AMA Journal of Ethics® May 2018 Volume 20, Number 5: 419-523 Trauma Surgery Ethics From the Editor Caring for the Wounded—the Ethics of Trauma Surgery 421 Sara Scarlet Ethics Cases How Should Trauma Patients’ Informed Consent or Refusal Be Regarded in a Trauma Bay or Other Emergency Settings? 425 Commentary by Ashley Suah and Peter Angelos How Should Complex Communication Responsibilities Be Distributed in Surgical Education Settings? 431 Commentary by Bradley M. Dennis and Allan B. Peetz What Are Ethical Implications of Regionalization of Trauma Care? 439 Commentary by Sandra R. DiBrito and Christian Jones Should Trauma Physicians Treat a Severely Injured Patient for the Sake of Elucidating Preferences about Organ Donation? 447 Commentary by Sandra R. DiBrito and Macey L. Henderson Should Family Be Permitted in a Trauma Bay? 455 Commentary by Matthew Traylor Podcast How Trauma Systems Respond to Change: An Interview with Dr. David Hoyt and Dr. Karen Brasel The Code Says The Code of Medical Ethics’ Opinions Related to Urgent Decision Making 464 Danielle Hahn Chaet AMA Journal of Ethics, May 2018 419 State of the Art and Science Defining “Community” and “Consultation” for Emergency Research that Requires an Exception from Informed Consent 467 Samuel A. Tisherman Medicine and Society Gun Violence Research and the Profession of Trauma Surgery 475 Allan B. Peetz and Adil Haider What Is the Institutional Duty of Trauma Systems to Respond to Gun Violence? 483 Sara Scarlet and Selwyn O. Rogers, Jr. History of Medicine The Evolving Surgeon Image 492 Heather J. Logghe, Tyler Rouse, Alec Beekley, and Rajesh Aggarwal Images of Healing and Learning Memento Mori and Photographic Perspective of Roadside Trauma 501 Artwork by David B. Nance and captions by David B. Nance, Sara Scarlet, and Elizabeth B. Dreesen Second Thoughts Does Family Presence in the Trauma Bay Help or Hinder Care? 507 Benny L. Joyner, Jr. Correspondence Metaphorically or Not, Violence Is Not a Contagious Disease 513 Michael B. Greene Response to “Metaphorically or Not, Violence Is Not a Contagious Disease” 516 Gary Slutkin, Charles Ransford, and Daria Zvetina About the Contributors 520 420 www.amajournalofethics.org AMA Journal of Ethics® May 2018, Volume 20, Number 5: 421-424 FROM THE EDITOR Caring for the Wounded—the Ethics of Trauma Surgery In a fraction of a second, trauma changes us. Trauma injures organs, fractures bones, and makes us bleed, but it also leads to suffering, demoralization, and fear. While physical injuries can often be neatly classified, emotional and spiritual injuries cannot. These burdens are shouldered by many, not just those who are physically injured. Families, friends, communities, and even those who care for the injured are also wounded. Trauma professionals’ decisions can change us, too. Trauma surgeons must make high- stakes decisions, often in rapid succession and without knowledge of a patient’s identity or history. In our field, the “golden hour”—the hour just after an injury when medical care is most likely to prevent death—is dogma [1]. For this reason, action almost always outpaces deliberation. Choices such as whether to give blood, go to the operating room, amputate, or try to salvage a mangled extremity are often made without an understanding of our patients’ life goals and values. As a result, we almost always sacrifice respect for autonomy in favor of what we presume to be our patients’ best interest. Just as the treatments we provide may prioritize best interest over autonomy, so the structure of spaces in which we practice prioritize functionality over comfort. Trauma bays, by design, are utilitarian. They help clinicians assess and treat patients in a systematic, streamlined manner. Patients lie underneath bright lights, surrounded by dozens of unrecognizable clinicians who shout observations and instructions above the cacophony. To the untrained observer, the trauma bay is hectic and perhaps cruel. To the specialist, it is specifically designed to give us the power to save lives. However, providing care in this manner is not without costs—it is possible that medical interventions retraumatize patients or that the treatments provided are not congruent with patients’ wishes. How, then, can we maximize the benefits of our care while minimizing these associated burdens? This issue of the AMA Journal of Ethics will explore the ethics of urgent decision making in trauma settings, what it means for clinicians to approach decisions responsibly, and what it means for patients and their loved ones to have the aftermath of decisions communicated with clarity and compassion. This issue also will explore what trauma care policies can mean for public health, community planning, and resource allocation. AMA Journal of Ethics, May 2018 421 When ethical dilemmas do occur, clinicians must quickly weigh the risks and benefits of their actions along with the little they know of their patients. Clinicians practicing this “speed ethics” cannot rely on careful deliberation and discussion typically used in ethical decision making. Our patients are frequently unable to engage in informed consent discussions. Often, there is simply no time. Ashley Suah and Peter Angelos discuss the nature of consent in the trauma bay—which is presumed rather than requested— through examination of the case of a patient who resists being intubated. Although this practice allows trauma surgeons to expeditiously provide lifesaving care, for those unaccustomed to trauma care or to physicians in training, it can be viewed as paternalistic. Just as we care for patients, so we care for their families who often have been traumatized by the events—such as car crashes or violence—that brought their loved one to a trauma center. It is crucial that we take family members’ emotional state into consideration as we communicate with and chaperone them in health care settings. Despite the importance of conducting these difficult conversations skillfully, surgical training tends to deemphasize acquisition of communication skills, instead assigning greater priority to the technical aspects of care. In their communication with families, how can surgeons balance clarity and compassion against the need for swift, high- stakes decisions? Bradley M. Dennis and Allan B. Peetz examine challenges trainees face in communicating medical information and discussing goals of care with families in a case of imminent brain death. Sometimes, family members wish to accompany patients as they receive trauma care in an act of support or perhaps even closure. Benny L. Joyner, Jr., draws on the literature and his experience with family presence in the pediatric intensive care unit to explore the benefits and burdens of allowing family members to be present during their child’s resuscitation. In his winning essay for the John Conley Ethics Essay Contest, Matthew Traylor argues that family presence during cardiopulmonary resuscitation and in the trauma setting are not completely analogous but that the latter can be ethically justified if chaperoning systems are in place. When trauma care is not life saving, ought clinicians to prioritize organ recovery? For patients who have not specified their wishes related to organ donation, and sometimes even for those who have, how should we discuss these topics with families in the wake of trauma? In analyzing a case of a young trauma patient who dies with no family present, Sandra R. DiBrito and Macey L. Henderson discuss hospital procedures for communicating about organ donation and the need to uphold the principles of nonmaleficence and respect for patients and families. Trauma care professionals in all settings must use resources judiciously, as allocation of these resources can influence a patient’s course, although resources vary within and 422 www.amajournalofethics.org between regions. Health care professionals know that within rural areas or urban “trauma deserts,” proximity to a trauma center can influence mortality [2]. Higher-level- of-care transfers to trauma centers, which occur frequently as a result of regionalization of trauma care, also utilize precious resources. DiBrito and Christian Jones analyze a case in which regionalization of trauma care has potentially influenced a patient’s course, arguing that trauma professionals ought to regard transfer as an element of trauma care, rather than a delay in care, as they make critical decisions. What is the role of the trauma surgeons outside of trauma bays and acute care settings? Peetz and Adil Haider argue that trauma surgeons have a special moral obligation as well a professional responsibility to engage in gun violence prevention and advocacy. I and Selwyn O. Rogers, Jr., explore the duty of trauma centers not only to treat those who suffer violent injuries but also to engage in violence prevention efforts in order to help stop the cycle of violence that plays out, in part, under the bright lights of the trauma bay. And Samuel A. Tisherman examines the challenges that trauma researchers face in defining and reaching out to the relevant at-risk community. Patients’ and other clinicians’ perceptions of trauma surgeons can set the tone for their interactions with trauma surgeons. Unfortunately, misperceptions and stereotypes can lead to implicit bias, as discussed by Heather J. Logghe, Tyler Rouse, Alec Beekley, and Rajesh Aggarwal. They argue that though the classic stereotype of the abrasive white male surgeon continues to influence surgeons’ interactions with colleagues and patients, social media movements and an inclusive interpretation of history are challenging this stereotype. For those affected by trauma, the location of the event or “the scene,” as clinicians providing trauma care call it, can become a powerful symbol of the human condition and of loss. According to photographer David B. Nance, these spaces “confront us with the reality of death as an actual event that arrives for a particular person, at a particular place, at a particular time” [3]. Nance’s powerful collection of images of Descansos, or roadside memorials to people who have died as a result of motor vehicle collisions, were collected as part of his exploration of these sites throughout the American West, and Nance, I, and Elizabeth B. Dreesen reflect on their implications for trauma care. Finally, in the podcast, Karen Brasel and David Hoyt discuss how trauma systems have developed over time and how they respond to the changing needs of patients and communities. They explore how trauma surgeons are incorporating geriatric trauma care into their practice as a result of the growing population of elderly patients and outline other ways that trauma surgeons can promote health equity in their work. Trauma bays are at the nexus between health systems and the diverse communities in which they are located. As a result, trauma care lies at the intersection of public health AMA Journal of Ethics, May 2018 423 and the health and well-being of individuals. This issue of the AMA Journal of Ethics aims to help guide trauma surgeons in their work at the intersection of clinical practice, ethics, and public health. References 1. Rogers FB, Rittenhouse KJ, Gross BW. The golden hour in trauma: dogma or medical folklore? Injury. 2015;46(4):525-527. 2. Crandall M, Sharp D, Unger E, et al. Trauma deserts: distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago. Am J Public Health. 2013;103(6):1103-1109. 3. Nance DB. Descansos: roadside memorials on the American highway: about these photographs. http://webpages.charter.net/dnance/descansos/#aboutthesephotos. Accessed April 2, 2018. Sara Scarlet, MD PGY-5 Resident in General Surgery University of North Carolina Chapel Hill, North Carolina Acknowledgements I would like to thank Bruce Cairns, Jean Cadigan, Arlene Davis, Liz Dreesen, Gary Gala, and Mark Siegler for their incredibly thoughtful feedback and support and, most importantly, for challenging me and for nurturing my curiosity. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA. Copyright 2018 American Medical Association. All rights reserved. ISSN 2376-6980 424 www.amajournalofethics.org AMA Journal of Ethics® May 2018, Volume 20, Number 5: 425-430 ETHICS CASE How Should Trauma Patients’ Informed Consent or Refusal Be Regarded in a Trauma Bay or Other Emergency Settings? Commentary by Ashley Suah, MD, and Peter Angelos, MD, PhD Abstract The precipitous and unexpected nature of trauma requires training health care practitioners to think and act quickly, according to the best medical interest of the patient. The urgency of treatment for trauma patients, who frequently have temporary alterations in their abilities to make autonomous and competent decisions, often results in presumed consent for medically necessary treatment. Academic trauma centers use protocol-based management of injuries to facilitate their simultaneous evaluation by multiple clinicians and to avoid delays in treatment, ensuring that trauma patients receive the best possible care. In this article, we will discuss the issues of deferred informed consent and surgical education as they relate to trainees’ graduated responsibility in the trauma bay. Case Mr. X is a 39-year-old man rushed to a North Carolina teaching hospital after a motor vehicle collision. He was the unrestrained driver of a semi that collided with a utility pole. First responders at the scene found him approximately 50 feet away from the vehicle lying in a ditch. On initial presentation to the trauma bay, Mr. X has a blood pressure of 90/52, heart rate of 123, and an oxygen saturation of 87 percent despite receiving 100 percent oxygen via facemask—the maximum concentration of supplemental oxygen that can be delivered. He is in obvious respiratory distress. Physical exam is notable for flaccid paralysis, which might suggest that Mr. X has a spinal cord injury. The senior surgical resident, Dr. S, performs the primary and secondary survey, standardized exams used to identify and manage life-threatening injuries in the trauma bay. Mr. X’s respiratory distress and oxygen saturation levels become worse, so Dr. S prepares the trauma team for emergent intubation and mechanical ventilation. Although an intubation would normally be performed by the in-house attending trauma surgeon, Dr. F, she is currently unavailable as she is responding to another patient’s cardiac arrest. Dr. S is comfortable intubating Mr. X, and the team prepares to assist her. As Dr. S quickly explains this plan to Mr. X, AMA Journal of Ethics, May 2018 425 who appears frightened and does not seem to agree, he states, “Don’t intubate me,” and his comment is heard by the entire trauma team. The respiratory therapist continues to prepare the ventilator and obtain tools for intubation. She points toward the monitor at Mr. X’s diminishing oxygen saturation level, now 85 percent. “He’s hypoxic—we can’t not intubate. He’ll die if we don’t.” She passes the laryngoscope to Dr. S, who wonders what to do. Commentary The practice of informed consent is a legal concept based on the belief that adults of sound mind have the right to bodily self-determination [1, 2]. Outside of emergent circumstances, it is the physician’s responsibility to provide a medical recommendation, explain the nature of the recommended intervention, and discuss its risks and benefits as well as possible alternatives to treatment [1-3]. Patients must have been offered an explanation of the recommended treatment and its associated risks for patients to be considered informed; they should be provided enough information to agree to or refuse a procedure [2, 3]. The process of obtaining informed consent should be a meaningful conversation between a physician and patient rather than simply have as its goal a signature on a document. Patient understanding relies upon adequacy of physician disclosure, the patient’s mental status and decision-making capacity at the time of the discussion, and social determinants of health such as education. Given the realities of providing emergency care to patients, it is not surprising that informed consent discussions are often rushed, abbreviated, or completely removed from acute settings in order to expedite medical treatment [4]. There are very few exceptions to the need for consent to medical treatment. One of the well-known reasons not to obtain informed consent is a medical emergency. In the setting of acute or traumatic injury, patient understanding is easily jeopardized by fear, anxiety, pain, medications, and physiological derangement, resulting in unreliable decision making. Delirious or unconscious patients lack capacity and cannot provide consent. In these cases, it is a physician’s duty to seek consent from a suitable surrogate. However, in some cases, even getting consent from a surrogate is excused if the surrogate is not immediately available and waiting to find the surrogate would cause harm to the patient by delaying care [3]. Thus, responsibility is placed upon the physician in these cases to act in the patient’s best interest and proceed with the appropriate medical interventions. It is important to recognize that physicians’ personal beliefs and possible concerns related to litigation can influence the decisions they make for their patients. However, in emergency situations, when there might be no available surrogate decision makers, the physician must act in a manner that will provide the maximum possible benefit and the best outcome for the patient. 426 www.amajournalofethics.org Should Mr. X Be Intubated? Mr. X arrives in the trauma bay in shock. His injuries and poor clinical status upon arrival are concerning and appropriately alert the trauma team that he has likely sustained multiple life-threatening injuries. However, based on his age and profession, we can assume that he was likely an independent, fully functional person prior to this injury. Considering functional outcomes, we can expect him to make a full recovery following resuscitation, operative intervention, and post-operative physical therapy. With consistent social support and posttraumatic counseling, we can hope for meaningful emotional and mental restoration as well. Following her initial evaluation, Dr. S quickly recognizes that Mr. X is demonstrating signs of impending respiratory failure. Securing an adequate airway is one of the most essential skills a trauma surgeon can master, as without the ability to reliably ventilate or oxygenate patients, severe disability and death are inevitable. Progressive hypoxia despite receiving the highest dose of supplemental oxygen, accompanied by hypotension, tachycardia, and signs of a possible spinal cord injury, provide Dr. S with enough clinical substantiation to intubate Mr. X. Dr. S is confident in her decision to proceed with intubation until Mr. X declares that he does not want to be intubated. There is no time to explore Mr. X’s refusal of this intervention and, unfortunately, there are no accompanying family members or other surrogate decision makers present to speak on the patient’s behalf. Dr. S is conflicted, as she wishes to respect Mr. X’s autonomy but also feels a responsibility to save his life. In this specific instance, the patient’s understanding of his critical clinical status must be called into question. Based on his blood pressure and heart rate, he is in stage III shock, meaning that he has likely lost 30-40 percent of his total blood volume. His respiratory status is seriously compromised, and it has been well established that at this stage of shock patients are anxious and confused [4-6]. If Dr. S believes that the complexity of Mr. X’s current injuries have left him without decisional capacity, she should proceed with intubation in order to save his life. In situations in which there is uncertainty or disagreement among trauma team members, as in this case, progression in care should be guided by trauma protocols. Application of trauma protocols can streamline decision making in highly stressful patient encounters. These protocols are implemented in an effort to standardize the evaluation and treatment of severely injured patients. The goal is to avoid errors in diagnosis while facilitating efficient, yet thorough, assessment. These protocols are learned and practiced by all members of the trauma team (e.g., respiratory therapists, physicians, and nurses) in order to allow concurrent evaluation by multiple care professionals upon a patient’s arrival in the trauma bay. The collaborative goal of the AMA Journal of Ethics, May 2018 427 interdisciplinary trauma team should always be to provide the patient with the best possible outcome. Challenges in Training Surgeons to Become Competent Decision Makers Victims of trauma represent a physically, emotionally, and mentally vulnerable population whose life-threatening conditions jeopardize self-determination. Providing quality care for patients who have sustained traumatic injuries, specifically in the setting of academic trauma centers where junior and senior surgical residents are trained to become confident and competent decision makers, poses special ethical challenges. Trauma surgery affords surgical trainees unique opportunities to develop clinical reasoning skills and technical proficiency in stressful, time-sensitive situations. Academic medical programs mandate that attending physician supervision is required at all resident levels, while acknowledging the significance of practicing graduated responsibility [7, 8]. At our institution, when critically ill patients arrive in the trauma bay, the residents are responsible for conducting the examination, ordering tests, resuscitating the patient, and performing any necessary immediate procedures, such as chest tube or central line placement. Typically, a senior resident who has previously demonstrated proficiency in these areas will serve as the “team leader” by directing the other members of the trauma team through resuscitation and performance of procedures. Opportunities to make independent decisions are imperative to the development of surgical residents; however, adult level I trauma centers require that an attending trauma surgeon actively participate in all major therapeutic decisions and in management of all critically injured patients [9]. Thus, as trainees are running the trauma codes, an attending trauma surgeon is also present in the trauma bay, overseeing all of the resident’s instructions as well as performance of all of the procedures. Having an attending physician present to provide direct supervision ensures patient safety and facilitates opportunities for immediate feedback for trainees. Attending physicians might step in to take over a procedure or offer an additional option for medical management to ensure the best outcome for the patient. As surgical residents demonstrate acquisition of sound surgical judgment, the extent of attending physician supervision decreases, fostering resident autonomy. Despite the 24-hour presence of attending trauma surgeons at academic trauma centers, there are often circumstances when the attending trauma surgeon cannot be physically available to supervise residents as they provide care for critically ill patients. In Illinois, for example, senior surgical residents are permitted to initiate resuscitation of patients while awaiting the arrival of the attending surgeon; however, they cannot act independently from the attending surgeon [10]. In our experience, inability to provide direct supervision is usually due to an attending surgeon’s commitment to caring for another critically injured patient. This recognized dilemma in academic trauma centers has been somewhat remedied with the use of electronic communication devices such as 428 www.amajournalofethics.org