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his right atrium. Looking back, I cannot remember how long we were in the trauma room. Things were moving so fast, and yet, I felt like we were in there for an eternity. Within seconds of losing consciousness, a breathing tube was placed, his chest was cracked open, and his heart suddenly lay in the hands of the physician who relentlessly pumped his heart manually. I do not think I have ever had so many different thoughts entering and leaving my head at once. I felt excited, yet truly saddened; calm, yet anxious; and hopeful, but truly wary of a poor outcome. I worried about how his parents would react. For some reason, I had an overwhelming urge to go find them, hug them, and tell them that they did all they could to save him. While I do not currently have children, I thought about how devastated I would be if my child suddenly died. I thought about how it would feel if someone in my family suddenly died, and I even thought about my own death. I contemplated the steps I would take if I were heading the care of this patient. Would I be able to handle the pressure? I was so impressed by how diligently and efficiently the entire team worked to resuscitate him, and I hoped that I could one day reach a similar level of competence. I will never forget the solemn expressions on everyone’s face, the sweat-soaked scrubs of the physician who was pumping the child’s heart, and the tears that rolled down one of the nurse’s cheeks during the follow-up discussion. The team’s dedication and camaraderie were truly admirable. Overall, this was a very sad but enlightening experience. While I was watching the team hard at work, I constantly wondered how amazing it would be to save a patient’s life. Leaving the ED that evening, I was overcome by the desire to learn as much medicine as possible in hopes of one day being able to effectively contribute toward that goal. doi: 10.1197/j.aem.2007.03.1352
Nizar Mukhtar Medical Student Vanderbilt University School of Medicine Nashville, TN
Commentary: Spectator Sport: Observing a Pediatric Resuscitation Three broad themes emerge from these students witnessing a child’s tragic posttraumatic death in the emergency department (ED). The first involves their perspective as spectators, the second concerns the limitations of medicine, and the third is their thoughts about the way this child died, separated from those he loved and who loved him. Over the past decades, educating medical students has become a spectator sport. Rather than participating in the resuscitative efforts, these students were asked to simply stand and watch. Their resulting narratives, stemming from clinical naivete´ and colored by the media’s depiction of medical theater, naturally emphasize this case’s medical drama. This perspective simply emphasizes the students’ position as outsiders, not yet close to assuming the mantle of clinician. Too bad, because this was an opportunity for their mentor to insert them into a
RESIDENT PORTFOLIO
career-defining clinical activity, beginning their transformation into the clinician role for which they are training. As it was, they were simply voyeurs, without the need to think clinically, with no guilt or fear, and without any motivation to act. One student remarked that, ‘‘I’m still amazed I actually belong in these situations.’’ But, in reality, she doesn’t ‘‘belong’’; she’s only permitted to be there. ‘‘I had all these thoughts while watching what was going on,’’ she wrote, with her mind taking in the drama while thinking of the boy’s life and the circumstances of his injury. In contrast, during the resuscitation, the clinicians were thinking, ‘‘What should I do next to save his life? How can I do this better or more effectively? Can we save his life?’’ The clinicians had no time for idle thoughts. Action, logic, and emotion arise from different areas of the brain. What makes these students’ experiences so different from those of the clinicians is that, having no need to act and little need for logic, they were left with emotion. At their learning stage, having these emotional responses is important, but the students must also recognize that they are a world away from being a clinician. A vast chasm in motivation and thinking separates the observer and the clinician, the spectator and the player. Yet perhaps because these students’ observations are clinically naive, infused with the shock and horror of seeing a medical tragedy, and showing little insight into the clinicians’ world, they provide a very human appreciation of the events often missed by those who have passed into the more clinically focused, some would say hardened, outlook on human misery and tragedy. Unencumbered as they were with clinical thoughts or the need to act, they had time to reflect on death and dying in the ED, thoughts that may shed light on dark places in our policies, and perhaps in our souls. They direct us toward elements of emergency medicine practice that we often ignore, consciously or unconsciously. One student had had a somewhat parallel situation when volunteering in a remote region of the Amazon rain forest. She had seen a child die without the benefits of modern medicine, but the child she witnessed with a ruptured heart was dying in a ‘‘leading university hospital in the most medically advanced country in the world. surrounded by physicians and nurses, and the newest technology, and yet he died anyway.’’ Quite forcefully, she was faced with the limitations of medicine and of physicians. As I constantly remind my students and residents, we are only physicians. It would have been kind to remind them, as well as the rest of the clinical team, of this during the debriefing. Unfortunately, these students do not seem to have been separately debriefed after witnessing this horror. Rather than simply writing their reflections of this event, as relative medical neophytes who had never before seen anyone (especially a child) quickly die in front of them, a separate, careful, and thoughtful debriefing was essential. The students saw ‘‘tears that rolled down one of the nurse’s cheeks during the follow-up discussion.’’ These tears came from an experienced health care professional, demonstrating that even experienced clinicians often need special and careful debriefing after a pediatric death, especially one where the patient came in alive and then died. Imagine how the students felt. Debriefing could also have helped the students understand how medical team members separated their
ACAD EMERG MED September 2007, Vol. 14, No. 9 www.aemj.org
emotions from applying their skills, knowledge, and optimal performance. It would have been useful to explain that the patient (and his family) did not need emotions from the health care professionals at these times; they wanted optimal medical interventions. Observing team members’ apparent lack of emotion, the students wondered ‘‘how people deal with this every day. I wonder if it will get easier, or if I want it to.’’ Something experienced ED professionals rarely reflect upon is how we separate our emotions from our need to act. There is no single or easy answer, but discussing coping methods can be career saving and, sadly, sometimes lifesaving. Some ED professionals compartmentalize, keeping their personal and professional lives distinctly separate. Others rely on support from the ED team. This, of course, requires caring colleagues and a willingness to share feelings. Rationalization works for others, for example, the belief in this case that the child had a lethal injury and nothing could have been done to save him. More destructive strategies are trying to repress the events or self-medicating with drugs or alcohol. Finally, those who cannot deal with the stress and sadness of emergency medicine practice go into other specialties or leave medicine entirely. Emergency medicine still carries the stigma from the untrained physicians who, decades ago, first staffed EDs and quickly fled to other specialties. One student wrote, ‘‘Would I be able to handle the pressure?’’ In many cases, you don’t know until you have the responsibility to act. I always advise students to ‘‘suit up’’ and participate as early as possible in real clinical encounters. My advisees often begin clinical work in the ED on their first day of medical school. My own briefing came, decades ago, when I was about to begin caring for ambulance patients with the Wheaton Rescue Squad (Maryland). I wondered how I would fare if I encountered ‘‘blood and guts’’ at a major accident. My experienced lieutenant calmly told me that everyone has strong emotions when faced with horrors. My job was to do what I could to benefit the patient. If I wanted to get sick or cry later, that was fine. But, to paraphrase Tom Hanks’ character in A League of Their Own, there’s no crying in the trauma rooms. The third point the students made was that, unlike the dying child in the Amazon basin, this child died without his loved ones at his side. How sad! In the rain forest, family and friends surrounded the dying child for comfort. Yet, aside from many pediatric wards and a relatively few EDs, family are rarely present during resuscitations in our modern hospitals. Why not? The reasons for this abound: from unfounded legal concerns to fears that relatives will interfere with, decompensate during, or simply not understand the resuscitative process. This leads to substantial resistance from many physicians and nurses to having families present.1 Not only was the family robbed of their last chance to say goodbye to their son, they also remain unaware of the efforts that went on trying to save him. While the students were impressed with the health care team’s hard work trying to save the child, all that the family and friends know is that their boy came in alive and left dead. They know nothing about the horde of professionals, dramatic procedures, and sweat that went into the resuscitative effort. The family’s reaction to the team
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leader’s announcement that the resuscitation failed was, inevitably, disbelief, anger, and hostility that the physicians didn’t do everything they could have to save their child.1 Will the team ever receive thanks for their efforts, as they often do if the family is present? It’s not likely. Ultimately, my question to the students would be: Was it useful to write your reflections about the case? Or would participation and a personal debriefing have been better? As James Thurber wrote, ‘‘It is better to know some of the questions than all of the answers.’’2 They did come up with some great questions. If only the students had gotten at least some answers in a more timely manner, I suspect that it would have been more helpful. doi: 10.1197/j.aem.2007.03.1350
Kenneth V. Iserson, MD, MBA (
[email protected]) University of Arizona Tucson, AZ
References 1. Iserson KV. Grave Words: Notifying Survivors About Sudden Unexpected Deaths. Tucson, AZ: Galen Press, Ltd.; 1999. pp 168–70. 2. Bartlett J. Bartlett’s Familiar Quotations, 14th ed. New York, NY: Little Brown; 1968. p 1033.
Commentary: Additional Reflections about ‘‘First Death’’ This portfolio differs somewhat in that it was written by two preclinical medical students who witnessed a pediatric death while observing in the emergency department (ED). Their perspective, along with Dr. Iserson’s commentary, provides several poignant lessons to the emergency medicine resident. Residents work with ED students in varying capacities, and for many this continues throughout their career. Being aware of the emotional framing of a resuscitation and death in the ED for such ‘‘voyeurs’’ is important (as opposed to the more detached, intellectual approach experienced by the care providers). Dr. Iserson’s recommendation of asking such ‘‘voyeurs’’ to ‘‘suit up’’ and become care providers is good advice, allowing an additional perspective of the experience beyond simply emotional. As such, they experience the resuscitation as a member of the team. The second point worthy of reflection by the resident is the need to, at some point, deal with the emotional components of the experience. If the care provider is so compartmentalized that the death of a child creates no emotion, he or she may well be on the pathway to ‘‘burnout.’’ When one loses this basic humanistic reaction, his or her effectiveness as a care provider surely must suffer. In our busy training EDs, we often have little or no time to ‘‘debrief,’’ instead immediately turning our attention to the living who require our care. However, developing a method to ‘‘debrief’’ the team following such a situation promotes quality care, teamwork, and emotional health for all involved. Be cognizant of the profound impact such an experience has on the novice learner and facilitate the
