LATIF NASSER: Quick warning: this episode features some quite gruesome and gory injuries. If you're sensitive to that sort of thing or are listening with someone who is, keep in mind you might want to skip this one.

[RADIOLAB INTRO]

LULU MILLER: So is today a day off? Are you working later?

AVIR MITRA: I'm working overnight tonight.

LULU: Oh, man!

AVIR: I work at midnight. [laughs]

LATIF: Whoa.

LULU: Hey, I'm Lulu Miller.

LATIF: I'm Latif Nasser. This is Radiolab.

LULU: What are the tides bringing into the ER right now?

AVIR: Oh man. I mean, it'll be like everyone thinking they're dying but it's allergies.

LULU: Okay.

AVIR: "But no, this never happens to me." I'm like, "I'm pretty sure this does happen to you."

LATIF: Today, we're here with our ER doctor correspondent, Avir Mitra. And this time he's got a story for us from the trauma bay.

AVIR: Yeah. So, you know, in the ER, I guess I'm lucky or cursed enough to see all sorts of crazy things.

[ARCHIVE CLIP, Avir Mitra: All right, let's move him.]

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

[ARCHIVE CLIP, Avir Mitra: On your count.]

AVIR: ... it's like a trauma.

[ARCHIVE CLIP, nurse: One, two, three.]

AVIR: Like, something really bad just happens to a person out of nowhere.

[ARCHIVE CLIP, Avir Mitra: How's the airway?]

AVIR: Like a gunshot wound.

[ARCHIVE CLIP, nurse: Airway looks clear.]

AVIR: Drowning, stabbing, car crash. And all of a sudden ...

[ARCHIVE CLIP, Avir Mitra: What do you want to do?]

AVIR: ... their life is in the balance.

LULU: Oof!

AVIR: 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.

LATIF: Yeah.

AVIR: 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.

LULU: Hmm. Okay.

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

LATIF: Oh my God!

AVIR: 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.

LULU: Oh my God!

AVIR: And he's got a head injury. Bring him onto the gurney. And I'm just—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. Like, 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. And I just froze.

LATIF: Hmm.

AVIR: And 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. 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. When I looked into it, it sort of all originates from this one kind of insane story.

LULU: Interesting! There's a story waiting in that—that change?

AVIR: There's a story.

LULU: Okay.

AVIR: It starts with this guy. Name's Jim Steiner. 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 in Lincoln, Nebraska.

LULU: Okay.

AVIR: 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.

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

AVIR: This is Randy. He was seven at the time.

RANDY STEINER: We got to the airport, and we'd just stand around and talk and watch the planes come and go. You know, little airplanes coming and landing. I wish that I could just have a Polaroid of that moment because it was the last time we were ever gonna have a moment like that. At any rate ...

AVIR: Eventually they get on this little six-seater plane.

RANDY STEINER: The B55 Beechcraft Baron.

AVIR: And Jim's up in the cockpit because he's actually an amateur pilot.

LULU: Whoa!

AVIR: Yeah. So he's flying them home to Nebraska.

RANDY STEINER: My dad did all his checks. He got the weather report, contacted the FAA and gave them a flight plan. And we took off and headed east.

AVIR: So they fly through New Mexico. They go through Kansas.

RANDY STEINER: And I just spent my time looking at the world below.

AVIR: 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.

LULU: Oh, no!

AVIR: So now it's foggy, and Jim really can't see anything.

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

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

RANDY STEINER: 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 had visual with the ground.

AVIR: 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.

RANDY STEINER: So he thought he was flying 500 feet above the ground. He was flying about 50 feet above the ground.

LATIF: [gasps] Oh, no!

RANDY STEINER: Yeah, and he was—we were moving at almost 200 miles an hour. God, probably less than 30 seconds later, the plane went right through two large pine trees. And then all of a sudden everything stopped.

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

LATIF: Oh!

AVIR: So Jim gets knocked out.

RANDY STEINER: He had a broken rib. He—you know, he had a hole in his face. His eye was completely swollen shut.

AVIR: And when he comes to, he starts looking around. And he looks to his right. And Charlene is just not there.

LULU: Wait—meaning ...?

AVIR: She's like—she's nowhere to be—like, that part of the plane is gone.

LATIF: Oh, no!

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

RANDY STEINER: My whole scalp was ripped back all the way to my skull, and my sister had a big chunk out of her face.

AVIR: And three of them—Randy, Rick and Kim—are knocked out. They're unconscious.

LULU: [gasps]

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

RANDY STEINER: He did a quick assessment of us there.

AVIR: Randy had this huge gash on the back of his leg.

RANDY STEINER: So he went and pulled out a bunch of suitcases to get clothes out of so he could fashion a tourniquet.

AVIR: And once Jim got their wounds under control, he went looking for Charlene.

RANDY STEINER: Shouted for her, and was looking for her. And he'd walked about 25 feet before he found her. And she was dead.

LATIF: Oh!

RANDY STEINER: She didn't suffer, for whatever that's worth.

LULU: Oh my God!

AVIR: Yeah. And as far the kids go, it was pretty clear, like, if he didn't get them to a hospital, they were gonna die too.

RANDY STEINER: Yeah.

AVIR: So Jim's out there with these kids for eight hours.

LATIF: Eight hours?

RANDY STEINER: Eight hours.

AVIR: You've got to remember, 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.

RANDY STEINER: My dad was getting pretty frustrated because he really couldn't believe that nobody knew we were missing. But eventually, as the fog began to lift and the clouds began to lift, all of a sudden this moon came out.

AVIR: And so Jim could see what's around him.

RANDY STEINER: He could see the treeline we came from. He could see the field rolling out from around him.

AVIR: And he decides to go looking for the nearest road.

RANDY STEINER: Try and get us some help.

AVIR: 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.

RANDY STEINER: In a little town called Hebron, about five miles down the road.

AVIR: So finally, after being, like, stranded for hours, they arrive at this hospital.

LATIF: Oh, thank God!

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

RANDY STEINER: 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.

AVIR: And the front door is locked.

LULU: Oh, my God!

AVIR: So they're banging on the door. And they see a couple of nurses inside.

RANDY STEINER: One of the nurses walked up to the front door.

AVIR: And she's like, "The hospital is closed. Sorry, we can't let you in because there's no doctor here."

LATIF: But Jim's a doctor!

AVIR: Yeah, exactly. And Jim is, like, in disbelief.

RANDY STEINER: 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—to stabilize us, to get us in there.

AVIR: 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!"

RANDY STEINER: "Open this door."

AVIR: So they unlock the door.

RANDY STEINER: My father kind of just burst in.

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

RANDY STEINER: He had to get the—the gurneys out into the parking lot and start getting us loaded on there, and then getting us wheeled into the hospital.

HELEN BOWMAN: 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.

AVIR: This is Helen Bowman, a nurse called in that night.

HELEN BOWMAN: I had seen a lot of nasty cases, but this was the worst.

RANDY STEINER: Yeah. So my dad was doing the initial assessment on us. He was trying to get the nurses to help with taking vitals.

AVIR: Eventually, two doctors showed up on the scene.

RANDY STEINER: Dr. Penry and Dr. Bunting showed up.

AVIR: And so Jim's like, "Okay, great."

RANDY STEINER: 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 plan.

AVIR: But Jim wasn't exactly letting go of the reins. From his perspective ...

RANDY STEINER: They were really just running around like chickens with their head cut off.

AVIR: They seemed completely overwhelmed by this situation.

HELEN BOWMAN: It was chaos. It was just total chaos.

AVIR: I mean, Jim wasn't making their jobs easy.

HELEN BOWMAN: He was very agitated.

RANDY STEINER: He started taking—yelling, barking out orders.

AVIR: But that's because these doctors and nurses, they didn't know how to handle all these injuries.

RANDY STEINER: 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 gonna require surgery to close. You can't just come in here and suture this up."

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

RANDY STEINER: Basically, if it looked bad, that's what they started on. You know, they saw that I had a—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.

AVIR: So they were focused on them. But all the while, Rick, who wasn't covered in blood ...

RANDY STEINER: He had the most serious injury.

AVIR: He was drifting in and out of consciousness, and sort of like thrashing around and, like, Jim knew that this must mean that he had a pretty serious head injury.

RANDY STEINER: And knowing what he knew about head and neck injuries and how they worked together, he wanted to get head and neck x-rays right away.

AVIR: But after, like, pushing and pushing and pushing them to do the x-rays ...

RANDY STEINER: All they did was x-ray the skull. 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."

AVIR: And at that point, Jim just broke.

RANDY STEINER: 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."

AVIR: 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.

RANDY STEINER: They got us into ambulances and took us to the emergency room at Lincoln General Hospital.

AVIR: When they get there, like, a dozen doctors descend on the family.

RANDY STEINER: The beehive got hit, and everybody jumped into action and started taking care of us. And I was going to go to surgery.

AVIR: And at this point, you know, Jim is seeing his close co-workers and they're like, "Jim, get on the bed." You know, "We're putting you under. Like, goodbye," you know? And he's—finally lets go of the reins and becomes the patient.

RANDY STEINER: He did and, you know, he managed to calm down. We were all in the same room.

AVIR: Three of the kids were still in comas.

RANDY STEINER: I was in a coma for three days, Kim and Rick were in a coma for seven.

AVIR: But eventually they all woke up and they all survived.

LULU: Aww.

LATIF: Wow!

LULU: Okay, that's great.

AVIR: Yeah. So the family returned to their lives. They try to move on from this insane tragedy.

RANDY STEINER: 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 more, my dad was very lonely. He had four kids that he was now raising on his own. He still had an incredible amount of guilt.

AVIR: I mean, I never got to talk to Jim about any of this. He passed away this year, but according to Randy, he just became totally obsessed with what went wrong in the ER in Hebron that day.

RANDY STEINER: He spent a lot of time complaining about it and saying, "I don't get this. How could this happen? It's 1976 and we're still dealing with—with hospitals that have no idea how to handle, you know, a mass casualty event?" And not even a really significant mass casualty event. There were five of us.

AVIR: The thing is, angry as he was, Jim knew it wasn't actually the fault of the doctors or the nurses there.

RANDY STEINER: As he thought about it, he knew they were competent. He knew they weren't yokels. You know, it's not the people.

AVIR: 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 stomach ache or eye infection. 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. 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 a new field. There weren't a lot of specialists.

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

AVIR: This is Dr. Sharon Henry. She's a professor of trauma surgery at Shock Trauma in Baltimore.

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

AVIR: 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.

RON CRAIG: Correct. I didn't have any training. I learned what I learned in the ER. It's whatever rolled through the ER doors.

AVIR: So this is Ron Craig. He worked with Jim at Lincoln General.

RON CRAIG: I worked in Lincoln General Hospital's emergency room for three years.

AVIR: 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.

RON CRAIG: 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.

RANDY STEINER: 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?"

RON CRAIG: I apparently said something to the effect of, "Put your money where your mouth is," or "Put up and shut up."

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

LATIF: That's after the break. Stick with us.

LULU: Lulu.

LATIF: Latif.

LULU: Radiolab.

LATIF: Okay, so where were we?

AVIR: 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." So the two of them start meeting up.

RON CRAIG: In my dining room.

RANDY STEINER: For a couple of hours.

AVIR: Randy Steiner again.

RANDY STEINER: Just to talk about it.

AVIR: 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? 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? Like, each of those injuries requires a different specialist doctor. So Jim and Ron start by calling all those different kinds of doctors.

SHARON HENRY: Experts.

AVIR: This is Dr. Henry again.

SHARON HENRY: Let's go to the thoracic surgeons.

AVIR: 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?"

RANDY STEINER: What did you do to treat that?

RON CRAIG: And I just took notes.

AVIR: Then they go to a heart doctor.

SHARON HENRY: Yeah, the heart's kind of important.

AVIR: And say, "Okay, if the bullet went through the heart, like, what do we do first for that?"

RANDY STEINER: "This is what I did in this case. This worked. That patient lived. This patient dies."

RON CRAIG: So what went wrong there? What should we do differently?

AVIR: They called lung doctors.

SHARON HENRY: Orthopedists.

AVIR: Neurologists.

SHARON HENRY: Neurosurgeons.

AVIR: 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?"

RON CRAIG: We got information from whoever we could get information from.

AVIR: And then Jim and Ron add it all up.

RON CRAIG: Spread out our ideas on paper.

AVIR: 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. 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. 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.

RON CRAIG: You got it.

AVIR: And what emerged was a process that looked like it could kind of work for every different kind of trauma. A plan that ...

RON CRAIG: Doctors can apply to almost any situation.

LATIF: So what—what was the plan?

LULU: How do you universally approach all potential chaos itself as it impacts the body?

AVIR: The answer I'm almost, like, embarrassed to say it because you're gonna be like, "And?"

LATIF: [laughs]

AVIR: Like, it's basically something called the ABCs.

LULU: The ABCs.

AVIR: 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.

LULU: Okay.

AVIR: And it's basically like a mnemonic, like A-B-C-D-E. Each of those letters sort of stands for a different step you would take when you first receive a trauma patient.

RON CRAIG: The ABCs of what you have to do to stabilize this patient while you get further help.

LATIF: Huh. Okay, so what do they stand for?

AVIR: A is for "airway," B is for "breathing," C is for "circulation," D is for "disability," and E is for "exposure."

LATIF: Okay, and what does this actually look like? Like, give me an example.

AVIR: Okay, so let's say you have a patient who was just in a car accident. And they roll in on the stretcher, so there's blood everywhere. They're screaming. Maybe their leg is broken and twisted back in a weird direction. 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."

[ARCHIVE CLIP: Airway.]

AVIR: 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? 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.

RON CRAIG: Simply because, if you don't breathe, you don't live.

AVIR: After you've done the airway, then you can move to "B."

[ARCHIVE CLIP: Breathing.]

AVIR: So B is like a verb. Now that you have a tube open where oxygen can get from the air to the lungs, now you've got to make sure the lungs are going in and out and breathing. That's where you listen to the lungs. 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 to suck the lung back open. 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, now let's, like, stop the blood from pouring out of you.

RON CRAIG: That's step C.

[ARCHIVE CLIP: Circulation.]

AVIR: You think about blood and heart. So okay, if someone's bleeding, stop the bleeding.

LULU: Got it.

AVIR: So then you stop the bleeding. Then D ...

[ARCHIVE CLIP: Disability.]

AVIR: ... is disability.

LATIF: Okay.

AVIR: Which is essentially a bad name for, like, a quick assessment of is there any brain or spinal damage here?

LULU: Ah!

AVIR: So the doctor's gonna check your pupils to see are they reacting properly? They're gonna 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.

[ARCHIVE CLIP: Exposure.]

AVIR: So you take scissors, and we cut off all their clothes and we look at their entire body.

LULU: And are you mostly looking for cuts and bruises? Anything else?

AVIR: Holes. Big—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.

LULU: Oof!

AVIR: You know, you just have to bang through these things.

LATIF: Hmm.

AVIR: Now Jim and Ron realize that a lot of these small-town docs weren't necessarily gonna know how to do a lot of this stuff. So in addition to coming up with the ABCs, they also developed, like, this crash course in trauma life support.

RANDY STEINER: They were gonna take these doctors from these rural settings and train them on every step of the process.

AVIR: 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.

RANDY STEINER: Not knowing for sure if it was even gonna work.

AVIR: They explained the ABCs, and then dove right into practicing how to deal with each one. Eventually, the class would expand to include these lifelike simulations with dummies and fake blood, and sometimes even actors playing the injured patients.

LATIF: Huh!

AVIR: And the class was profoundly strange for these doctors, not just because of the simulations, because of the way that it made them think. It was kind of the opposite of what they'd learned in medical school.

LATIF: What do you mean?

AVIR: Well, think about the doctors you see on television. 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.

[ARCHIVE CLIP, House: Roll over.]

AVIR: You check this for these heart sounds. You listen to their stomach.

[ARCHIVE CLIP, House: Any idea what's wrong with her?]

AVIR: You ask questions.

[ARCHIVE CLIP, House: What is that?]

AVIR: Did the patient have any rashes? Yeah. Okay, now let's come up with a list of all the things it could be.

[ARCHIVE CLIP, House: It could be adrenal gland disorders, blood issues, anaphylaxis.]

AVIR: And once you make the diagnosis, then you create a treatment plan.

[ARCHIVE CLIP, House: I'm starting you on a cocktail of STD meds.]

AVIR: Jim and Ron are basically like, "To hell with all of that. Like, forget about the tests, forget about questions. This is the plan. It's called ABCDE. You just start doing it."

LULU: Huh! And let the complexities go.

AVIR: Yeah!

LULU: Forget nuance. Go!

AVIR: Yeah. 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 gonna be received at all. But the first group liked it, so they were like, "Okay, let's try this again."

RON CRAIG: We rounded up our instructors.

AVIR: Held the next class in Scottsbluff, Nebraska.

RON CRAIG: They showed up.

AVIR: Those docs also loved it. And throughout the rest of 1978 and '79, they kept holding more classes around Nebraska, and they're finding this groundswell of support. All these doctors are like, "Thank God we have a plan. Like, something that tells us how to deal with these incredibly stressful situations." And then finally in 1980, just a few years after Jim and Ron invented ATLS, it went mainstream.

SHARON HENRY: It was adopted by the American College of Surgeons.

AVIR: And since then, it's just spread everywhere.

SHARON HENRY: Canada.

AVIR: Most parts of Europe.

SHARON HENRY: Mexico.

AVIR: The Middle East.

RON CRAIG: We intended for this to be a program for primary caregivers in small towns, but it obviously grew beyond that.

AVIR: And now today, over 1.5 million doctors have been trained in ATLS, and every year 50,000 more get the training.

LULU: Wow!

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

LATIF: Okay. So, like, and it works.

AVIR: Yeah.

LATIF: Do—do we know how well it works?

AVIR: 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.

LULU: I mean, how many lives do you think it's saved?

AVIR: 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. Like, you can't take it back, you know?

LULU: [laughs] Yeah. It's like in the water. Yeah.

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

LATIF: Wow!

AVIR: And basically ...

LULU: Sorry, does it become mandatory?

AVIR: Yes. To become an ER physician, you have to get this training.

LULU: Okay.

AVIR: And you need that. I think you need that because when a trauma patient comes in, it can be like, the ultimate overwhelm.

LULU: Right.

AVIR: I'm—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 the whole thing, the whole sun, I'm gonna get burned. So I'm only gonna look at a small piece at a time. So I'm gonna look at A and I'm gonna allow myself to see all the horrors of A. And I'm gonna make a few key decisions and do things, then I'm gonna stop looking at A and open my mind to B.

LULU: Yeah.

AVIR: 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, you know?

LATIF: Yeah.

LULU: Mm-hmm.

LATIF: Wait. Okay, so, like—so A, B, C, D, E—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," when you're, like—clearly the bleeding out is the problem, though.

AVIR: Yeah.

LATIF: But you—but—but even if you have a sense like that, you don't skip.

AVIR: You don't skip.

LULU: Wow. Really? Do you ever skip?

AVIR: You're not supposed to skip.

LATIF: It feels—it feels—as you describe it like that, it feels very robotic.

AVIR: Very robotic.

LULU: Mm-hmm.

REUBEN STRAYER: Yeah, following step-by-step instructions like a robot.

AVIR: Okay, so I called up this guy, Dr. Reuben Strayer.

REUBEN STRAYER: Hi, I'm Reuben. I'm an emergency doc at the largest hospital in Brooklyn, Maimonides Medical Center.

AVIR: Reuben's worked in a lot of different trauma centers over the years, and he thinks that ATLS has gotten a little too rigid.

REUBEN STRAYER: Yeah. And when we apply a rigid structure in the evaluation of care, sometimes we end up with thoughtless care.

AVIR: 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.

REUBEN STRAYER: Everyone's getting a finger in their bum.

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

REUBEN STRAYER: It's a CAT scan that includes the head, the neck, the chest and the pelvis.

AVIR: Now Reuben would agree that, like, in serious traumas, you know, like someone's feet are coming in a bag, yeah, the ABCs are crucial.

REUBEN STRAYER: I'm more on board with following an algorithm if the algorithm compels you to act.

AVIR: But even then, you 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.

REUBEN STRAYER: Yes. 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. I just want to go through the algorithm and move on."

AVIR: And I love my job. Like, I love working with patients. But I do experience this going through the ABCs. It's almost like this technical video game. "Okay, I'm intubating. I'm gonna put this scope in here, and the first thing I'm gonna see is this. I'm gonna travel here. I'm gonna see this. I'm gonna make a left turn. I'm gonna expose this. I'm gonna move my hand like this." So it becomes very technical because you're not seeing them as a person. You're seeing it as, like, a body part.

AVIR: And when you're treating them, you know, you kind of want to be in that mode. It helps you stay focused. But it can be really tricky because once you've stabilized the situation, you need to become a human again. And that's just as hard, honestly. Like, sometimes you'll be talking with another doctor in the room and just talking shop in this almost robotic way, right? And the family is like, "Did you just say, like, if we don't do this, my brother is 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? So it can be hard sometimes to snap in and out of this way of thinking.

LULU: Yeah. I mean, it makes me think about—well, just in general—like, I feel like a booster for nuance and complexity. And talking about medicine in general, I think we want our doctors to be really thinking about nuance and being human and being attuned. But then there is—like, except maybe in trauma when, like, the clock is running and actual instincts might get in the way. Like, I really see its value.

AVIR: I was gonna say, like, you know, we want our doctors to be human, but maybe in this case, when there's, like, some unimaginable trauma going on, it's nice to dehumanize a little.

LATIF: Yeah, but, like, to me, the fundamental irony of this story is that the guy who figured out how to roboticize yourself, like, that kind of came out of the most human, the most messy, the most emotional situation you could possibly, you know, engineer.

LULU: Yeah.

LATIF: There's a kind of a very funny irony there.

AVIR: Yeah. 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.

LULU: Hmm.

LATIF: Yeah.

AVIR: Like, I wish Jim, I wish all the doctors there had something like ATLS that night to help them.

LULU: Yeah.

AVIR: You know, in the way that it helps me. To me it's like there's this sort of—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 where I messed up as a human but also as an early doctor, whereas it's like, if something goes right, like, I'm great. If something goes wrong, I'm terrible. But I'm still the same me, and sometimes things go great, sometimes things go terrible. Sometimes patients die. But with ATLS, even if the person dies, you can say, "I followed the process." And the chips will fall where they will. And that'll be happy or sad but—but at least I can sleep at night, you know?

LATIF: This episode was reported by Avir Mitra, with help from Maria Paz Gutiérrez, Sarah Qari, Becca Bressler, Suzie Lechtenberg, Heather Radke and Ana González. It was produced by Maria Paz Gutiérrez, Becca Bressler and Pat Walters, with help from Ana González. Original music and sound design contributed by Maria Paz Gutiérrez and Jeremy Bloom, with mixing help from Jeremy Bloom. Fact-checking by Diane Kelly, and edited by Becca Bressler and Pat Walters. Special thanks to John Sutyak and Brian Zinck and why not, to every ER doctor everywhere. That's it for us. We'll catch you next time.

[LISTENER: Hi, this is Danielle, and I'm in beautiful Glover, Vermont. And here are the staff credits. Radiolab was created by Jad Abumrad, and is edited by Soren Wheeler. 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. Harry Fortuna, David Gebel, Maria Paz Gutiérrez, Sindhu Gnanasambandan, Matt Kielty, Annie McEwen, Alex Neason, Valentina Powers, Sarah Qari, Sarah Sandbach, Arianne Wack, Pat Walters and Molly Webster. Our fact-checkers are Diane Kelly, Emily Krieger and Natalie Middleton.]

[LISTENER: Hi, this is Ellie from Cleveland, Ohio. Leadership support for Radiolab's science programming is provided by the Gordon and Betty Moore Foundation, Science Sandbox, a Simons Foundation initiative, and the John Templeton Foundation. Foundational support for Radiolab was provided by the Alfred P. Sloan Foundation.]

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