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evin A., barely 20, lies bloody and broken on a gurney in my emergency department. He was ejected through the front windshield of his friend’s car as it rammed into a telephone pole. It’s hard to look at his ravaged face without feeling my own teeth breaking into pieces.

During the ambulance ride, his thready pulse vanished, if he ever had one. The medics couldn’t distinguish what they felt from what they wished they felt. Regardless, Kevin’s heart isn’t beating now. The trauma team cracks open his rib cage and sternum in search of blood filling the sac around the heart, or a hemorrhage from one of the large blood vessels. It’s always a last-ditch effort and rarely works.

As the time of death is called, a brief silence descends over the trauma room.

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It’s broken by angry yells from the driver of the car. He’s in a trauma room across the hall, intoxicated, screaming at the staff, and ignorant to the tragic fates of his passenger-friends. The back-seat passenger is in another trauma room. She is likely to survive, but due to her injuries will likely lead a life very different from the one of unbridled promise she possessed earlier that evening.

The team in Kevin’s room — doctors and nurses, techs and social workers — share looks without actually looking at one another. Our expressions hide feelings that range from sadness and grief to injustice and rage.

So much to process and make sense of, yet we don’t talk about it. Instead, we seek safe harbor in our respective duties and rituals. We document. We clean the body. We notify the organ bank. We rip off blood-streaked gowns and gloves and toss them into garbage bins. We snap a fresh sheet over Kevin’s body and brace for the families to arrive.

And we move on.

“That’s what we do,” the senior emergency medicine resident said to me the following night at the hospital. I’d confessed how the case had followed me home when I got off my shift. The resident admitted that he hadn’t slept well either. A nurse described being similarly haunted.

“But that’s what we do, right? Move on?”

I nodded. The nurse nodded. The resident nodded. But something felt wrong about those ready nods.

How can any sentient being move on after exposing a human heart that a short time ago pumped with life and promise? But moving on is embedded into emergency medicine practice. Simultaneously caring for a large number of patients, juggling the sick, the not so sick, and the needy. This feat involves handling a mix of complex work-ups, procedures, and conversations. There’s always too much to do and too little time. Focusing on any one activity for long means that other patients wait. We move on because desperation and efficiency demand that we do so.

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This attitude isn’t without its perils. Moving on might be what we do, but that doesn’t make it right or healthy. Despite attempts at bravura, emergency medicine providers, along with other frontline specialists, burn precariously bright when it comes to depression and burnout. When physicians suffer, patients may suffer, too. When my emotional reserve drops, it means I have a limited supply of what my patients deserve — compassion, patience, and comfort with stories that unwind without direction.

Many factors have been posited as contributors to burnout in medicine. They include lack of control over the work environment, a disparity between personal values and the system, more time spent with electronic health records than with patients, and a sense of not making a difference, not to mention the ever-lengthening shadow of litigation.

There are also stressors specific to emergency medicine that place its practitioners at further risk for burnout, including the constant exposure to patients suffering from extreme physical and emotional trauma.

Add to this list the “it’s what we do” mental trap.

Sadly, the senseless death of a young man is a familiar story, another entry in the ledger of senseless deaths and tragedies that make up the ambient reality of work in a trauma center. Whether moving on is the product of this dulled resignation or the root of the problem, I can’t say. Regardless, Kevin’s death hit me in a vulnerable place. That a young man’s heart lay exposed and unprotected before me and I didn’t feel a chill caused me to shudder.

So did imagining tomorrow for the driver of the crash who, once he woke up, would face a lifelong hangover of sadness and regret.

The impulse to keep moving is natural and invested with purpose and pride. But what Kevin’s untimely death taught me is that it comes with a cost. A numb heart is hard to recognize until it begins to warm and nerve endings crackle to life. The ache throbbed with the gravity of it all — Kevin’s death, the trauma code, the lives of so many others irrevocably changed — and the realization that the nobility of the “it’s what we do” attitude often serves as easy cover for those crushing experiences that deserve to be recognized, not blindly endured.

I tell the emergency medicine resident that I screwed up. I should have brought the team together for a few minutes after we pronounced Kevin dead. Trauma centers have described “the pause,” a moment of silence after an unsuccessful resuscitation that honors the life that is now gone. But instead of a pause, maybe it should have been a complete stop. Such a gesture would not only honor Kevin and the other lives altered by this tragedy, but remind us all that such deaths are not normal, and we shouldn’t pretend otherwise.

Jay Baruch, M.D., is an associate professor of emergency medicine and director of the Scholarly Concentration Program in Medical Humanities and Ethics at the Warren Alpert Medical School of Brown University in Providence, R.I.

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  • Such a sad case,but also remind’s us to take a little more time to take notice of our live’s and the things that matter most and things that do not, for they may become the most important.. #NO DRINKING AND DRIVING!

  • Please, please always debrief with the staff. It’s tough enough to be in the middle of such trauma but not to discuss it afterwards leaves it hanging on the “buts, what if, maybe we could have, should haves”. There is no correct answer in such instances. I think to the positive of organ procurement and how others are blessed and graced by a the act of giving to allow others to carry on and live their lives. God leads us all on a wonderful journey, but we have to take our guidance and blessings even from a painful event… prayers to you all and thank you for what you do. Marlene Hedrick, Cardiac OR Rn.

  • Traumatic exposures in Emergncy Medicine has and continues to be an under recognized ailment. As a paramedic I have had more than my fair share of incidents that have triggered emotional responses. In the 25 plus years I have been a paramedic the resources available to help deal with these type of exposures is limited to non existent. In the system I work in we are chronically understaffed with high and increasingly higher call volumes that do not allow for decompression time.

    The provided access from the employer for assistance is a form of corporate EAP, that is ill equipped to handle the issues that Emergency Providers have. An example is when I recently had some stress issues after a particularly horrific call, I called our available EAP and was directed to a Marriage and Family Therapist. After explaining my exposure and stressors, the therapist stated “I do not have the tools to help you and don’t know where to direct you in our system. Good Luck”.

    The lack of mental support for Emergency Services needs to be addressed in the same way that physical injuries are addressed. Programs exist for physical injury prevention and management with little to no addressing of psychological effects that this type of work exposes an individual to.

    I and my fellow coworkers are lucky in the fact that we have a strong peer support system that we have created using ourselves. Even with that self created peer support we are very limited in what we can provide.

    Changes will not be made by employers to provide the necessary tools and support systems until they are made to.

  • Thanks for the article. It is a good step back from the directed energy of a trauma and the wispy dissipation of that focus when we’re all left standing around at the terminus of a stranger’s brief dance of life.
    I don’t know if the writing itself has brought you healing, but, for myself I have begun writing for just that reason, to try to stay sane. I’m an infrequent blogger now and find the sharing of stories brings people together and can promote dialogue that as you have alluded doesn’t have a natural starting point in the space of our work days.

  • After 15 years of nursing, 10 of them in critical access ERs, I now have nightmares every night – PTSD from a career I love and can’t imagine not having anymore. If I could film the night mares they would be blockbuster action/adventure thrillers. Unfortunately they make me wonder how much longer my sanity will allow me to be the type of ER nurse my patients need and deserve.

  • This was heart felt with various degree of emotions. I am a Psychiatric nurse practitioner and I believe in debriefing. Whether it is a tragic trauma an out of control psychiatric patient , allowing each member of the team to express their feelings at the end of an outcome, of any situation would often bring some closure. Debriefing should take no more than 10 minutes, and should be done at the end of the outcome. This will allow for an emotional outlet, otherwise the next case, the next patient , your spouse,or even you will experience what should have been a released emotions.

    • Absolutely correct, as the triggers are ready, as woe be: ” . . . the next case, the next patient, your spouse, or even you will experience what should have been a released emotions.”

  • Love this article and commentary. To me, making time for honoring and sharing the emotional impact of our work is essential to our own wellbeing and the care we provide. In addition to making the time, we also have to cultivate the emotional intelligence and communication skills necessary for awareness, expression, and deep listening. As a nurse specializing in teaching these skills, I’ve found Medical Improv to be an effective and fun way to promote them as well as decrease stress. This medline post explains how this process can help us talk about death and dying. http://mkt.medline.com/advancing-blog/five-ways-medical-improv-can-help-nurses-talk-about-death-and-dying/

  • Either a hard stop, if time permits-it almost always does..or a defusing at the end of shift, right after shift change.
    These attitudes should begin in medical- or nursing, or other professional schools, and continue to develop and adapt during residency programs. It’s past time to bring this from a good idea to policy and programs, borrowing from our best practices and making them part of the culture of the delivery of medical care to our colleagues, as well as our patients.

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