I’ll never forget the first time I was told about the “rules of trauma.” I was a junior resident and had just completed a month-long rotation on trauma. On my final day on service, the attending pulled me aside to thank me for making meaningful contributions (apparently, he had not expected someone of my level to do so). As a parting gift, he explained to me, in a grandfatherly tone, the five rules of trauma:
- Never get on a motorcycle.
- Always wear a seat belt.
- Never be the first one through a green light.
- Buying or selling drugs is just as dangerous as using them.
- In trauma, it’s good to be a little fat.
I had never before heard the collective wisdom of decades of experience treating traumatic injury described as a list of rules. More commonly, I would hear comments in the moment like, “Motorcycle jousting?! How did they think this story would end?” As a collective whole, such disjointed comments could support the theory that behavior modification leads to outcome modification, but no one had put it so plainly to me before. The rules just made so much sense, and as I thought back over the previous month, almost all of our patients had broken these rules in one way or another.
Even rule No. 5, which is a bit counterintuitive without context, was right on the money. During my rotation, a handful of patients passed through the trauma bay after being shot or stabbed, only to be sent home the same day. A bullet or knife had passed through only their skin and subcutaneous fat (or “urban body armor” as the trauma team at this particular facility liked to call it), staying far from any structure of importance. I often asked myself whether the bullet or knife would have made contact with the patients at all if they had been thinner, but there were certainly times when subcutaneous adiposity came to the rescue. For example, an assailant may have assumed they had “done enough” when they felt the knife pierce well beneath the skin, and patients who stabbed themselves would often stop before reaching vital structures because, well, it hurts. Having a thicker layer of fat between the outside world and vital structures was often more helpful than harmful in trauma, unlike in every other field of medicine.
Now, over a decade and thousands of patients later, I can say that I have barely had to edit the “rules of trauma.” I have made one notable addition: Never get on a ladder alone. Ideally, no one who isn’t a trained professional should ever get on a ladder, but that’s not a tremendously practical rule. However, most of the time, if someone had asked a friend, neighbor, or family member to help prior to getting on a ladder, their chance of injury would have dropped dramatically. Perhaps more importantly, involving someone else makes it less likely that older and weaker people would climb a ladder at all, as the person they ask for help may just climb the ladder for them.
As a side note, and it may go without saying, ladders should never be placed on anything other than a flat surface. Stacking a ladder onto an SUV, for example, tends to end, predictably, with the climber under my care. I did once have a patient who chose this course of action in an effort to pick mangoes from a particularly high tree. After I told him it would be best if he didn’t do this again, he had a family member bring me one of those mangoes to prove to me he wasn’t crazy. The mango was indeed delicious, but it wasn’t more delicious than being alive and able-bodied.
At the end of the day, each person’s “rules of trauma” are subjective and personal. I know plenty of trauma and orthopedic surgeons who, despite taking care of motorcycle-related injuries regularly, still choose to ride a “donorcycle” themselves. Personally, I stick with my six rules and don’t stray. Besides, I would look ridiculous on a motorcycle, and paying someone to clean out our gutters is a lot less expensive and emotionally distressing than an ICU stay.
What core lessons about health and safety do you abide by? Share your thoughts in the comments.
Dr. Danielle Pigneri is a trauma and acute care surgeon practicing in the Dallas-Fort Worth metroplex. When not working, she enjoys her other job, being a mom to two sweet young children. Dr. Pigneri is a 2022-2023 Doximity Op-Med Fellow.
Illustration by Diana Connolly