Medical ink

If your spouse’s initials are “D.N.R.,” you should probably think twice before tattooing them on your chest. Then again, if your end-of-life plans include a do-not-resuscitate order, maybe it’s not such a bad idea after all.

It appears the tattoo craze has expanded beyond mere aesthetics into medicine. Some people are setting down advance directives on skin in addition to paper. Others are opting for tattoos on their wrists instead of Medic Alert bracelets, favouring ink over jewellery. Though there are advantages to turning your epidermis into a medical record — you can’t accidently leave your forearm at home — some health professionals fear that paramedics and emergency physicians might not notice the tattoos, let alone treat them as proper instructions.

“Emergency responders understand the concept of MedicAlert bracelets and they look for them on the wrist. It is possible that some have learned that people are using tattoos but the chances of them looking for it are much less,” says Robert Ridge, president and CEO of the Canadian MedicAlert Foundation. “There is no overriding body that governs emergency services in Canada, so when something changes there is no national means to communicate it. Getting every emergency responder to look for something new can be a challenge.”

The days of tattoos being associated only with bikers and ex-cons are long gone. Now tattooing is firmly planted in the mainstream. A woman is as likely to have one as a man. There are reality television shows about tattoo artists. Celebrities sport tattoos, including the popular actress Angelina Jolie, who has nearly a dozen. Many professional athletes are covered in more ink than an incontinent squid.

In the United States, 36% of people in the 18–25 age bracket have a tattoo, and that percentage increases to 40% for people between the ages of 25 and 40, according to the Pew Research Center in Washington, DC (http://pewresearch.org/databank/dailynumber/?NumberID=237). By contrast, only 10% of people aged 41–64 have one.

So perhaps it should come as little surprise that some young people with allergies or conditions such as diabetes have no qualms about tattooing that information on their bodies. Some people prefer tattoos because they can’t wear jewellery to work (electricians, for example) or because bracelets and necklaces are easily broken and lost during certain sporting activities, such as surfing. Others simply like the look of a tattoo more than jewellery.

Tanyss Christie, a 35-year-old from Chilliwack, British Columbia, got a tattoo last year that declares she has type 1 diabetes. “I have a friend and she got one, too, after she saw mine,” says Christie, a mother of two. “I got a little bit different of a design for mine. It’s close to a MedicAlert bracelet, but with a little twist [see picture].”

Mike Hillier, a 29-year-old from Mississauga, Ontario, also has type 1 diabetes. He was diagnosed late, at age 24, and never took to wearing a MedicAlert bracelet, despite being encouraged to do so by his mother and doctor. “I never really wore mine, and I was looking to get another tattoo anyway,” says Hillier, a technologist with a satellite broadcasting company. “I wanted it to be something that actually meant something.”

How many people have medical tattoos? It’s difficult to say. There is no organization keeping track. At very least, it appears to be a trend on the rise, if the extensive gallery on the website for the group Diabetes Advocacy is any indication (www.diabetesadvocacy.com/tattoos.htm). Still, despite becoming more popular, medical tattoos are still relatively rare, according to those who work in the ink trade.

“I believe over the years we have maybe done a few of these types of tattoos but it’s nothing I would consider by any means common,” Jennifer Wiet, general manager of Adrenaline Montreal Tattoos & Body Piercing, writes in an email. “Personally I feel it’s a great idea, especially for people who have a hard time wearing a regular medical alert bracelet. For example I have a friend who had so many medical ‘issues’ that she requires 2 medic alert bracelets ... not that pretty. Or my mother who is supposed to wear one but is severely allergic to anything that isn’t at least 14k gold. That’s an expensive medic alert bracelet!”

Chilliwack, British Columbia-resident Tanyss Christie designed her medical tattoo to look like “a MedicAlert bracelet, but with a little twist.”

Image courtesy of Tanyss Christie

Ron Smith, a tattoo artist at Adrenaline, writes in an email that he has done tattoos relaying medical information such as diabetes, heart conditions and high blood pressure but never for a do-not-resuscitate order. Mathieu Samson, another Adrenaline tattooist, also indicates that he has done a few MedicAlert-type tattoos.

Nicole Nickerson, of the Sin on Skin Tattoo Studio in Halifax, Nova Scotia, says her shop has done a few medical tattoos over the years, mostly in the MedicAlert style on people’s wrists. One client, a soldier who got a tattoo of his blood type, told the studio how his ink helped him on the battlefield. “2 years ago one of our clients while out in a hummer had been hit by a road side bomb and the shrapnel stopped at his tattoo which was his blood type,” Nickerson writes in an email. “He called later (jokingly) to say our work was bulletproof as well as great.”

Beyond anecdotes, however, there is little information available on medical tattoos. If you conduct a search for data on the topic in medical literature, you might just see digital tumbleweeds roll across your screen. There is one 20-year-old paper, though, that presented the case of an aging emergency physician with a symbol indicating “do no defibrillate” on his chest (West J Med 1992;156:309–12). The primary purpose of the tattoo wasn’t to offer directions, however, but rather to “make a principled statement about the futility in emergency departments of continuing ACLS [advanced cardiac life support] on patients who do not respond to prehospital resuscitative efforts.”

Though relatively rare, it is still time that medical researchers pay more attention to patients who use their bodies to relay important medical information, says Dr. Saleh Aldasouqi, an associate professor of medicine at Michigan State University in East Lansing and the medical director of the Sparrow Diabetes Center.

“This is something of medical relevance. I’m not promoting it. I’m just reporting something that I see on my patients, and I see it as a problem because they are doing it without medical advice,” adds Aldasouqi, one of the few academics to ever write about medical tattoos (Am Fam Physician 2011; 83:796). “We are burying our heads in the sand if we are saying this is not occurring and we don’t have to worry about it.”

The problem with MedicAlert-type tattoos is that, unlike bracelets and necklaces, there are no guidelines regarding their design or location on the body. Indeed, a Google Image search reveals medical tattoos on upper backs, shoulders, wrists, forearms and chests. Some are simple, others elaborate. Some are black, others exploding with colour. There are medical tattoos featuring ribbons, angel wings, snakes, horses, butterflies, skulls, hearts and even the cartoon character Hello Kitty. You see more fonts than in a word processor drop-down menu. A medical tattoo may also be hard to spot on a person with many other tattoos.

“This thing has to be standardized,” says Aldasouqi. “We have to at least teach and educate emergency personnel so they become more aware.”

As for the legal ramifications of ignoring a do-not-resuscitate tattoo, that is another matter altogether. Those types of tattoos, however, appear to be very rare. There is the odd case that pops up and makes a splash in the popular media. Dr. Ed Friedlander, a 60-year-old pathologist in Kansas City, Missouri, has a “No CPR” tattoo on his chest. Then there is Joy Tomkins, a senior citizen in Norfolk, England, who has “Do Not Resuscitate” tattooed over her heart and the letters “P.T.O.” (for “please turn over”) on her upper right shoulder.

But emergency personnel are not obligated to follow a tattooed directive, which does not carry the legal weight of a written, properly authenticated do-not-resuscitate document, according to Dr. Philip Goscienski, a retired pediatric infectious disease specialist from San Diego, California. Furthermore, it could lead to trouble if a person loses consciousness for a reason unrelated to a medical condition.

“There are a lot of things that can cause someone to collapse that are not cardiac-related,” says Goscienski, who has written that “No CPR”-type tattoos are not legal documents and are a waste of good ink (www.nctimes.com/news/opinion/commentary/forum-no-cpr-tattoo-a-waste-of-good-ink/article_ddd86ce4-fb09-5319-9bca-c6ac2363fda0.html).

“Encountering something like that could slow down the process,” he adds. “Paramedics might be reluctant to proceed at the same speed. Maybe they would start searching for an official document. The confusion issue becomes a problem.”