Health Policy$ense

How Patients Experience the Trauma Bay

Surprising findings from patient interviews

After a shooting, a stabbing, a car crash, or a fall, emergency services rush an injured patient to the emergency room. They bypass the waiting room and come directly to a specialized area called the trauma bay, where a team of clinicians performs a fast, intense, full-body exam and initiates treatment for injury. Trauma providers have organized this protocol, known as trauma resuscitation, to identify and treat life-threatening injuries as quickly as possible. Or at least that’s how we see it.

But how do patients see and experience it? What is it really like to lie on a hard stretcher under bright lights, likely in pain, and have a swarm of strangers surround you, strip you, draw your blood, poke and prod your body, all while yelling back and forth to one another?

After participating in hundreds of trauma resuscitations during the first three years of my general surgery residency, I became concerned that this experience could add to the physical and mental trauma our patients were living through. This abrupt introduction to the health care system could make it difficult for patients to engage with the team, ultimately impairing their recovery. I wanted to know how we could make this experience easier on patients, without compromising the speed and efficiency that can be lifesaving.

Together with colleagues Therese Richmond, Douglas Wiebe, Sara Jacoby, and Daniel Holena, I talked to patients about what they experienced. We wanted to know if trauma resuscitation could be patient-centered care.

What we found was surprising. Contrary to our expectations, patients were generally very satisfied with their care. Participants drew satisfaction from trauma team members’ demeanor, expertise, and efficiency and valued clear clinical communication, as well as words of reassurance.

More than that, they seemed to calibrate their priorities to the clinical urgency of their situation. As one patient put it, “I didn’t want to die, so I was just like—just let them do whatever they have to do to save my life.” Another patient described the use of medical jargon but did not object to it, saying, “I didn’t know what they was talking about but I knew it was something like a bunch of tools to help me.”

Many of what I’d thought to be the most jarring aspects of trauma resuscitation were less salient to patients. Painful procedures, rectal exams, and the placement of urinary catheters were rarely mentioned in our interviews. This may be because the process was “surreal” and blurred together into “a lot of people working on me trying to put me back together.”

One patient provided a clear definition of patient-centered care in an emergency setting:
 

They have a huge number of people dedicated to 1 person. I mean, I felt really – like I was somebody special. And, in fact, I’m not…They were very attentive, that they were focused on me, that they were speaking only about what was going on with me. So, I mean, it seemed to be me-centered.

 

When I’ve presented these findings to my fellow trauma clinicians, I have found that many share my sense of being pleasantly surprised. We are doing better than we thought. At the same time, there are some opportunities for improvement.

  1. While many patients thought that communication was clear, others remained confused about their injuries, or concerned that clinicians were speaking negatively outside of the patient’s hearing. Clinicians should briefly introduce themselves and discuss the resuscitation process with patients.
  2. Patients reported confusion about their injuries and prognoses, and they identified a variety of nonclinical concerns relating to work, family, and safety that they had not shared with trauma team members. Reviewing events and plans and addressing patient concerns at the conclusion of the resuscitation could reduce confusion. This should be brief enough to avoid delaying or compromising identification and treatment of life-threatening injuries.
  3. Many interview participants recalled having their clothing cut off, and to them this signaled the seriousness of their injuries and the intensity of their care. Only the few participants who could not afford new clothes were truly upset about the loss. Greater effort could be made to remove clothing intact in stable patients with low suspicion of spinal injury, and to replace clothing for patients in need.

In an invited commentary, Sanders et al. argue that achieving patient-centered care in the trauma bay would result in unacceptable delays. While I agree that in-depth conversations about patient priorities and values are impractical, our patient participants found much in trauma resuscitation that was already patient-centered. Rather than demanding to be treated as consumers, these patients appreciated efficiency and expertise in their doctors and nurses. While these authors rightly point out that the most severely injured patients cannot afford any concessions in clinical care, many patients who go through the same process are less severely injured, and are stable throughout the process. The changes we outline above could be accomplished quickly in many such patients without sacrificing their well-being.

We are currently developing interventions and assessments of patient experience based on our findings, and hope to test them at multiple centers. As long as patient experience can be improved without compromising clinical outcomes, patient-centered care remains a valuable goal.