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.
“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.