Uneasy as ABC

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Speaker 9 Quick warning: this episode features some quite gruesome and gory injuries.

Speaker 11 If you are sensitive to that sort of thing or listening with someone who is, keep in mind you might want to skip this one.

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Speaker 14 to Radio Lab. Lab.
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Speaker 15 WNYC.

Speaker 5 So is today a day off or are you working later?

Speaker 15 I'm working overnight tonight.

Speaker 16 Oh, man.

Speaker 10 I work at midnight.

Speaker 16 Hey, I'm Lula Miller.

Speaker 11 I'm Lethifnasser.

Speaker 10 This is Radio Lab.

Speaker 5 What are the tides bringing into the ER right now?

Speaker 15 Oh, man. I mean, it'll be like everyone thinking they're dying, but it's allergies.
Okay.

Speaker 15 But no, this never happens to me. I'm like, I'm pretty sure this does happen to you.

Speaker 1 Today, we're here with our ER doctor correspondent, Avir Mitra.

Speaker 11 And this time, he's got a story for us from the trauma bay.

Speaker 15 Yeah. So, you know, in the ER,

Speaker 15 I guess I'm lucky or accursed enough to see

Speaker 15 all sorts of crazy things.

Speaker 9 All right, let's move them.

Speaker 15 You know, it's like everything from appendicitis to strokes to broken bones. But sometimes

Speaker 15 it's like a trauma one two three like something really bad just happens to a person out of nowhere how's the air work like a gunshot wound

Speaker 15 drowning stabbing car crash and all of a sudden

Speaker 15 their life is in the balance

Speaker 15 so as you can imagine when a trauma happens, your job is to act quickly. You have to think quickly.
You have to get very focused very quickly.

Speaker 15 Because my job in that situation is to keep that patient alive and stabilize them, get them to the point where we can send them to the surgeon where they can get fixed up.

Speaker 15 And at this point, I feel like I can do a pretty good job of that. But that was definitely not always the case for me.

Speaker 15 I still remember one of my first trauma cases where it was a guy who just drank too much.

Speaker 15 You know, this is in New York and he was walking to catch the subway, tripped, fell onto the subway tracks and got hit by a train.

Speaker 14 Oh my God.

Speaker 15 Yeah. So like we get the call, ambulance brings this guy in and his feet are in a bag.
Like his feet are separate from him in a bag.

Speaker 15 And

Speaker 15 he's got a head injury. We bring him onto the gurney and I'm just

Speaker 15 like, I can't get over the fact that there are these feet in a bag, you know, and I'm looking at all the wrong. things.

Speaker 15 Like I'm, I remember looking at his fingernails and just being like, oh, his hands kind of look like mine, you know, and just all these thoughts are racing through my mind. None of them are useful.

Speaker 15 And I just froze.

Speaker 15 And I mean, I just have a ton of memories like this, you know, during my training. But the truth is, I've gotten to the point where I'm pretty good at this.

Speaker 15 Like I can save a life in a trauma situation. And it's because of this different way of thinking.
It's the way that we've all learned in the trauma bay how to think. And it's pretty counterintuitive.

Speaker 15 When I looked into it, it sort of all originates from this one kind of insane story.

Speaker 5 Interesting. There's a story waiting in that, that change?

Speaker 15 There's a story.

Speaker 14 Okay.

Speaker 15 It starts with this guy. His name's Jim Steiner.

Speaker 15 This is in February of 1976. Jim's a doctor.
He's not just any doctor. He's kind of a big deal.
He's an orthopedic surgeon. He works at this big hospital hospital in Lincoln, Nebraska.
Okay.

Speaker 15 And him and his family, they're heading back from this wedding that they were just at in California. So it's him, his wife, Charlene, and he's got four kids: Chris, Kim, Rick, and Randy.

Speaker 8 I remember it was a really nice day, completely clear. You know, in California, that's that's a really nice time of the year.

Speaker 15 This is Randy, he was seven at the time.

Speaker 8 We got to the airport and we just stand around and talk

Speaker 8 and watch the planes come and go, you know, the little airplanes coming and landing.

Speaker 8 I wish that I could just have a Polaroid of that moment because it was the last time we were ever going to have a moment like that.

Speaker 15 At any rate, eventually they get on this little six-seater plane.

Speaker 8 The B-55 Beechcraft Baron.

Speaker 15 And Jim's up in the cockpit because he's actually an amateur pilot.

Speaker 14 Whoa. Yeah.

Speaker 15 So he's flying them home to Nebraska.

Speaker 8 My dad did all his checks. He got the weather report, contacted the FAA, and gave him a flight plan and we took off and headed east.

Speaker 15 So they fly through New Mexico, they go through Kansas, and just, you know, just spent my time looking at the world below.

Speaker 15 And as they're coming into Nebraska, all of a sudden, a pretty unexpected cloud cover just appeared and kind of started to engulf the plane.

Speaker 14 Oh, no.

Speaker 15 So now it's foggy and Jim really can't see anything.

Speaker 8 It was getting near six o'clock at this point in time, so the sun was going down.

Speaker 15 And it's just getting darker and darker, and the air pressure is changing around him.

Speaker 8 My dad had started to get a bad feeling, and he decided that he was going to go under the clouds and you know make sure that he's had visual with the ground.

Speaker 15 He was trying to get to about 500 feet to sort of orient himself. But it turns out his altimeter, which is telling you how high or low you are, is getting thrown off.

Speaker 8 So he thought he was flying 500 feet about the ground. He was flying about 50 feet above the ground.

Speaker 8 Oh no!

Speaker 8 Um, yeah, and he was, we were moving at almost 200 miles an hour.

Speaker 8 God, probably less than 30 seconds later, the plane went right through two large pine trees,

Speaker 8 and then all of a sudden, everything stopped.

Speaker 15 The plane had crashed into the middle of this huge 100-acre cornfield in the middle of nowhere, Nebraska.

Speaker 14 Oh.

Speaker 15 So Jim gets knocked out.

Speaker 8 He had a broken rib. He, you know, he had a hole in his face.
His eye was completely swollen shut.

Speaker 15 And when he comes to, he starts looking around and he looks to his right, and Charlene is just not there.

Speaker 5 Wait, meaning

Speaker 15 she's nowhere to be like that part of the plane is gone.

Speaker 14 Oh, no.

Speaker 15 He looks behind him. He sees that all the kids are alive, but they've got all these different injuries.

Speaker 8 My whole scalp was ripped back all the way to my skull. And my sister had a big chunk out of her face.

Speaker 15 And three of them, Randy, Rick, and Kim, are knocked out. They're unconscious.

Speaker 15 So Jim just snapped into doctor mode. He pulled his kids out of the plane and set them on the ground.

Speaker 8 Did a quick assessment of us there.

Speaker 15 Randy had this huge gash on the back of his leg.

Speaker 8 So he went and pulled out a bunch of suitcases to get clothes out of so he could fashion a tourniquet.

Speaker 15 And once Jim got their wounds under control, he went looking for Charlene.

Speaker 8 He shouted for her and was looking for her. And he'd walked about 25 feet before he found her and she was dead.

Speaker 8 She didn't suffer

Speaker 14 for whatever that's worth.

Speaker 16 Oh my God. Yeah.

Speaker 15 And as far as the kids go, It was pretty clear like if he didn't get them to a hospital, they were going to die too. Yeah.

Speaker 15 So jim's out there with these kids for eight hours eight hours eight hours you got to remember that this is the 70s so there's no cell phones there's no gps it's so foggy he can't even see anything and it's freezing cold so he's covering them with clothes to keep them warm my dad was getting pretty frustrated because he really couldn't believe that that nobody knew we we were missing but eventually as the fog began to lift and the clouds began to to lift all of a sudden this moon came out out and so jim could see what's around him she could see the tree line we came from he could see the the field rolling out from around him and he decides to go looking for the nearest road try and get us some help eventually he finds this road that's like less than a mile away he flags down this car with a couple guys in it they pick up the kids and they make their way to the closest hospital a little town called hebron about five miles down the road so finally after being like stranded for hours they arrive at this hospital.

Speaker 14 Oh, thank God.

Speaker 15 Well, you would think so, but the reason I'm actually telling you this story is because of what happened next at that hospital.

Speaker 8 When we pulled into the parking lot, the guys who were in the car with us jumped out and ran to the front door of the hospital.

Speaker 15 And the front door is locked. Oh, my God.
So they're banging on the door and they see a couple nurses inside.

Speaker 8 One of the nurses walked up to the front door and she's like, the hospital's closed.

Speaker 15 Sorry, we can't let you in because there's no doctor here.

Speaker 16 But Jim is a doctor.

Speaker 15 Yeah, exactly. And Jim is like in disbelief.

Speaker 8 From his experience, you know, at the hospital in Lincoln General, it was 24-hour access there. They would have had a whole army of people showing up to

Speaker 8 stabilize us, to get us in there.

Speaker 15 And so Jim Steiner, he just walks up and smashes his hand into the glass door, leaving this like blood-soaked palm print. And he says something like, the doctor is here.

Speaker 8 Open this door.

Speaker 15 So they unlock the door.

Speaker 8 My father kind of just bursts in.

Speaker 15 They page a couple doctors and nurses. And in the meantime, Jim just takes charge.

Speaker 8 He had to get the gurneys out into the parking lot and start getting us loaded on there and then getting us wheeled into the hospital.

Speaker 19 The one boy, the oldest boy, he was conscious. He had a broken arm and he could talk.
Now, the other three, they were unconscious. They had dried blood on them.
They were cold.

Speaker 15 This is Helen Bowman, a nurse called in that night.

Speaker 19 I have seen a lot of nasty cases, but this was the worst.

Speaker 8 Yeah.

Speaker 8 So my dad was doing the initial assessment on us. He was trying to get the nurses to help with taking vitals.

Speaker 15 Eventually, two doctors showed up on the scene. Dr.

Speaker 8 Pemry and Dr. Bunting showed up.

Speaker 15 And so Jim's like, okay, great.

Speaker 8 He got a sense of comfort from them saying, okay, we'll start handling. Since there were two doctors, it would be a little easier to triage and to start working on a treatment plant.

Speaker 15 But Jim wasn't exactly letting go of the reins From his perspective, they were really just running around like chickens with their head cut off. They seemed completely overwhelmed by the situation.

Speaker 19 It was chaos. It was just total chaos.

Speaker 15 I mean, Jim wasn't making their jobs easy.

Speaker 19 He was very agitated.

Speaker 8 He started taking, yelling, barking out orders.

Speaker 15 But that's because these doctors and nurses, They didn't know how to handle all these injuries.

Speaker 8 One of the nurses had gone out and gotten a suture kit to start stitching up the back of my leg. My dad freaked out.
He said, You know, that's this is going to require surgery to close.

Speaker 8 You can't just come in here and suture this up.

Speaker 15 And it wasn't just that they didn't know how to treat these kids, they didn't know who to treat first.

Speaker 8 Basically, if it looked bad, that's what they started on.

Speaker 8 You know, they saw that I had a six-inch section of my scalp pulled back, and that my sister had blood all over her face, and she had a cut over her eye.

Speaker 15 So they were focused on them, but all the while, Rick, who wasn't covered in blood, he had the most serious injury. He was drifting in and out of consciousness and sort of like thrashing around.

Speaker 15 And like Jim knew that this must mean that he had a pretty serious head injury.

Speaker 8 And knowing what he knew about head and neck injuries and how they work together, he wanted to get head and neck x-rays right away.

Speaker 15 But after like pushing and pushing and pushing them to do the x-rays, all they did was x-ray the skull.

Speaker 8 My dad asked him about the x-ray of the neck. The doctor just blew it off.
He said, I see no reason to do that.

Speaker 15 And at that point, Jim just broke.

Speaker 8 That's when my dad said, you people don't know what you're doing. You leave us alone.
You are no longer caring for my family. You've got to get us to Lincoln.
You've got to get us to Lincoln General.

Speaker 15 So after all this stuff, a helicopter lands in the parking lot of this small hospital. They get the family onto the helicopter, fly them over to Lincoln General.

Speaker 8 They got us into ambulances and took us to the emergency room at Lincoln General Hospital.

Speaker 15 When they get there, like a dozen doctors descend on the family.

Speaker 8 The beehive got hit and everybody jumped into action and started taking care of us and I was going to go to surgery.

Speaker 15 And at this point, you know, Jim is seeing his close co-workers and they're like, Jim, get on the bed.

Speaker 15 You know, we're putting you under, like, goodbye, you know, and he's finally lets go of the reins and becomes the patient.

Speaker 8 He did. And, you know, he managed to calm down.

Speaker 8 We were all in the same room.

Speaker 15 Three of the kids were still in comas.

Speaker 8 I was in a coma for three days. Kim and Rick were in a coma for seven.

Speaker 15 But eventually they all woke up and they all survived.

Speaker 14 Wow.

Speaker 14 Okay, that's great. Yeah.

Speaker 15 So the family returned to their lives. They try to move on from this insane tragedy.

Speaker 8 I was dealing with a lot of stuff. Obviously, the death of my mother.
You know, my brother Rick had a fairly slow recovery, but even

Speaker 8 more.

Speaker 8 My dad was very lonely. He had four four kids that he was now raising on his own.
He still had an incredible amount of guilt.

Speaker 15 I mean, I never got to talk to Jim about any of this. He passed away this year.

Speaker 15 But according to Randy, he just became totally obsessed with what went wrong in the ER in Hebron that day.

Speaker 8 He spent a lot of time complaining about it and saying, I don't get this. How could this happen?

Speaker 8 It's 1976 and we're still dealing with hospitals that have no idea how to handle a mass casualty event, event and not even a really significant mass casualty event there are five of us the thing is as angry as he was jim knew it wasn't actually the fault of the doctors or the nurses there he has he thought about it and he knew they were competent he knew they weren't you know yokels you know it's not the people it's just that they weren't trained to deal with emergencies like this which are completely different from someone coming into the ER with a stomachache or eye infection.

Speaker 15 Like the second a trauma comes in, you're already behind the eight ball. You're already behind this flaming blaze.
You have to act fast to save their life.

Speaker 15 And how fast or even what to do in these emergencies, it wasn't really known. Like at the time in the mid-70s, emergency medicine was the new field.
There weren't a lot of specialists.

Speaker 20 Yeah, so the people who staffed emergency departments in rural parts of the country were usually family physicians or general practitioners.

Speaker 15 This is Dr. Sharon Henry.
She's a professor of trauma surgery at shock trauma in Baltimore.

Speaker 20 You know, as long as you had completed medical school and perhaps an internship, you were qualified to work in an emergency department.

Speaker 15 And even in the big city hospitals with ER specialists, like a lot of the doctors were really just figuring it out on the fly. Correct.

Speaker 17 I didn't have any training. I learned what I learned in the ER.
It was whatever rolled through the ER doors.

Speaker 15 So this is Ron Craig. He worked with Jim at Lincoln General.

Speaker 22 He worked in Lincoln General Hospital's emergency room for three years.

Speaker 15 And he wasn't just a colleague. like he knew Jim.
They went to church together. They were friends.
So he was one of the people that Jim was talking to about all of this all the time.

Speaker 22 One day Jim Steiner was in the doctor's lounge with me and he was complaining rather loudly about the state of affairs in rural hospitals when it comes to trauma.

Speaker 8 And that was the point where Ron Craig came to it and said, Steiner, why don't you stop bitching about it and do something?

Speaker 22 I apparently said something to the effect of put your money where your mouth is or put up and shut up.

Speaker 15 And what Jim did next, with Ron's help, would change the way ERs work across the world and kind of rewire my brain in ways that I'm still trying to understand.

Speaker 21 That's after the break.

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Speaker 10 Okay, so where were we?

Speaker 15 So where we left off, Jim's been complaining about like how bad the care was in this small emergency room. And his buddy Ron's like, okay, let's do something about it.

Speaker 15 So the two of them start meeting up. In my dining room.

Speaker 8 For a couple of hours.

Speaker 15 Randy Steiner again.

Speaker 8 Just to talk about it.

Speaker 15 And they're like, okay, so one of the things that makes trauma so hard is that it can involve all different types of injuries and even just one gunshot, right?

Speaker 15 It could cause internal bleeding, a broken bone, damage to your lung, your liver, your spine. So which one do you deal with first? And how do you deal with it?

Speaker 15 Like each of those injuries requires a different specialist doctor.

Speaker 15 So, Jim and Ron start by calling all those different kinds of doctors.

Speaker 8 Experts.

Speaker 15 This is Dr. Henry again.

Speaker 5 Let's go to the thoracic surgeons.

Speaker 15 Asking them, how do we deal with your part of it? Like, take the internal bleeding. Like, what's the first thing we do to save someone from that?

Speaker 8 What did you do to treat that?

Speaker 22 And I just took notes.

Speaker 15 Then they go to a heart doctor.

Speaker 20 Yeah, the heart's kind of important.

Speaker 15 And say, okay, if the bullet went through the heart, like, what do we do first for that?

Speaker 8 This is what I did in this case. This worked.
That patient lived. This patient died.
So, what went wrong there?

Speaker 22 What should we do differently?

Speaker 15 They called lung doctors, orthopedists, urologists, neurosurgeons, and asked them, like, if the bullet went through the part of the body you specialize in, what's the first thing you would do to save this person's life?

Speaker 22 We got information from whoever we could get information from.

Speaker 15 And then Jim and Ron added all up.

Speaker 22 Spread out our ideas on paper.

Speaker 15 They're trying to figure out, like, okay, do we deal with the bleeding first or the lung puncture or the stomach injury? And, you know, they're not just doing this for gunshots.

Speaker 15 Like, they're doing this for every kind of trauma that you can imagine. So they're thinking about car crashes, like someone stuck in a burning house, a drowning, someone falling out of a window.

Speaker 15 Figuring out how you respond to all these different injuries and what order you need to respond to them in, like to save someone's life.

Speaker 17 You got it.

Speaker 15 And what emerged was a process that looked like it could kind of work for every different kind of trauma.

Speaker 22 A plan that doctors can apply to almost any situation.

Speaker 14 so what was the point

Speaker 5 how do you universally approach all potential chaos itself as it impacts the body the answer i'm almost like embarrassed to say it because you're going to be like and like

Speaker 15 it's basically

Speaker 15 something called the ABCs.

Speaker 9 The ABCs.

Speaker 15 Yeah. So they got the idea from these cardiac surgeons who had been developing a process for how to save someone, you know, if their heart stopped.

Speaker 14 Okay.

Speaker 15 And it's basically like a mnemonic, like ABCDE. Each of those letters sort of stands for a different step you would take when you first receive a trauma patient.

Speaker 22 You, the ABCs, what you have to do to stabilize this patient while you get further help.

Speaker 16 Huh. Okay, so what do they stand for?

Speaker 15 A is for airway. B is for breathing.
C is for circulation. D is for disability.
And E is for exposure.

Speaker 13 Okay, and what does this actually look like?

Speaker 10 Like, give me an example.

Speaker 15 Okay, so let's say you have a patient who is just in a car accident and they roll in on the stretcher.

Speaker 15 So, there's blood everywhere, they're screaming, maybe their leg is broken and twisted back in a weird direction.

Speaker 15 But according to this game plan that Jim and Ron just wrote, you don't worry about any of that. All you do is think: A,

Speaker 15 and basically, that means you can just go up to them, look at their mouth and look in there. Is there blood in there? Is there a tooth in there?

Speaker 15 You know, you need to make sure that there's an open tube from the world to their lungs. And if not, you need to suction things out or put a breathing tube down.
That's all you worry about first.

Speaker 17 Simply because if you don't breathe, you don't live.

Speaker 15 After you've done the airway, then you can move to B. Breathing.
So B is like a verb.

Speaker 15 Now that you have a tube open where oxygen can get from the air to the lungs, now you got to make sure the lungs are going in and out and breathing. That's where you listen to the lungs.

Speaker 15 You decide: okay, is there a collapsed lung? If there's a collapsed lung, you poke a hole in the chest, put a chest tube in, suck the lung back open.

Speaker 15 Now that you have like an open tube that's bringing oxygen to your lungs, and you have lungs that are working, that are taking oxygen, putting it into the blood.

Speaker 15 Now let's like stop the blood from pouring out of you.

Speaker 14 That's step C.

Speaker 8 Circulation.

Speaker 15 You think about blood and hearts. So, okay, if someone's bleeding, stop the the bleeding.
Got it. So then you stop the bleeding, then Disability.
Is disability,

Speaker 15 which is essentially a bad name for like a quick assessment of is there any brain or spinal damage here? So the doctor's going to check your pupils to see are they reacting properly.

Speaker 15 They're going to put a finger in your butt to see if you have like good rectal tone. Like is your spinal cord working? Last one is E.

Speaker 10 Exposure.

Speaker 15 So you take scissors and we cut off all their clothes and we look at their entire body.

Speaker 5 And are you mostly looking for cuts and bruises? Anything else? Holes, big injury.

Speaker 15 I mean, you'd be amazed at all the things you can find. And I should say, these ABCs, they're supposed to happen in that exact order and pretty damn quick, like 60 seconds per letter at most.

Speaker 15 You know, you just have to bang through these things.

Speaker 15 Now, Jim and Braun realized that a lot of these small town docs weren't necessarily going to know how to do a lot of this stuff.

Speaker 15 So, in addition to coming up with the ABCs, they also developed like this crash course in trauma life support.

Speaker 8 They were going to take these doctors from these rural settings and train them on every step of the process.

Speaker 15 They called it ATLS, Advanced Trauma Life Support. And they held the first class in February of 1978 in a little town called Auburn, Nebraska.

Speaker 8 Not knowing for sure if it was even going to work.

Speaker 15 They explained the ABCs and then dove right into practicing how to deal with each one.

Speaker 15 Eventually, the class would expand to include these lifelike simulations with dummies and fake blood and sometimes even actors playing the injured patients.

Speaker 15 And the class was profoundly strange for these doctors, not just because of the simulations, but because of the way it made them think.

Speaker 15 It was kind of the opposite of what they'd learned in medical school.

Speaker 9 What do you mean?

Speaker 15 Well, think about the doctors you see on television.

Speaker 15 Like picture an episode of house, you know, a patient comes in, you talk to the patient, you get the whole story, and then you do this long physical exam.

Speaker 15 You check this for these heart sounds, you listen to their stomach. Any idea what's wrong with her? You ask questions.
What is that? Did the patient have any rashes? Yeah, okay.

Speaker 15 Now let's come up with a list of all the things it could be.

Speaker 28 It could be adrenal gland disorders, blood issues.

Speaker 15 Once you make the diagnosis, then you create a treatment plan.

Speaker 8 Starting on a cocktail of STD meds.

Speaker 15 Jim and Ron are basically like, to hell with all of that. Like, forget about the test, forget about questions.
This is the plan. It's called A B C D E.
You just start doing it.

Speaker 14 Huh?

Speaker 5 F the complexities, go. Yeah.
Forget nuance. Go.

Speaker 14 Yeah.

Speaker 15 And because the class was so strange, it was so different from what doctors were used to, they really weren't sure how it was going to be received at all. But the first group liked it.

Speaker 15 So they were like, okay, let's try this again. We rounded up our instructors, held the next class in Scotts Bluff, Nebraska.
They showed up. Those docs also loved it.

Speaker 15 And throughout the rest of 1978, 79, they kept holding more classes around Nebraska. And they're finding this groundswell of support.

Speaker 15 All these doctors are like, thank God we have a plan, like something that tells us how to deal with these incredibly stressful situations.

Speaker 15 And then finally, in 1980, just a few years after Jim and Ron invented ATLS, it went mainstream.

Speaker 20 Was adopted by the American College of Surgeons.

Speaker 15 And since then, it's just spread everywhere. Canada, most parts of Europe, Mexico, the Middle East.

Speaker 17 We intended for this to be a program for primary caregivers in small towns, but

Speaker 17 it obviously grew beyond that.

Speaker 15 And now today, over one and a half million doctors have been trained in ATLS, and every year, 50,000 more get the training. Wow.

Speaker 15 And so anyone who's a surgeon or an emergency medicine doc gets this training. So I got the training.

Speaker 16 Okay. So, so like, and it works.

Speaker 21 Yeah.

Speaker 30 Do we, do we know how well it works?

Speaker 15 I mean, like outcomes today in trauma are way better than they were in 1976. You know, like you are much more likely to survive today.
And that's definitely in part due to ATLS.

Speaker 5 I mean, how many

Speaker 5 lives do you think it's saved?

Speaker 15 So it is like a hard thing to study, right? Like no one was studying this when they rolled it out. And now once people know how to do this, you can't exactly make them forget.

Speaker 15 Like you can't take it back.

Speaker 16 Yeah, it's like in the water.

Speaker 15 It's in the water now. But there have been studies, you know, when they roll this out to to a new country that show the survival rates increase from 32% to 67%.

Speaker 14 Whoa.

Speaker 15 And basically.

Speaker 5 Sorry, does it become mandatory?

Speaker 15 Yes. To become an ER physician, you have to get this training.
Okay. Okay.
And you need that. I think you need that because when a trauma patient comes in, it can be like the ultimate overwhelm.

Speaker 14 Right.

Speaker 15 I'm only when when you when there's two it's almost like looking at the solar eclipse like I can't look at that if I try to look at this the whole thing the whole sun, I'm going to get burned.

Speaker 15 So I'm only going to look at a small piece at a time. So I'm going to look at A

Speaker 15 and I'm going to allow myself to see all the horrors of A and I'm going to make a few key decisions and do things. Then I'm going to stop looking at A and open my mind to B.

Speaker 14 Yeah.

Speaker 15 And then there, I get to look at a few things, make a few decisions, then I stop thinking, I'm on the letter C. Let's go.
You know, it's almost like putting blinders on.

Speaker 9 Okay, so like, so the, the, okay, so A, B, C, D, E,

Speaker 13 like, imagine someone comes in with like a gunshot wound or something and they're like bleeding out and you're like, oh, let me look at the airway.

Speaker 11 When you're like, clearly the bleeding out is the problem, though. Yeah.

Speaker 13 But you can't, but, but even if you have a sense like that, you don't skip.

Speaker 15 You don't skip.

Speaker 14 Wow.

Speaker 14 Really? Do you ever skip?

Speaker 15 You're not supposed to skip.

Speaker 10 Well, it feels so, it feels when, as you describe it like that, it feels very robotic.

Speaker 14 Very robotic.

Speaker 18 Yeah, following step-by-step instructions like a robot.

Speaker 15 Okay, so I called up this guy, Dr. Ruben Strayer.

Speaker 10 Hi, I'm Ruben.

Speaker 18 I'm an emergency doc at the largest hospital in Brooklyn at Maimonides Medical Center.

Speaker 15 Ruben's worked in a lot of different trauma centers over the years, and he thinks that ATLS has gotten a little too rigid. Yeah.

Speaker 18 And when we apply a rigid structure in the evaluation of care, sometimes we end up with thoughtless care.

Speaker 15 Like, for instance, often someone might come into the ER after a car accident, but they just happen to have a sprained ankle and the doctors will run the full ATLS on them.

Speaker 18 Everyone's getting a finger in their bum.

Speaker 15 They're getting their clothes cut off. And a lot of doctors these days will just give people a full body CAT scan.

Speaker 18 It's a CT scan that includes the head, the neck, the chest, and the pelvis.

Speaker 15 Now, Ruben would agree that, like, in serious traumas, you know, it's like someone's feet are coming in in a bag. Yes, the ABCs are crucial.

Speaker 18 I'm more on board with following an algorithm if the algorithm compels you to act.

Speaker 15 But even then, you know, know, there are still some downsides. Like he's seen how ATLS can kind of put you on autopilot.
It puts this distance between the doctor and the patient. Yes.

Speaker 18 And I have colleagues that, for example, I think they would be the first to say, I don't really want to get too deeply involved in thinking about this, about this trauma patient.

Speaker 18 I just want to go through the algorithm and move on.

Speaker 15 And I love my job. Like I love working with patients, but I do experience this going through the ABCs.

Speaker 15 It's almost like this technical video game. Okay, I'm intubating.
I'm going to put this scope in here. And the first thing I'm going to see is this.
I'm going to travel here. I'm going to see this.

Speaker 15 I'm going to make a left turn. I'm going to expose this.
I'm going to move my hand like this. So it becomes very technical because you're not seeing them as a person.

Speaker 15 You're seeing it as like a body part. And when you're treating them, you know, you kind of want to be in that mode.
It helps you stay focused.

Speaker 15 But it can be really tricky because once you stabilize the situation, you need to become human again. And

Speaker 15 that's just as hard, hard, honestly. Like, sometimes you'll be talking with another doctor in the room and just talking shop in this almost robotic way, right?

Speaker 15 And the family is like, Did you just say, like, if we don't do this, my brother's gonna die? And it's like, oh, yeah, I did say that. Like, I probably shouldn't say it like that.
You know what I mean?

Speaker 15 So it can, it can be hard sometimes to snap in and out of this way of thinking.

Speaker 16 Yeah.

Speaker 5 It may, I mean, it makes me think about,

Speaker 5 well, just just in general, like I feel like a booster for nuance and complexity.

Speaker 5 And talking about medicine in general, I think we want our doctors to be really thinking about nuance and being human and being attuned.

Speaker 5 But then there is a like, except maybe in trauma when like the clock is running and actual instincts might get in the way. Yeah.
Like I said, I really

Speaker 5 see its value.

Speaker 15 I was going to say, like, you know, know, we want our doctors to be human, but maybe in this case, when there's like

Speaker 15 some unimaginable trauma going on, it's nice to dehumanize a little bit.

Speaker 9 Yeah, but like to me, the like to me, the fundamental irony of this story is that the guy who figured out how to roboticize yourself,

Speaker 13 like that kind of came out of

Speaker 30 the most human, the most messy, the most emotional situation you could possibly, you know, engineer.

Speaker 21 Yeah.

Speaker 13 There's a, there's a kind of a very funny irony there.

Speaker 14 Yeah.

Speaker 15 But if you think about it, like so much of those emotions and all the messiness of that night really happened because there was no system.

Speaker 15 Yeah. Like I wish Jim, I wish all the doctors there had something like ATLS that night to help them.

Speaker 14 Yeah.

Speaker 15 You know, in the way that it helps me. To me, it's like there's this sort of,

Speaker 15 it's like you can never control the outcome, you know, you just can't. And if you try, I think that's, I think that's what I, where I messed up as a human, but also as an early doctor, where is it?

Speaker 15 It's like, if something goes right, like I'm great. If something goes wrong, I'm terrible.

Speaker 15 But I'm still the same me. And sometimes things go great, sometimes things go terrible, sometimes patients die.

Speaker 15 But with ATLS, even if the person dies,

Speaker 15 you can say,

Speaker 15 I followed the process,

Speaker 15 and the chips will fall where they will, and that'll be happy or sad, but it's, but at least I can sleep at night, you know?

Speaker 21 This episode was reported by Avir Mitra with help from Maria Paz Gutierrez, Sara Kari, Becca Bressler, Susie Lechtenberg, Heather Radke, and Ana Gonzalez.

Speaker 13 It was produced by Maria Paz Gutierrez, Becca Bressler, and Pat Walters with help from Ana Gonzalez.

Speaker 13 Original music and sound design contributed by Maria Pazgutierz and Jeremy Bloom with mixing help from Jeremy Bloom. Fact-checking by Diane Kelly and edited by Becca Bressler and Pat Walters.

Speaker 13 Special thanks to John Sutyak and Brian Zink.

Speaker 21 And why not?

Speaker 10 To every ER doctor everywhere.

Speaker 16 That's it for us.

Speaker 13 We'll catch you next time.

Speaker 31 Hi, this is Danielle, and I'm in beautiful Glover, Vermont, and here are the staff credits. Radio Lab was created by Jad Ebum Rod and is edited by Soren Wheeler.

Speaker 31 Lulu Miller and Latif Nasser are our co-hosts. Dylan Keefe is our Director of Sound Design.
Our staff includes Simon Adler, Jeremy Bloom, Becca Bressler, W.

Speaker 31 Harry Fertuna, David Gable, Maria Paz Guterres, Sindhu Nianusumbum Dum, Matt Gilty, Annie McEwen, Alex Neeson, Valentina Powers, Sarah Kari, Sarah Sandbach, Arianne Wack, Pat Walters, and Molly Webster.

Speaker 31 Our fact checkers are Diane Kelly, Emily Krieger, and Natalie Middleton.

Speaker 32 Hi, this is Ellie from Cleveland, Ohio.

Speaker 32 Leadership support for Radiolab Science Programming is provided by the Gordon and Betty Moore Foundation, Science Sandbox, Sandbox, a Simons Foundation Initiative, and the John Templeton Foundation.

Speaker 32 Foundational support for Radio Lab was provided by the Alfred P. Sloan Foundation.

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