Each time she moved her hand it caught my eye: the glint of her bejeweled fingers sharply contrasting with the spare gurney and paper-thin blanket. The fat heaviness of her rings seemed startling against her bony fingers, as if they should have shrunk in parallel with her collagen and fat. She fought against the technician removing her belongings while her protestations melded with my trauma survey.

“GCS14.”

“Leave me alone.”

“Front scalp hematoma.”

“What are you doing?”

“Pupils equal and reactive.”

“Those are mine!”

She was an elderly woman with head trauma after a fall. We thought we were saving her life with a trauma activation. She thought we were robbing her of precious life possessions.

For years I have stripped trauma patients, probing their painful wounds for elusive injuries and examining them with a level of detail usually reserved for mothers studying their newborn babes. Patient after patient, trauma activation after activation, my trauma surveys became rote and depersonalized by necessity. Yet, I could never shake the nagging feeling that I was performing exams without patients’ explicit consent. Or even worse, against their verbal objection. I couldn’t escape that I was traumatizing my patients with a trauma activation.

Consent to a trauma evaluation is presumed when a patient presents as a trauma activation; implied consent applies to all life-threatening emergencies and is not unique to trauma activations. However, patients are neither knowledgeable about our opaque trauma protocols nor informed about trauma activations. The concept of rapid assessment for heart attacks and strokes is not foreign to the general public, but these emergencies do not include rapid destruction of clothing, private examinations performed in front of audiences, or a quick succession of invasive procedures. Trauma is unique.

Throughout the Advanced Trauma Life Support manual, a mere three sentences relate to the murky ethics of trauma consent: “Consent is sought before treatment, if possible. In life-threatening emergencies, it is often not possible to obtain such consent. In these cases, provide treatment first, and obtain formal consent later.”¹ The time pressure of trauma resuscitations and the variable severity of injury make obtaining informed consent before a trauma exam difficult. Thus, a full disclosure of the process and alternatives seldom happens. Too many times we offer, in place of full disclosure, a simple statement—“I’m going to examine you head to toe for injuries”—and accept fearful silence as voluntary agreement. This process is worse for systemically marginalized populations, including people with mental-health comorbidities, primary languages other than English, minorities, and those who have experienced assault.

The salvage of life and limb is the purpose of trauma activations and surveys, but it assumes that moral injury is an appropriate sacrifice in pursuit of that goal. Many of my colleagues fear personally experiencing a trauma activation—not due to personal injury, but because they know about the process. Interviews with patients who experienced trauma resuscitations reveal themes similar to our unspoken professional fears. The violation of personal space and dignity and removal of valued objects without explanation or consent are common frustrations.² The same patients are reassured by our competence, yet we must address the times when acuity, standardized protocols and patient values are misaligned. During one of our recent surges, I rushed through discharging a man without serious injuries after a fall, my mind distracted by the burgeoning waiting room. I asked what questions he had and the only one was about his sweatshirt. His wife had died six months earlier and I had destroyed her last remaining possession, one that he kept with him.

These days, I attempt to balance a less morally injurious trauma resuscitation with the need for rapid stabilization and treatment. The other night I stood in the trauma bay, listening to rain patter against the automatic doors, awaiting an ambulance. The doors slid open and above the rain I heard a woman yelling repeatedly in mixed English and Dari, “No, I do not consent,” while paramedics relayed their concern for a spinal injury after she fell down concrete steps. We found an interpreter, took her vitals, and did one of the harder things to do in a trauma bay—we paused. It took time, but we learned how we could perform a trauma survey aligned with her values and she understood the process. Wearing a cut-up trauma sheet as a hijab, she walked out of our emergency department several hours later, intact and not traumatized.

Dr. Lebold is an emergency medicine resident and physician scientist at Stanford University in Stanford, Calif., with a professional focus on the care of critically ill patients. She completed her MD and PhD training at Oregon Health & Science University in Portland, Ore. Her research focuses on earlier prognostication of acute respiratory distress syndrome.

Dr. Eagle is currently a third-year emergency medicine resident physician at Stanford University in Stanford, Calif. She has broad interests across emergency medicine including wilderness, toxicology, and limited resource medicine, and her artwork can be found accompanying various medical literature and research.

Acknowledgement: Luz Silverio, MD, who provided content review and editing assistance.

References

1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support: Student Course Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018.
2. Kaufman EJ, Richmond TS, Wiebe DJ, et al. Patient experiences of trauma resuscitation. JAMA Surg. 2017;152(9):843.