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How to Tell a Mother Her Child Is Dead

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By NAOMI ROSENBERGSEPT. 3, 2016 New York Times

 

Philadelphia — First you get your coat. I don’t care if you don’t remember where you left it, you find it. If there was a lot of blood you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother’s name and you use her child’s name. You may not adjust this part in any way.

I will show you: If it were my mother you would say, “Mrs. Rosenberg. I have terrible, terrible news. Naomi died today.” You say it out loud until you can say it clearly and loudly. How loudly? Loudly enough. If it takes you fewer than five tries you are rushing it and you will not do it right. You take your time.

After the bathroom you do nothing before you go to her. You don’t make a phone call, you do not talk to the medical student, you do not put in an order. You never make her wait. She is his mother.

When you get inside the room you will know who the mother is. Yes, I’m very sure. Shake her hand and tell her who you are. If there is time you shake everyone’s hand. Yes, you will know if there is time. You never stand. If there are no seats left, the couches have arms on them.

You will have to make a decision about whether you will ask what she already knows. If you were the one to call her and tell her that her son had been shot then you have already done part of it, but you have not done it yet. You are about to do it now. You never make her wait. She is his mother. Now you explode the world. Yes, you have to. You say something like: “Mrs. Booker. I have terrible, terrible news. Ernest died today.”

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Then you wait.

You will not stand up. You may leave yourself in the heaviness of your breath or the racing of your pulse or the sight of your shoelaces on your shoe, but you will not stand up. You are here for her. She is his mother.

If the mother has another son with her and he has punched the wall or broken the chair, do not be worried. The one that punched the wall or broke the chair will be better than the one who looks down and refuses to cry. The one who punched the wall or broke the chair will be much easier than the sister who looks up and closes her eyes as they fill.

Security is already outside the room and when they hear the first loud noise they will know to come in. No, you will not have to tell them. They know about the family room in the emergency department in summer in North Philadelphia. It is all right. They will be kind. If the chair cannot be sat in again that is all right. We have money for new chairs every summer. If he does not break your chair you stay in your chair. If he does you find a new place to sit. You are here for the mother and you have more to do.

If she asks you, you will tell her what you know. You do not lie. But do not say he was murdered or he was killed. Yes, I know that he was, but that is not what you say. You say that he died; that is the part that you saw and that you know. When she asks if he felt any pain, you must be very careful. If he did not, you assure her quickly. If he did, you do not lie. But his pain is over now. Do not ever say he was lucky that he did not feel pain. He was not lucky. She is not lucky. Don’t make that face. The depth of the stupidity of the things you will say sometimes is unimaginable.

Before you leave you break her heart one more time. “No, I’m so sorry, but you cannot see him. There are strict rules when a person dies this way and the police have to take him first. We cannot let you in. I’m so sorry.” You do not ever say “the body.” It is not a body. It is her son. You want to tell her that you know that he was hers. But she knows that and she does not need for you to tell her. Instead you tell her you will give her time and come back in case she has questions. More questions, or questions for the first time. If she has no questions you do not give her the answers to the questions she has not asked.

When you leave the room, do not yell at the medical student who has a question. When you get home, do not yell at your husband. If he left his socks on the floor again today, it is all right.

An Emergency Physician’s Lament

An Emergency Physician’s Lament

by AlChristian Cosca Villaruz

We are a group of People that has been trained to save lives

We deal in stress
We deal in raw emotion
We deal in extreme situations
We deal in intense catharsis
We deal in terse language
We deal in multi-tasking
We deal in Irony
We deal in Objective Reality

We deal with Unfiltered Humanity

We deal in inexorable Time constraints
Time?
Time is more dead myocardium
Time is more irreplaceable brain cells
Time means an undesirable outcome
Time?
TIME to
Get off your ass
And do that
ER Doc
Thing
Go Go Go

We don’t deal in sales
We dislike Drama

We feel that pit
Of Uncertainty
In our stomachs
The Risk
The Vague Nausea
When We take
Decisive Action
Based on
Very
Limited
Information

BUT

We MUST
Take Action
DO
SOMETHING
DOCTOR!

We can get something right
999 times
And be forever remembered
And vilified
For the
1 time
We get it wrong
That’s not fair?

Life is not fair

We dislike ambulance chasing attorneys
With extreme prejudice
They collect a fee whether they win or lose
When we lose
Or are wrong
Somebody dies
Or is permanently disabled

Life is not Fair

We inhabit that
No Man’s Land
That divides Life from
Death
There
We try to prevent the two
Mutually Exclusive Realities
From
Intersecting

This has changed us.

We are often
Just getting to work
When you are
Just going to bed
We have felt the isolation
And Responsibility
Of being the only Doctor
Or Nurses
Or EMTs
Awake
For many miles in
Any direction
One of us is
Always awake
Ever vigilant
In the lonely watches of
Night
We are there
WHENEVER
You need us
Nothing will touch you
While we keep up
Our

Solitary

Vigils

When we go home
The Rising Sun greets us
And yet
You still sleep

We have seen worlds unravel
And we want to cry out for Help
Then we remember
WE ARE THE HELP
We give of ourselves
To the point of exhaustion
And Illness
And indelible memories
Until there is nothing
Left to give

This has changed us

And made us Comrades forever

We don’t know quite
How to answer you
When you ask us
“How was your Day?”

Do you really want to know?

Do you want to hear of the Unraveling?
Of the Great Undoing?
Of the Intensely Personal Apocalypse
That comes with
The Loss
Of a Loved one?
Do you wish to hear
Of Devastating Diagnoses
Of breaking Bad News
Of Neglect
Of Abuse
Of Indifference
Of Ignorance
Of what happens
When someone
“Falls through the Cracks?”
(We are
The Safety Net
Of Society)
Do you wish to learn
Of Migrants
Of the Mentally Ill
Of the Forgotten
Of the Forsaken
Of the Undocumented
Of Lives built upon Lies
Lies
Upon
Lies
Of the Sordid Underbelly
Just below the Surface?

Do you really want to know
How my Day was?

Do you REALLY?

It has changed us.

We want to cry out for help
But We are the Help
Who Helps
The Helpers?
For it is True
It is those
That seem the
Strongest
Among Us
That often need
The Most Help

Will you help us?
CAN you help us?
When OUR worlds
UNR AV E L?

But in Honor
And in Learning
There is Hope
And
Hope will
Always remain
While
The Company is
True

And
In Our ER World
Light is often
Recovered from Darkness
At great cost
Through much
Effort
Empathy replaces Apathy
Enlightenment casts out Ignorance
Death is denied
Its due
And
We bear witness to
A Love so Large
That It can swallow up
All Evil
A Love
Stronger
Than Death
A Love that rekindles Hope

And Life Occurs
Sometimes
Against All Probability

Because of Our
Honor
Learning
Love
Sometimes
We accomplish
The Impossible

And That
Makes US
MIGHTY

EM Mindset

EM MINDSET – JOE LEX – THINKING LIKE AN EMERGENCY PHYSICIAN

Author: Joe Lex, MD (@JoeLex5 – Clinical Professor of Emergency Medicine, Temple University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

“Emergency Medicine is the most interesting 15 minutes of every other specialty.”

– Dan Sandberg, BEEM Conference, 2014[1]

Why are we different?  How do we differentiate ourselves from other specialties of medicine?  We work in a different environment in different hours and with different patients more than any other specialty.  Our motto is “Anyone, anything, anytime.”[2]

While other doctors dwell on the question, “What does this patient have? (i.e., “What’s the diagnosis?”), emergency physicians are constantly thinking “What does this patient need?[3]  Now?  In 5 minutes?  In two hours?”  Does this involve a different way of thinking?

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues.  Yes, we do it on a daily basis, many times during a shift.  Every time I introduce myself to a patient, I never know which direction things are going to head.  But I feel like I should give the following disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues.[4],[5] You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  After today, we will probably never see one another again.  This may turn out to be one of the worst days of your life;[6] for me it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.

I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.[7]

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG.  I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.[8]

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part this has not changed.  In addition, Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.”[9]  Remember, you don’t come to me with a diagnosis; you come to me with symptoms.

You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good.  You may have an uncommon presentation of a common disease, or a common presentation of an uncommon problem.  If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.[10]

The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.[11]

You may be disappointed that you are not being seen by a “specialist.”  Many people feel that when they have their heart attack, they should be cared for by a cardiologist.  So they think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection?  So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical.  We are the specialty trained to think like this.[12]

If you insist asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know, but it’s safe for you to go home” without giving you a diagnosis – or without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved and other doctors will anchor on that diagnosis and you may never get the right answers.[13]

Here’s some good news: we are probably both thinking of the worst-case scenario.  You get a headache and wonder “Do I have a brain tumor?”  You get some stomach pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.[14]

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.[15]

I will use my knowledge and experience to come to the right decisions for you.  But I am biased, and knowledge of bias is not enough to change my bias.[16]  For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.[17]

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).[18]  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).[19]  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.[20]

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is essential for me to do so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.[21]

What’s that?  You say you don’t have insurance?  Well that’s okay too.  The US government has mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact I can be fined a hefty amount if I don’t.  And a 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.[22]

But you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracostomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter.  I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure, and I can talk you through your bad trip.[23]

Emergency medicine really annoys a lot of the other specialists.  We are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.[24],[25]

Yes, I have seen thousands of patients, each unique, in my near-50 years of experience.  But every time I think about writing a book telling of my wondrous career, I quickly stop short and tell myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.[26]  What you construe as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings – they are so trite, so threadbare.  Nonetheless, they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”[27]

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premier creators of the 20thcentury.  He started as an imitator of older musicians, but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these disparate parts he created something unique, unlike anything ever heard before.  Coltrane not only changed music, but he altered people’s expectations of what music could be.  In the same way, emergency medicine has taken from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

When people learn I work in the Emergency Department they usually ask, “How do you do it”? or say “Wow, I bet you see a lot of crazy things”. My answer aloud: “It’s never dull”. My answer in my head: “You have no idea”.

What profession do you walk out of a room that someone has just yelled, “I’m gonna kill you bitch” and laugh? Do you preform CPR, call a time of death, then talk about your weekend plans all in the same breath? It gets worse. You don’t want to know.

Even the bad ones: a rape or child abuse. Even that has to be walked away from and on to the next stomach ache, cold/cold or even heart attack. It may, for a minute, leave a pit in your stomach the weight of bowling ball. But even then, you can usually get rid of it with a sigh so deep that it goes all the way down to your toes. Sometimes it takes two sighs.

Sometimes I give a high five to someone on my team. Not to say “congrats”, but to feel a little human touch and know I’m not alone.

If a tear even feels like it might try to work its way up from your throat, you swallow it quick. It does no one any good to let it out. The family can’t see it. Your co-workers can’t see it. We all get one turn to break down and then everyone else has to be strong. We can’t all walk around like sobbing messes. When I see another on my team tear up (dead children do it the most to us), I know this time, it can’t be my turn.

So we suck it up. We learn to turn “it” off. To well, in fact. What choice do we have? We cope. We walk into fatal car accidents with our first questions (mentally, at least) being…”were they drinking, were they high, they probably weren’t wearing their seat belts”. Something, ANYTHING, to separate us from this. Something, ANYTHING so we can sleep at night and try to convince ourselves that we are not so temporary. That our spouses and our children are not so temporary.

When we can’t find reasons, we have no choice but to swallow that lump. We come home, we hugs our kids, and we cope. By the time we wake up for our next shift, it’s almost gone.

Each time I had to do that, and I suspect I’m not alone, I lost a little something. I shut off that pathway: “sadness, remorse, fear” too many times. That now those feelings are hard to come by at all.

But I’m not alone. And it’s the people by my side that make me feel normal about this chaos that we live in. This peephole into reality, that only a few of us see. We, more than anyone understand the temporariness of it all. The unfairness of it all. That even children aren’t safe from this awful game of life that no matter what ALWAYS ends in death. What choice do we have? This our job. This is our life. Even if we quit it, it’s too late. Once you peep through that hole, you can’t pretend you haven’t seen it.

If you don’t live in our world then that last sentence is greepy, maybe…morbid? Depressing? In our world, it is fact. It is life. It is truth. We have no veil of ignorance when it comes to our own mortality. Much to the dismay of our family and friends we sometimes come off as “cold” and (I hate this one)…”insensitive”.

So we may cry a little less. But here is the upside: we also laugh a lot more. We love fully. We live without regret. We generally don’t waste time on negativity or pessimism. We understand fully “one life” and we aren’t about to waste it. We wear our seat belts and don’t drink and drive. We live smart, but never in moderation! We are the ones laughing the loudest! We don’t shelter our kids, because even children without trampolines are sometimes “temporary”. So we let them jump and we let them laugh, we just have a net! We don’t keep them home from the park because we are worried about the “Boogy man” because we know most of the time it’s “Creepy Uncle Ralph” that is doing naughty things to the babies anyway.

If I did this job alone, the isolation would be maddening. But, I’m not. My co-workers are my sanity. My family: my rock. Together we get through this life with our eyes wide open. I wouldn’t change my world for anything.

Seriously, wth is wrong with me tonight?

Don’t look at ER staff as cold, insensitive, and mean since patients and family have NO idea that they aren’t the only ones who are human.

Seriously, wth is wrong with me tonight?

When people learn I work in the Emergency Department they usually ask, “How do you do it”? or say “Wow, I bet you see a lot of crazy things”. My answer aloud: “It’s never dull”. My answer in my head: “You have no idea”.

What profession do you walk out of a room that someone has just yelled, “I’m gonna kill you bitch” and laugh? Do you preform CPR, call a time of death, then talk about your weekend plans all in the same breath? It gets worse. You don’t want to know.

Even the bad ones: a rape or child abuse. Even that has to be walked away from and on to the next stomach ache, cold/cold or even heart attack. It may, for a minute, leave a pit in your stomach the weight of bowling ball. But even then, you can usually get rid of it with a sigh so deep that it goes all the way down to your toes. Sometimes it takes two sighs.

Sometimes I give a high five to someone on my team. Not to say “congrats”, but to feel a little human touch and know I’m not alone.

If a tear even feels like it might try to work its way up from your throat, you swallow it quick. It does no one any good to let it out. The family can’t see it. Your co-workers can’t see it. We all get one turn to break down and then everyone else has to be strong. We can’t all walk around like sobbing messes. When I see another on my team tear up (dead children do it the most to us), I know this time, it can’t be my turn.

So we suck it up. We learn to turn “it” off. To well, in fact. What choice do we have? We cope. We walk into fatal car accidents with our first questions (mentally, at least) being…”were they drinking, were they high, they probably weren’t wearing their seat belts”. Something, ANYTHING, to separate us from this. Something, ANYTHING so we can sleep at night and try to convince ourselves that we are not so temporary. That our spouses and our children are not so temporary.

When we can’t find reasons, we have no choice but to swallow that lump. We come home, we hugs our kids, and we cope. By the time we wake up for our next shift, it’s almost gone….almost.

Each time I had to do that, and I suspect I’m not alone, I lost a little something. I shut off that pathway: “sadness, remorse, fear” too many times. That now those feelings are hard to come by at all.

But I’m not alone. And it’s the people by my side that make me feel normal about this chaos that we live in. This peephole into reality, that only a few of us see. We, more than anyone understand the temporariness of it all. The unfairness of it all. That even children aren’t safe from this awful game of life that no matter what ALWAYS ends in death. What choice do we have? This our job. This is our life. Even if we quit it, it’s too late. Once you peep through that hole, you can’t pretend you haven’t seen it.

If you don’t live in our world then that last sentence is creepy, maybe…morbid? Depressing? In our world, it is fact. It is life. It is truth. We have no veil of ignorance when it comes to our own mortality. Much to the dismay of our family and friends we sometimes come off as “cold” and (I hate this one)…”insensitive”.

So we may cry a little less. But here is the upside: we also laugh a lot more. We love fully. We live without regret. We generally don’t waste time on negativity or pessimism. We understand fully “one life” and we aren’t about to waste it. We wear our seat belts and don’t drink and drive. We live smart, but never in moderation! We are the ones laughing the loudest! We don’t shelter our kids, because even children without trampolines are sometimes “temporary”. So we let them jump and we let them laugh, we just have a net! We don’t keep them home from the park because we are worried about the “Boogy man” because we know most of the time it’s “Creepy Uncle Ralph” that is doing naughty things to the babies anyway.

If I did this job alone, the isolation would be maddening. But, I’m not. My co-workers are my sanity. My family: my rock. Together we get through this life with our eyes wide open. I wouldn’t change my world for anything.

~author unknown