14 May 2006

Each word a hammer

Every ER has a "Quiet Room." Small, drab, windowless little rooms, with a couch and a couple of chairs, a phone and some tissues, all alike. Nothing good ever happens there.

I've walked into the quiet room hundreds of times. Eyes look up to meet me, full of apprehension and dread. Nobody is ever happy to see me. They are afraid of me, I think. They want very much to talk to me, but they are deathly afraid of what I will say.

"My name is Dr. Y. Are you David's wife?"

"Are you her father?"

"Is John your brother?"

"Are you Anne's husband?"

It's a weird conversation. I begin with pleasantries and very concrete small talk. They play along. Always. The stupid little social niceties frame the conversation and allow it to develop in a bizarre but comprehensible manner.

"Did you know your dad had heart problems?"

"You know the accident was pretty serious, right?"

"Was she awake when you saw her last?"

Start with a question. Either rhetorical or very concrete. Sometimes it prompts a long story, but usually the answers are pretty short and direct. But the question sets the stage. Sometimes a subtle shift in tense can presage what's coming. Deep breath.

"I wish I had good news for you."

"I think you know that he was pretty sick."

"Her breathing was pretty bad when she got here."

"You know the paramedics were doing CPR."

Then let it fly.

"I'm sorry to tell you that he died."

Each word a hammer.

"I'm sorry to tell you that she died."

With each hammer blow their faces crumple like so much tin.

"We were not able to restart his heart, and he died."

Each word a hammer.

"The paramedics did everything they could, but she died."

Weeping and wailing. Rage. Questions. Disbelief. Shouting. Quiet acceptance. Silent tears. It's never quite the same, after. I can talk a bit more, but it doesn't matter. They don't hear or remember anything I say from that point on. Perhaps a polite lie that the deceased did not suffer. Who knows? True or not, it seems to be good to hear. Offer more information. Ask some more questions, maybe. Then an awkward departure. That's tough. What do you say to end that particular conversation? "I've got paperwork to do"? "I've got to go take care of the living"? You show up, introduce yourself, devastate a total stranger with eight words, and leave. They tell me I'm pretty good at it. An artist with the hammer. I guess that's good, though a dubious distinction. Lord knows I've had enough practice.

So I promise to come back, I put my hammer back in my pocket, leave them amidst the wreckage of their lives, and move on.


  1. Not that any amount of training could prepare you to perform this awful duty, but what type of training do they give vous in terms of how to deliver the terrible news and deal with your own emotional reactions to the "job".

    It may be "dubious", but if you can pull off being respectful, professional, and caring in such an awful circumstance, then that is something to hang your hat on.

  2. Like so many other things, you learn by doing -- and at a trauma center, you get to do this again and again. I got some guidance and examples -- both good and bad -- from senior attendings at my training program. Mostly -- make sure you use the "D" word, avoid euphemisms, be direct and clear, don't take blame, do express regret and sympathy, use neutral language (i.e. "his heart did not respond" rather than "we couldn't restart his heart"). Some docs are huggers and touchers; I'm not. A lot of it is personal style.

    And yeah, I am glad I am good at it. But usually I can take pleasure in being good at something. This is not fun, but I guess I am glad for the ability.

  3. Every word a hammer. I'm sure. It sounds like you do a very good job at it, but I don't envy you.

    Thanks for this post, for sharing this difficult part of your working life, for showing us a piece of your heart.

  4. I have had to encounter medical personnel in many serious situations, more than I ever thought I would by my mid 30s....and while I have thankfully never had to receive news of a death, those doctors that could demonstrate the kind of clarity and compassion you describe allowed me to deal more directly with the news I was receiving rather than the way it was delivered, or some trivial info or misinformation. After many struggles with my daughter and medical professionals, a doctor said to me last month "thank you for trusting me." I had never heard those words before and I could see that he meant it. Doctors like him, and I am sure, like you, make very difficult things not less diffcult, but more honest.

  5. Thanks for your comments. There are good days in the ER and not so good days. It reminds me of when I was an intern and very gung-ho for the acute trauma and excitement of emergency medicine. One of the more senior residents said to me "Never forget that your best day is always somebody else's worst day." True dat.

    It helps to vent a bit.

    Since the other night, no fewer than three people (a chaplain and two nurses) came to me and said how much they appreciated how well I had handled the difficult situation the other night (details omitted, but it involved seventeen-year-olds and automobiles). As awful as it was to deal with, it's nice to be told that how I handled it was perceived to make a difference.

  6. Very good. You know having friends who are doctors (and I seem to have a lot) is an interesting lesson. When we were all in college together, it kind of gave me the creeps that you people I had seen being... well, less than responsible, were going to be the last defense for other people's lives so directly and so often.

    As I've grown though, I've begun to recognize that we're all just humans, making all the mistakes that implies, and given that fact, you guys are in those class of people who are best suited for the job. Really, I think the world is lucky you all have chosen the jobs you have. And if are reading this and you know me well enough to be in my actual inner circle of close friends, then this includes you too.

  7. Thanks, Matt.

    The Wife still has some cognitive dissonance every time I manage to screw up the diswasher or get baby poop on the wall from a diaper-change gone horribly awry. "They let you take care of people?" And I can see why someone who is a six-time winner of the Dumb Guy [tm] award might not seem to be the best candidate for a trauma doc.

    But one of the nurses who I talked to yesterday, a cynical crusty old nurse if ever there was one, said, "95% of what we do is bullshit -- moving meat and pushing paper. It's the stuff like this that is important."

    And by the way, this RN is the source of the title of this blog. I should credit her publicly, but I won't.

  8. Oh, don't think I don't have that same reaction all the time. It's just that sometimes I go lucid for short periods.

  9. Powerful! Eloquent. I couldn't have described the situation any better.

  10. Praise from Caesar indeed.


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