“Please don’t cut off my pants,” he pleaded. “I am homeless, and they are my only pants. Please.”
He could say these words as we were conducting our initial assessment in the trauma bay so at least he was hemodynamically stable with an intact airway at that moment in time. However, he had arrived seconds earlier with potentially life-threatening injuries as a level 1 trauma activation. Based on the location of wounds that were visible on his torso this was a real possibility, so we needed to quickly conduct our secondary assessment. That meant rapid exposure by taking the trauma shears, one on each pant leg from my assistants, as we examined him from head to toe, front to back, in every crevice or crease that might hide a wound.
I looked him straight in the eye and said “Don’t worry. We will get you a pair of pants, but right now we have to take care of you.”
Straight in the eye.
He relented. How could he not? The pants were already cut off even as I made eye contact. The process takes just seconds in the hands of a coordinated trauma team.
He was a very polite young man. He didn’t yell or kick or scream. He followed all of our instructions. He quietly told us his health, social, and family history. He told us he was scared. His life story mirrored that of many of our trauma patients: food insecurity, lack of affordable housing, few resources for education and job training, addiction, interpersonal violence, an endless vicious cycle. He was caught in that cycle, and it was obvious that he was heartbroken to be there. He wanted a better life and tonight in the trauma bay, without his pants, he had failed once again to break it.
I always say that I was attracted to a career in trauma surgery because I am part surgeon and part social worker. In reality neither I nor the social worker employed by my hospital to help patients in need of socioeconomic support have much to offer our patients with these very real struggles. The policy level changes and investments that would bring grocery options, better schools, safe and affordable housing to our most underserved areas are not in our control. Even for those patients who want to make a change, there are too few addiction treatment beds and job training programs. While these issues are clearly predictors of health, they are managed partly (addiction services) or entirely (basically everything else) outside of the healthcare system.
Yet every day we see the ravaging effects of socioeconomic insecurity on our population’s safety and well-being when they become our patients. We open the trauma bay doors and provide the full armamentarium of modern medicine to save a life acutely while feeling powerless to save lives at the societal level.
(Most trauma centers do provide targeted injury prevention like helmet, seat belt, or firearms safety education through small investments or grant funding, but these typically address to specific injury mechanisms rather than social policy.)
We finished examining and working up our patient. He was not going to die that night and could be discharged. Discharged where? It was 3 in the morning. The social worker could give him the address of a shelter in town. There might be a bunk free. She could refer him to addiction treatment. There might be an available bed. A local non-profit might intervene in the light of day if we could make the connection. But we had no way to guarantee that this man, who was lucky to be alive, would not simply just slip back into his otherwise unlucky life after discharge.
Oh, and there weren’t even any pants to give him. The social worker’s closet of donation was empty of men’s pants it turns out.
This was not something the trauma team to could bear. We might not be able to provide our patient with better groceries, housing, or addiction treatment to this man who in all of his words and actions as our trauma patient showed us a deep hope to be in a better place in life; but the least we could do is provide him the dignity of a pair of pants to head back into his unfair reality.
So we pooled our cash on hand, asked him what size he wore, and waited until the local Target and Kohl’s opened. The next morning the light in his face and the sincere words of gratitude when he saw his new jeans and a backup pair of track pants and shorts felt like as much of an accomplishment as stabilizing the unstable patients who had entered the trauma bay earlier or the exploratory laparatomy we had done.
“Thank you. Thank you. Thank you,” he said. “I really need these. Thank you.”
He needs so much more. But this was the least we could do.
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