Body Art: What EMS Needs to Know

As Bob Dylan likes to remind us, “The times, they are a-changin’.” This is so true in EMS, especially when it comes to encountering patients (of all ages) with body art. If you think your patients don’t have any, you’re probably not looking hard enough—and if you think you’ve seen it all, this brief review may help open your eyes to a whole new world of holes.

Honestly, as EMS professionals, why do we care what artistic liberties people take with their bodies or what is pierced where? In many cases we don’t, because it simply doesn’t (or shouldn’t) affect patient care. That’s true until the piercing, tattoo, etc. is in the way and we want to know, Do I go around it, through it, or simply get rid of it? After a traumatic injury, if something is causing harm or has the potential to (such as a sharp piece of jewelry cutting into tissue); may cause additional injury or complications due to edema or swelling; or might dislodge into the airway, then a few principles apply.

1. If the patient is awake, ask them to take the jewelry out. Chances are they can take it out faster than you can.

2. If the patient is unconscious and the jewelry needs to come out (rare but possible in EMS), ask yourself these questions:

• Do I know how to safely take it out?
• Do I have the proper tools, such as ring-opening pliers (not bolt cutters or the Jaws of Life)?
• Does it really need to come out? Just because you can doesn’t mean you should (and souvenirs are really frowned upon). Chances are you might be able to do what you need to do and then others can remove it later, if necessary, under safer conditions.

So when you encounter a patient with x, the real question in EMS is simply, “Can I perform y?” When it comes to body art and EMS, research over the years has shown that in most cases, the answer is probably yes.

Can I Do…

Airway:

• Nasal cannula? Yes—you can administer oxygen through a nasal cannula with nostril and septum piercings.
• Nasal trumpet? Yes—if the jewelry is on the one side of the nose, simply look at the other side. (The same idea works for nasogastric tubes or nasotracheal intubation.)
• Oral intubation with tongue jewelry? Yes—if they can walk with it, talk with it, eat with it, and sleep with it, chances are you can tube ’em with it.
• Cricothyroidotomy? Yes—if there’s a small piece of jewelry in the front of the neck, you are holding a big scalpel, and therefore a piece of jewelry is the least of your (and their) worries.

Spinal motion restriction? Yes—if there’s jewelry on the front or back of the neck, cervical collars are fine. The ER can remove any jewelry prior to imaging.

Chest? Yes—you can cardiovert or defibrillate with nipple jewelry. Just don’t put the pads or paddles on the nipples (which you shouldn’t do anyway).

Abdomen? Yes—things like navel piercings honestly aren’t a big issue for EMS. ER staff can remove any jewelry—or, even better, exchange it for an IV catheter to keep the tract open if removal is needed for imaging, surgery, etc.

Many piercings (other than earlobes) may shrink quickly and close even if they’ve been worn for years. This is a common reason why patients are reluctant to have their jewelry removed, especially if it’s perceived to be unnecessary. Patients with piercings are typically very appreciative when medical personnel attempt to preserve their piercings with a medical “retainer” (IV catheter, microbore IV tubing, etc.) or by leaving jewelry in place when possible.

Genital/Intimate Jewelry

This is of course at the discretion of the obstetrician or nurse midwife, but yes, you can deliver a baby with the vast majority of common women’s genital jewelry in place. You can also do a vaginal exam. You can place a Foley urinary catheter, with the only potential issue being the exceedingly rare Princess Albertina piercing, since that specific piercing rests in the urethra.

Genital piercings in men commonly aren’t an EMS issue, but in the ER it’s all about the Foley catheter. Can a Foley be placed in a man with genital jewelry? The answer is maybe. If there is jewelry sticking out of hole, aka the urethra (Prince Albert, etc.), you probably should remove the jewelry prior to catheter insertion. The maybe really applies to ampallang (horizontal) and apadravya (vertical/diagonal) piercings, as these sometimes cross the urethra.

So, what does that mean in real life? Try to insert the Foley catheter, and if resistance is felt long before the prostate, the jewelry should probably be removed before the catheter is placed.

Tattoos

While it is incredibly rare, there are documented issues with tattoos heating up during MRIs (magnetic resonance imaging). In an emergency you can start an IV through a tattoo, but if somewhere else is an option, choose another site. You can also place an intraosseous needle through a tattoo. There is currently nothing published that specifically addresses the question of placing IOs through a tattoo site, but the far bigger issue is that your patient is sick enough to need an IO.

Conclusion

Body piercing and tattooing have been performed for well over 5,000 years. Complications such as infections, scars, etc., have been well documented in medical journals and other publications. However, when one compares the thousands and thousands of body art procedures performed around the world each year to the number of published case reports, the incidence of complications is relatively rare.

There are two key considerations for people who choose to apply body art (piercings and/or tattoos). First, the person should have the procedure performed by a professional piercer or tattoo artist. If the experienced artist uses sterile equipment, jewelry, and ink, immediate complications are rare. Second, the care taken after the procedure is critical to avoiding complications. Research shows many piercings take weeks or even months to completely heal. In teens, with their short attention spans, this can be problematic. Getting the art is easy—caring for it is a whole different story!

Resources

Angel E. The Piercing Bible, Revised and Expanded: The Definitive Guide to Safe Piercing. Ten Speed Press: New York, NY, 2021.

Callaghan MF, Negus C, Leff AP, et al. Safety of Tattoos in Persons Undergoing MRI. N Eng J Med, 2019 Jan 31; 380(5): 495–6.

DeBoer S, Angel E. Body Piercing Removal Photo Guide for Healthcare Professionals. Pedi-Ed-Trics Emergency Medical Solutions, 2013.

Gualdi G, Fabiano A, Moro R, et al. Tattoo: Ancient art and current problems. J Cosmet Dermatol, 2021 Feb; 20(2): 602–4.

Hackenberg B, Große-Büning S, Hammes S, Strieth S. [Complications of cosmetic piercings and tattoos in the head and neck region]. HNO, 2020 Feb; 68(2): 131–40.

Iftekhar N, Zhitny V. Tattoo and body art: a cultural overview of scarification. Int J Dermatol, 2020; 59(10): 1,273–5.

Kluger N, Misery L. Seite S, Taieb C. Body Piercing: A National Survey in France. Dermatology, 2019; 235(1): 71–8.

Martinez BG, Campo MV. Opinion of a group of patients about health professionals with tattoos. Enferm Clin, 2019 Sep–Oct; 29(5): 313–7.

Preslar D,  Borger J. Body Piercing Infections. StatPearls [Internet], 2020; www.ncbi.nlm.nih.gov/books/NBK537336/.

Williams BM, Wright C, Leigh KH, et al. Tattoos in Nursing: Do We Practice What We Preach? J Christ Nurs, 2019 Jan–Mar; 36(1): 38–41.

Scott DeBoer, RN, MSN, CPEN, CEN, CCRN, CFRN, EMT-P, is an international pediatric emergency/transport nurse educator and founder of Pedi-Ed-Trics Emergency Medical Solutions.

Elayne Angel is the author of The Piercing Bible, Revised and Expanded: The Definitive Guide to Safe Piercing and a business member at large, Association of Professional Piercers.

Lisa DeBoer, NREMT-P/PI, CET, is a paramedic educator and president of Pedi-Ed-Trics Emergency Medical Solutions.

Michael Seaver, RN, BA, is a senior healthcare informatics and medical-legal consultant.