Recently I went to help out on a trauma, and it was hard to maintain my dignified facade. It was early in the night, and I heard the page for an incoming trauma and headed to the ER to help out.
When a trauma comes in, most emergency departments and hospitals use a protocol called ATLS, Advanced Trauma Life Support. It was originally devised by an orthopedic surgeon and amateur aviation enthusiast, James Styner in the 70s. When the light aircraft he was piloting crashed in rural Nebraska, he was very unhappy about the quality of care his family received, and realized part of the problem was that most hospitals didn’t have the training or preparation to deal with traumas.
ATLS is divided into three phrases. The first phase is about ensuring the basic stability of patients and making sure they stay alive. It’s about concentrating no the ABCDE’s (Airway, Breathing, and Cardiovascular Circulation, Neurological Disability, and getting Exposure to the patient and maintaining the patient’s environment, preventing hypothermia). Note that the last element there, E, includes removing the patient’s clothes. In a lot of trauma situations, the poor suffering patient might be unconscious or obtunded and may not be able to tell you what happened and where they are injured, they might be too confused or disoriented, or just might not know what happened. It is important to examine a patient all over, including the lower extremities to look for injuries to make sure you have looked for injuries you might have missed. For example, you don’t want to miss a bleeding popliteal artery at the back of the knee.
So I went to the trauma bay, and a gentleman was brought in by the paramedics in pretty banged up state, highly intoxicated, and as part of this misadventures that evening, he had been pepper sprayed. As the team was beginning to assess him for injuries, I put some gloves on and pitched in to help, by starting at the foot of his bed and taking off his socks and shoes, putting them in a plastic bag and then checking the pulses of his dorsalis pedis arteries (the artery that runs along the top of each foot). The presence and strength of these pulses tell you about how well blood is supplying his lower extremities. I next progressed to go up and try to take off his pants to get a look at his legs. It certainly can be disturbing to patients to have groups of people taking off their clothes, while they are asked to stay still in a C-collar, while IV’s are being put into their arms, and other people are doing things like shining lights in their eyes, and asking them questions. However, that is typically the kind of things that happen to a trauma patient, all with good reason. So, you make sure any bystanders that came in (such as family members that came in with the patient) leave, and that the patient is in a private trauma bay area and only the treating team is there. You tell the patient that you’re taking off their clothes to look for injuries, and make sure you have a blanket to cover them as you are removing clothing, and try to examine the body a piece at a time, exposing one part is covered as you examine another. It actually goes pretty quickly and smoothly as you have many people helping out that know what they are doing and are following a system, so that everyone can be working together with the same goals and known roles, the entire point of ATLS. It is pretty straightforward if the person is unconscious, but can be difficult if the person is particularly large and/or combative. In this case, the patient was relatively cooperative, but his pants were embedded with pepper spray, which I didn’t realize at first.
As we were working on this patient, other people in the room had some sneezes and a bit of watery eyes and coughing. However, as I was struggling to get his pants off, I liberated a decent amount of pepper spray into the air and into my face. I did have eyeglasses on, but my eyes were still watering and I was struggling to suppress the need to sneeze. I got his pants off, put them in another plastic bag, and was starting to look over his legs and getting ready to help turn him so the primary could look at his back and spine, when the urge to sneeze was just too great. Eyes watering, I knew I couldn’t use my hands to cover my mouth, which would normally be the polite thing to do, as I had gloves on and had been working on the patient, so I turned my head into my left shoulder and out came an enormous sneeze. The forceful rush of air wasn’t the only thing that came out, and the shoulder of my green scrubs was covered in all the watery mucus which had been produced a reflex to the pepper spray. It wasn’t a little bit. It was more like the scene in Ghostbusters with Slimer and his ectoplasm.
It did not feel like my finest moment in medical school.
There were plenty of people around helping at this point, so it took all of a few seconds to step out of the trauma bay, remove my gloves, wipe off my shoulder with a paper towel at the sink, put on more gloves, and I was back to helping the team with the patient.
In the end, the patient was a bit banged up, but overall okay.