.”

One thing he learned earlier this year has also helped him understand his life better. He saw James Redford’s two-minute trailer for one of his other documentaries,  The Big Picture: Rethinking Dyslexia, and finally, at the age of 64, realized that he was dyslexic. “I told my daughter about it, and she said, ‘Dad, I thought you knew! We all did.’”

Because of his understanding of ACEs, he realizes how dyslexia affected him in school, and that berating himself for years was damaging. So he told himself he was sorry, and was able to see how dyslexia had helped him. “I can’t do details very well, but I can see the larger picture. That’s been my resilience my whole life.”

This summer, Chiavetta is standing in line for ice cream and a 22-year-old woman approaches him. He remembers that he saw her in the ER where she was recovering from an opioid overdose.

“I had a short talk with her mom that night.” Chiavetta recalls, “and gave her my ACEs handout. The young women told me how she’d recovered and how proud she was of her six months of being clean. She did not remember my conversation with her mom that night. She said that she knew of a lot of her friends wanted to go to rehab but were afraid of their parents finding out. I gave her my ACEs awareness handout and explained the importance of ACEs and the use of drugs as a sedation. She told me her hope is to one day start up a rehab group for others so that she can help them.

5 responses

  1. Peter:
    This is so wonderful. I love your approach and many of us are kind of “ACEs in your face” so that made me laugh. I love how you demystify and contextualize ACEs with lots of different people. Thank you!
    Cissy

    Like

  2. Pingback: This EMT integrates ACEs, offers emotional first aid | Catherine Forsayeth ARTBLOG

  3. I like the notion of doing this. Actually, I love the notion. I would caution though, that this could cross over into grey areas. Here’s the scenario I imagine. A patient has a severe trigger reaction, and the firefighter doesn’t have the resources to ground the patient, because in the middle of it they arrve at the hospital, and then the patient is handed over. The question will come up in the emergency room by the staff there, as to why the patient is in such arousal, and imagine what that patient will sy, not maliciously, but in a triggered state. That gets back to the medical director of the local EMS. What are the odds of that director being trauma informed? He has a responsibility to the community, and the purview of those issues aren’t in the scope of an EMTs practice, and hence jeopardize that EMTs license. Is the help pertinent to the situation at hand? Not so far as an EMT is concerned: airway, breathing, circulation and anything threatening that. Our training and med kits don’t include anything like handouts, so if we bring “personal” stuff into the picture, there could be an issue. One has to consider the further tips suggested in scope of the time required to do so, and whether or not the treating responder actually takes the trip in the ambulance. Not all jurisdictions are built that way.

    That being said, I applaud the other efforts, and, maybe approaching the medical director with some good data might help in the further care of patients. It might help to bring about awareness and even action related to ACEs. I would also like to see some of this idea broached in academy, though my field is in empowering them to take care of themselves relative to stress and trauma, and the education of their own neurobiology during stress and trauma so they could 1) care for themselves (I teach them a technique), and 2) better assess in the field more accurately. I’ve had clients in emergency situations have to demand their rights to allow their body to process the physical stress and trauma. It shouldn’t be that way, and with good training in those aspects, would make for better responders.

    I agree that most of the stuff we see in the field is from childhood trauma, but we aren’t trained (where the liability dollar falls) to diagnose or assess that. I think there might be some pushback if we try a bottom up approach without authorization. Instead, bring about top down awareness, make sure the responders are trained in dealing with their own, and then I think we’ll see better field diagnoses, and/or, better treatments. It might not be an easy or swift change, but a necessary one. I would prefer to be wrong about this. Knowing my former districts though….

    Kudos to Mr. Chiavetta for bringing ACEs to awareness in this field.

    Like

    • Early on in my education of ACEs I decided to interview a person that I had no knowledge of their presence in town. The resident had lived at the address for 25 years. They told me that they were under treatment for suicide tendencies for the past 20 years. There were two completed suicides in the family. They agreed to take the survey. I can’t remember the score but it was substantial. What they said next remains a driving force in me. “The last therapist told me… What do you want me to say? I’m not going to say anything different than all the other therapists in the past 20 years.” Then they continued… ” I’ve never been asked these ACEs question before in my life.”

      Liked by 1 person

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