H Death and coats of mail ^ in the emergency department

Keith Edwards

Keith Edwards Emergency Registrar Liverpool Hospital

Address for correspondence: Dr Keith Edwards Emergency Department Liverpool Hospital Liverpool NSW

I recently attended the cremation of the 19 year-old daughter of good family friends. Although 1 had not seen Sarah for many years, I had followed her progress through adolescence and early university days via reports from family members. 1 remember her as a vibrant, capable and sensitive young girl, always very popular and the apple of her extended family's eye. She was killed in a car accident on one of those long, monotonous country roads early one Sunday morning. She and five friends were returning home from a country party when their utility ran off the road and overturned. Appar­ently Sarah was killed instantly whilst two of the others were seriously injured and were transported to a regional country hospital. Standing in the packed chapel at the crematorium 1 was reminded that it was just a year since I had attended the funeral of a medi­cal colleague who had committed suicide. I knew the colleague less well than I knew Sarah, but I can remember fighting back the tears as his family read out homilies to him. At Sarah's cremation 1 could not fight back the tears. It was a tragic experience but at the same time a salutary one. In emergency medicine we deal with death on a regular basis. It has been a constant concern to me that by the very nature of the work we

become hardened to death and crisis. I was glad for my tears at Sarah's cremation. A death in the emergency department makes us question our clinical judgement and skills in an attempt to discover what we might have done better. I wonder, however, if we devote sufficient time to really comprehend the impact of the death on the patient's family. It is not until a death affects you or someone close to you that the true tragedy becomes apparent. It is a bit like a news report of a disaster overseas where the death of one Australian among hundreds of other non Australians personalises the tragedy for us, making it seem all the more shocking. It may be argued that as emergency physicians we need to develop a coat of mail for our emotions to survive in the busy and sometimes tragic surroundings of an emergency department. If we allowed ourselves to be affected by each personal crisis or empathised too much with our patients, we would soon find ourselves emotionally fatigued and unable to respond to further demands,

While there is some truth in this, where do we draw the line?

Some might argue that we do not have the time nor the proper training to act as counsellors or become involved in people's personal prob­lems in depth. In all the emergency departments in which 1 have w^orked, medical staff relied on a social worker who is called to deal with the family that has just lost a loved one.

I always try to spend time with the relatives of a patient who has just died in the department, but 1 am the first to admit I have had no training in this sort of counselling. My experience in this aspect of our work has been from being "thrown in the deep end" as a junior resident or by asking advice from the social workers. 1 think it is true to say that it is never easy to talk to a newly bereaved person (1 certainly found it hard

40 Emergency Medicine 19% • Vol 8

Death and coat< of mail in the emergency department

to know what to say to Sarah's family), but it is something which we constantly have to deal with in our working lives.

We need to be better trained in this important skill, and also remove some of that emoHonal mail from other aspects of our work. We some­times lose sight of the fact that we are often dealing with people in crisis in an unfamiliar and frightening environment. Emergency departments are our home and what seems routine to us is totally foreign to many of our patients.

Take, for example, the distraught wife of a motor vehicle accident victim who wants to come in and see her husband, asking constantly if he is going to be all right. How many times has this person been dismissed with a simple, "Yes, he's going to be fine. Now you'll just have to wait outside while we examine him and do some tests. You can come in and see him as soon as we have finished". By the time we have finished, it is often an hour or two later For the patient's wife, that has been an hour or two of

sitting in the waiting room, not knowing what on earth is going on, yet fearing the worst.

What about the situation of an acute resusci-tahon? It goes without saying that the relatives should be outside in the waiting roc)m.

Or does it? The Foote Memorial Hospital in Michigan

USA has had a policy in place for many years that allows relatives into the resuscitation room during a resuscitation. Perhaps their clinicians took a step back from their emotional coat of mail and questioned whether a policy of exclu­sion of relatives from the resuscitation room was the most humane thing to do.

1 sometimes wonder whether the situations we deal with in emergency medicine give us a skewed view of the world and its problems, and that this has the potential to harden us to human tragedy and frailty.

Maybe if we sometimes took off that coat of mail we might be better able to put ourselves into our patient's shoes.

Emergency Medicine 1996 • Vol 8 41