Dying Inside

The ER Experience

    Working in the ER means you never know what’s going to happen on any given day.  It could be busy, slow, or weird. In the ER, you never know. Those of us who work in emergency medicine have a strange addiction to this suspense.  But this sort of unknown carries a risk.  The risk is that something terrible will happen.  And because it’s the ER, something terrible often happens. When clinicians experience death in the ER and the accompanying grief, what are they to do with it?  How do we support clinicians through these difficulties and help them stay healthy so that they have sustainable careers in caregiving?  We have to recognize that ER clinicians experience trauma regularly and we need to develop better ways to help them manage stress and grief so they can continue to practice medicine with their whole heart.  How can healthcare systems develop healthy ways to meet clinicians in these struggles and build communities that are supportive and caring?

    Over the course of my seventeen years of work in emergency medicine there are a few cases that always rise to the top of the list of my memories.  They are usually sad.  They are usually tragic.  I think this speaks to the fact that trauma imprints itself on my brain as a clinician in the moment of someone else’s tragedy. 

    The event that often comes to mind is the sudden death of a seven month old infant.  This was my first pediatric code experience.  The mother had driven the baby to the hospital and walked through the front door with a limp, breathless infant.  The triage nurse grabbed the baby from her arms and literally ran to the code room where the resuscitation effort began.  The physician stood at the head of the bed and gently but quickly gained the important history of events from the mother and prepared for intubation.  The mother stood at the side of the room with her hands on her face, staring at the baby and half concentrated on the physician’s questions.  I was a brand new nurse with only a year of ER experience.  I stood at the baby’s left side and it was my job to manage IV access.  This was, of course, impossible.  The child had been apneic (without breath) for over twenty minutes.  The only access we could obtain was an IO (intraosseous line).  This is inserted into the space just below the patella of the knee.  It sounds brutal but it is fast, relatively painless, and provides reliable access for medication and fluids used in resuscitation.  My hands shook as I inserted the line. It felt cruel and tortuous to do this to such a young baby.  I knew that the efforts were probably futile and the baby was probably dead.  We worked on the child for over an hour.  Children’s Hospital was notified of the need for emergent monitored transport to their facility.  When they arrived, we continued life saving efforts for another fifteen minutes or so until everyone was in agreement that nothing more could be done.  The child was pronounced dead at approximately two am.  

    This experience occurred over fifteen years ago.  I can remember almost every moment.  The next thing I remember is the sound of the cry coming from the mother as she learned her baby had died.  There is no sound like the cry of grief in the first moment the family is told of the death of their loved one.  It is raw, human emotion and its power strikes through the soul of everyone in the room like a shock wave.  It is profound to be in the room when a fellow human moves from life to death.  It is powerful.  It is humbling. I have to grit my teeth and swallow hard to avoid breaking down and crying.  I am always aware that life is delicate and we really aren’t guaranteed anything in this world.  It is an honor and a hardship to be at the bedside when someone passes away.  I often say a prayer over the person when everyone has left and the room is quiet.  It is strange and yet sacred to be alone with death.  

    Clinicians experience grief in the moments following the death of a patient.  But we are not supposed to express this grief.  Sometimes there is occasion to let a tear fall in sympathy with family.  But usually you get the sense that they need to be alone with one another and their lost loved one.  Besides, we’re supposed to remain strong.  We are there to present information, facts, and be objective.  We are supposed to explain the cause of death and explain all the efforts we took to save their life.  And then we are supposed to move on.  But do we move on?  Do we really just walk away from what just happened, forget about it, and never feel the consequences?

Barriers to Processing Grief

    There are a few significant barriers to effectively processing these difficult events.  Even if we wanted to express empathy and grieve along side our human brothers and sisters, there isn’t time.  The pressure and demands of the work in the ER do not stop.  In fact, usually after a resuscitative effort the work of the department has increased.  Physicians and staff are pulled into one room to focus on the critical case while the rest of the department gets backed up.  It is our job to turn down the hallway, go into the next room, and care for the next person.  Not long ago an elderly woman came in feeling quite ill.  Her course quickly became critical and she died within three hours of arrival.  I was shaken by how quickly this happened.  I took exactly one minute in the bathroom to cry and then dried my eyes and went to the waiting room to talk with the family.  I spent about ten minutes with them.  I spent another ten minutes completing paperwork and order entries.  And then I moved on to my next patient who was a two year old with a forehead laceration.  I turned on my happy, playful face and went into the room toestablish an environment of confidence and calm as we cared for her wound.  I was dying inside.

    Processing this grief can be further complicated because the grief we witness isn’t exactly our own.  It wasn’t our baby, our grandfather, our spouse.  It happened to somebody else.  But we did witness it.  We were directly involved.  To see a human being slip from life to death changes us.  It leaves a mark.  Grief work is also complicated by the fact that we had the responsibility to care for the person.  It is our job to do everything possible to save this person’s life and therefore, if they’ve died, we failed.  Or worse yet, what if a medical error led to their death?  What if we forgot something or missed a treatment option or caused the death by giving the wrong medication?  Guilt enters the picture.  And then there comes fear.  What will be the repercussions?  Will there be investigations, committee review, lawsuit?  Are we supposed to talk about these questions, doubts, and sadness?  The culture of medicine historically has been silence.  Don’t talk about it, just deal with it.  

Unhealthy Coping Mechanisms

    And people do deal with it.  Unfortunately, it’s not always healthy.  Most of my partners and the nurses I work with say that they take very little time to process the events after a patient has died.  Some will go home that night, hug their children a little tighter, and have a glass of wine before bed.  People have different coping mechanisms.  Some people go for a run or talk to their spouse.  Some people drink too much or turn to drugs for relief.  Most just shove the experience down deep in their heart and try to ignore it.  Some don’t even seem to remember the events at all.  

    But these traumatic events make their mark.  They always leave a mark.  “We find out that 36 % of the EPs (Emergency Physicians) find dealing with sudden death of a young person and traumatic accident/disease involving a young person the most traumatic experience during their work activity” Scand J Trauma Resusc Emerg Med. 2016 Apr 27;24:59.  The question I have been asking is what are we doing for the care of the souls of those present at these events?  What do we do to check in with doctors and nurses who have witnessed tragedy?  It is traumatic.  But do we talk about it?  What support is available for clinicians?  How are we supposed to deal with it? How do we maintain our humanity which requires that we be human ourselves and remain strong and decisive and unaffected by these traumatic events.  Dr. Brene Brown states “If you trade your authenticity for safety, you may experience the following: anxiety, depression, eating disorders, addiction, rage, blame, resentment, and inexplicable grief.”  So often clinicians trade their full humanity with its wounds and heartache for emotional “safety”.  

Working with the Whole Heart

    For clinicians to remain humane and do their best work, they have to come to work wholeheartedly.  “Whatever you do, work at it with all your heart, as working for the Lord, not for human masters” Colossians 3:23, NIV.  How can you continue to work with your whole heart if you have to take the broken pieces and shove them down to the bottom never to be spoken of again?  Brene Brown states, “we cannot selectively numb emotions.  When we numb the painful emotions, we also numb the positive emotions.”

    We need to start talking about the fact that we, as clinicians, experience grief and trauma too.  It isn’t to the extent that a family will experience in the moment of loss.  But it does happen a lot more frequently.  We see death and dying on a regular basis.  We try our best to intervene and save lives; but often, we fail.  People die and you can’t treat death.  But what do you do with the emotions that come along with working in these difficult situations.  How can we help clinicians process these events in an efficient and effective manner?

    I believe this starts with a deep respect for human beings as whole persons with physical, emotional, and spiritual needs.  This holistic view of humans must extend to clinicians as well as patients.  I would argue that this holistic care that so many in healthcare seek to offer must actually begin with clinicians and then flow out into patient care.  Jesus said, “A blind man cannot guide a blind man, can he?  Will they not both fall into a pit?” Luke 6:39, NAS.  How can we ask clinicians who are emotionally traumatized and struggling with burnout to care for the emotionally and physically needy?  You cannot pour from an empty cup.  Jesus also says in Luke 6:45 “the good man out of the good treasure of his heart brings forth what is good”.  Physician groups, healthcare systems, and clinical departments must be sure that the hearts of our staff are well tended and have every opportunity to bring forth good fruit.  If people are dying inside they can only bring forth rotten fruit.  They will try to cover over their pain and frustration and it will work for a season but eventually their wounds will overflow into their work. 

Debriefing

    Critical incident stress debriefing is an excellent way to open the door of communication and begin the process of coping with these difficult experiences.  “Debriefing is a form of psychological ‘first aid’ that has its origins in the military. General Marshall, chief historian of the United States Army during World War II, advocated the use of debriefing techniques and sessions on the battlefield. The sessions were intended to gather information about the fighting day, but he noticed they had a spiritually purging and morale-building effect on the troops” Emerg Med J 2008;25:328-330. 

    In the emergency department, after a code, the purpose of a critical incident stress debriefing (CISD) is to evaluate what was successful during the code as well as what needs improvement. It is designed to improve clinical outcomes and process.   It is also a meaningful way to begin the conversation about the emotional effects of the code on staff.  It is important to begin the conversation soon after the event and establish a culture where open communication from everyone is welcomed.  We have started to implement this in our facility.  Ideally this takes place within minutes of the event.  It can be done at a later date but it is difficult to gather everyone together because of scheduling challenges.  It is alsochallenging to implement because of the time and clinical demands that remain in the department immediately after a code.  Often, the care of other patients has been delayed because of the critical case.  Additionally, it takes proper training to effectively apply a CISD. It is important to investigate this intervention further because CISD establishes and supports a culture where communication about both the process improvement and the emotional health of clinicians is validated and supported.  

Mentoring relationships

    Another extremely useful tool for clinicians is the development of mentoring relationships.  Clinicians are encouraged to find people who are perhaps a little older, and definitely a little wiser who can help them navigate difficult clinical events and stressors.  “Finding a suitable mentor requires effort and persistence. Effective mentoring necessitates a certain chemistry for an appropriate interpersonal match. Prized mentors have ‘clout,’ knowledge, and interest in the mentees, and provide both professional and personal support”  Acad Med. 2003 Mar;78(3):328-34.  These mentors are available to discuss difficult events and stressors in the lives of clinicians.  They are a support when a clinician encounters a difficult case or need to process grief.  Challenges to establishing healthy mentoring relationships include difficulties in effective communication, personal differences, conflict, and lack of training in effective mentoring Acad Med. 2013 Jan;88(1):82-9.  This is such an important part of growth and development in any area of life including professional development and personal wellness in a stressful work environment.  Mentoring takes time and wisdom to implement well.  It requires both the mentor and mentee to commit themselves to the relationship.  But the value of of having a trusted advisor to counsel and encourage the clinician through difficult times cannot be overstated.

Healing the Healer’s Heart

    We have to start attending to the wounded hearts of clinicians.  People who have trained and given their life to the treatment of the sick and dying need support.  As a medical community, we need to recognize that the culture of ‘just deal with it and move on’ is crippling us.  We begin to build walls to protect these tender places in our hearts and before you know it we are jaded and emotionally disconnected from patients, coworkers, and probably even our own friends and families.  As Dr. Brene Brown states, you can’t just numb the painful emotions.  You end up working and living with only part of your heart.  I believe patients can sense this.  They know when somebody cares and when somebody doesn’t care.  We can turn into distant and unfeeling clinicians.  But we might be missing something when we think a clinician is rude or cold.  That doctor might not be indifferent, she might be hurting.  She might be protecting deep wounds of grief and sadness that have never seen the light of day. The broken heart has to be healed before it can function to its full capacity.  I’m not saying that we need to dwell in the place of grief forever.  Again, the loss of a patient is different from the loss of a loved one.  AndER people have a skill set both clinically and personally to deal with things quickly and move forward.  We wouldn’t be able to do what we do if we lingered over sadness indefinitely.  But we can’t ignore it either.  As much as we care for people and their families at the moment of their death, we need to take care of ourselves.  We need to take care of each other. 

    Hospitals have many tools that can be implemented to care for people under it’s own roof.  We have an impressive collection of clinical experts in one building.  We also employ counselors, psychologists, pastoral staff, and volunteers who can further their ministry by caring for their own.  The needs of each hospital department and clinic is unique and one size of intervention does not fit all.  The needs of nurses and physicians in an ER are incredibly different from the needs of staff on a hospice floor.  But I can guarantee you they all have needs.  It will require sensitivity and creativity and time to get to know these groups and develop relationships so that these vital conversations can begin.  Department managers and leaders need to think creatively and sensitively about ways to attend to their staff in a meaningful and supportive way.  My work in this area has led me to understand two things.  First, there is profoundbrokenness in the hearts of brilliant and caring medical clinicians.  And secondly, this work of tending to wounded hearts takes time and and it is rooted in relationship.  This work of healing must take place in and amongst people and it cannot be rushed or systemized.  It will look different in every department and every hospitalBut we must start.  We must start where we are, with what we have, and we must start now.

References

The impact of occupational hazards and traumatic events among Belgian emergency physicians.  Scand J Trauma Resusc Emerg Med. 2016 Apr 27;24:59

Brené Brown, The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are

Curr Opin Crit Care. 2013 Jun;19(3):188-94   Debriefing after resuscitation

Emerg Med J 2008;25:328-330 doi:10.1136/emj.2007.048942 Debriefing after failed paediatric resuscitation: a survey of current UK practice

Mentoring programs for physicians in academic medicine: a systematic review. Acad Med. 2013 Jul;88(7):1029-37

"Having the right chemistry": a qualitative study of mentoring in academic medicine.  Acad Med. 2003 Mar;78(3):328-34

Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers.  Acad Med. 2013 Jan;88(1):82-9.

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