DEATH!

Death, it happens. It happens everyday in emergency rooms all over the world. The tragedy is not the death itself, even if it was unexpected. The tragedy is having to inform someone their father, their spouse, or, the absolute worst, their child has just passed away. The loudest scream I ever heard was about four weeks into my internship. I was walking down the hall when I heard a deafening shrill fill the ED, and I knew instantly someone had just been given the news.

I thought to myself that whenever my times comes to give the news I would do it with such compassion and support that no one would feel the need to scream. I mean, I did take a two week course in medical school called death and dying. I felt adequately trained on the proper technique and the words to use. The problem was when the time came, I wasn't ready. It was 2:45 in the morning and I was on call on the trauma service. We had been pummeled all night, and even at that time in the morning things were still going strong. I was walking alongside a patient being wheeled to the CT scanner when I heard the trauma page ring out again overhead.

"Shit!"

I left the patient to return to the trauma bay. "Three car MVC, two trauma reds are five minutes out," I heard. At this point in the night I was numb to the whole thing. I was already staring at the clock counting down the hours until I could leave, go home, and fall asleep next to my wife. The two traumas arrived, and after just one look I knew they would be headed to the ICU. The problem was in the entire ICU we had only one bed remaining. 2 critical ill patients + 1 ICU bed = not a good situation.

Fortunately (depending on how you look at it), we received a call from the ICU saying one the patients that arrived earlier in the night had just expired. The attending looked at me and said, "Go tell that family of the patient in room 312 the situation. Do it quick so they can get the room ready for one of these guys.".

"The situation," I mumbled under my tongue. The situation was I have to go tell a family I don't know that their family member, a person I never met because he belonged to the other intern that was off handling other business, has just died. I got up to the room just in time to see the house staff putting the infamous white sheet over the body.

"Where's the family?" I asked the nurse.

"I'll send for them."

I looked in the patient's chart to see what caused his injuries. It turns out he was assaulted during a robbery at his residence and suffered massive head injuries. I didn't feel like reading any more, too depressing. The family approached, already shaken up from the events of the night. I looked at them, complete strangers, introduced myself and said, "in spite of the entire medical staff's efforts tonight, Mr. Johnson did not survive the injuries he sus... "

Screams.

I wasn't even able to finish the sentence. Other family members starting asking questions to which I did not know the answers, but as the only physician around I felt obligated to provide them with the most nebulous responses possible. It was terrible and at the end of the shift I think I felt just as bad as that family.

Now I'm not sure there is a good way to inform a family member about the death of a loved one. I haven't had to the give "the news" to anyone else since that time. I'm beginning to think there is no right way to inform someone about a death, and that it might just be easier to get used to the screams.

The Chaos

I struggled today. As an intern that's not uncommon for me (or anyone I imagine), but today was different. There was nothing special about the day, a random wednesday on the outside but absolute chaos on the inside. Every patient room was full (some with whole families being seen), the waiting area was standing room only and there were even patients being seen in the hallways.

I remember getting oriented and listening to my program director tell the intern class that we really aren't expected to see more than one patient an hour. That's all well and good until a day like today comes along and your looking around seeing everyone from the ANAs to the attendings trying to maintain some sense of sanity in the department. I don't know if it is the competitive spirit in me or if I feel the same urge to maintain a steady flow in the department the upper levels have, but inevitably I realize I am carrying way to many patients for not only my educational benefit but, more importantly, the well-being of the patient. In this I case I've noticed I start treating the patient's chief complaint rather than being a competent emergency physician. For example, I will enter a new patient's room already overloaded with patients and say, "Hi there, I'm one of the ED residents. What's the problem today?"

"My stomach hurts, doc!"

Abdominal complaints are classic in the ED, and I especially like them because I feel a good ED physician that takes a solid history and performs a thorough physical exam will, more times than not, be able to to discern the cause of the pain: whether it is a hot appendix, a lower lobe pneumonia, a biliary process or any of the other seemingly million causes of abdominal pain The problem with days like today is that when the person is further explaining what has been going on, I'm half paying attention and half thinking about the other labs and x-rays that I have to review, and by the time I leave the room I realize the only thing I truly remember is that my new patient has belly pains. Now I could go back in and repeat the questions, but then the patient will think I'm an idiot and lose all confidence (if he had any) in me in the first place. The other option is to go back to my computer an order all the labs possible that would like determine the cause of this guys abdominal pain: CBC, basic, hepatic, lipase, amylase, urinalysis, acute abdominal series, CT, EKG, cardiac enzymes, lactic acid, the list goes on...

The good thing about this technique is if all the labs come back negative I can feel pretty good telling the patient there is nothing emergent going on and he can be sent home to follow up with his regular doctor. After all, I am an emergency physician right?

There are so many things wrong with that scenario it is difficult to know where the critiquing should begin. FIrst and foremost this is terrible patient care, and secondly I gain nothing of educational value from practicing medicine that way. I don't mean to sound self-seeking, but that is the purpose of resident, right? I guess I'll maintain hope that improved efficiency comes with time....