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We are drowning.
“14-year-old male, gunshot wound to the chest and back, pronounced dead on arrival.”
“28-year-old female, front seat restrained passenger in motor vehicle accident, distal upper extremity fracture. The driver pronounced dead at the scene.”
I’m sitting in morning report listening to the barrage of death and tragedy again. Just 5 minutes ago, I overheard a colleague tell a patient their partner had died. I listened to the patient’s sobs through the thin curtain, her devastation without privacy. Then watched as the same colleague pivoted from breaking her heart to presenting the overnight trauma patients minutes later.
I’m a second-year emergency medicine resident, and I am exhausted. Every day, I bear witness to tragedies. I watch as patients experience the worst days of their lives. Pronouncing patients dead and hearing the cries of their loved ones. And immediately after these events, often horrible tragedies, on top of worsening emotional fatigue—my colleagues and I are expected to just get on with it. We finish our notes, call consultants, check off our to-do boxes, and see the next patient. Sometimes this is easy. We’ve learned to suppress our emotions, compartmentalize, and deal with death and loss by not dealing with it. We become callous, jaded, cynical. I’ve seen this during codes—“No way we get them back.” “Drunk driving, probably.” “Maybe at least I’ll get a chest tube out of this.” Flippant comments, just another code, just another death. We have done this before. This won’t be a problem. And maybe it won’t be, until it is. Until this not dealing with the emotional turmoil surfaces in other ways.
I feel this internal disquiet, unease, even after just a few years. I’m angry—angry at patients. Why did this patient come in during my night shift for earwax impaction? Do they really have nowhere else to go, no urgent care to call? Oh, and the next patient isn’t vaccinated against COVID-19, even after all of this time. Don’t they know about the dozens of deaths I’ve pronounced upstairs in the intensive care unit? Selfish. Inexcusable. In the next room, my patient wants to leave against medical advice. I can’t help but think, “One less hand-off to give, one less hospitalist to give report to.” I feel numb.
But really, I’m angry at myself. How can I feel this way? How can I be thinking these things? I hold empathy for patients and human connection in the highest regard. I want to understand people, to reach them where they are. So how did this happen? I feel disgusted with myself. I feel empty. I tell my parents about the patient I saw die in front of me in the emergency department. I remember the patient’s eyes—afraid. A massive gastrointestinal bleed, we did everything we could, but the patient didn’t survive. The patient’s family stood nearby watching as I inserted the endotracheal tube. I remember the patient’s glasses; I took them off and tossed them aside in the fray as I prepared to intubate; tiny drops of blood covered the lenses. Where did I put them? Did the family get the glasses back?
I feel disconnected from my nonmedical friends and family. It’s difficult to relate to them and difficult to care about other issues like world events and politics. My friends in business school joke about their bad days at work, their colleagues, their emails. Meanwhile, my bad day at work is a child dying in front of me. Hearing his mother’s screams as she falls to the ground, hands clutching the hospital bed as we declare time of death. Blood on the sheets. The alarming of the ventilator.
I am constantly on high alert. I jump at noises—the sounds of people running, raised voices. The noise of a wheelchair being pushed past me into the trauma bay, the patient slumped and unresponsive. My pager going off and saying, “CARDIAC ARREST.” These signs always accompany tragedy. They always indicate a critically ill patient, an unexpected code, intubation, death.
My colleagues and I witness so much tragedy. I tried to protect myself by not feeling but that has made me hardened and angry. I didn’t know how else to protect myself because feeling the pain all of the time was too much. But I don’t want to feel angry, dismissive, and patronizing. I see others doing the same, and I see myself in them. “Another COVID-positive patient who’s not vaccinated. I can’t even care at this point,” or “The patient just needs to toughen up.”
As health care workers, we are overworked, exhausted, suffering, and emotionally drained—and the system simply does not provide time to cope. I stand in the doorway of that child’s room, the mother still laying across the bed. I am frozen. I can’t think except to wonder where the nearest bathroom is as my eyes start to water. My phone rings. There’s another patient. I have to go. I tear myself away from the tragedy in front of me.
For many physicians, therapy is still largely seen as a weakness and psychiatric medications are still talked about in whispers. Sure, it’s true we have come a long way as a profession. Sure, we have group debriefs. Sure, we talk about difficult cases more than before. But we have so far to go. I have colleagues who budget for and pay out of pocket for therapy and antidepressants, afraid that their vulnerability will be detrimental to their future careers. Others don’t seek help at all. In reality, they are right to be skeptical. Change is needed. We need less stigma around mental health and more access to no-cost therapy through residency and beyond. We need the ability to take a few hours, maybe even a day, after a traumatic case as opposed to feeling guilty about calling in sick while a another resident has to cover. We deserve more time and space to process and heal. We can’t help our patients heal if we are breaking inside too.
I’m trying to be more present in my sadness. After a code ends and time of death is called, I stay for a bit and observe a moment of silence. I take this time to feel the pain before getting back to work as usual—honoring the patient, mourning them. On my drive home, I can still hear the heartbreaking screams of that mother echoing in my ears. I still remember the way my patient with the gastrointestinal bleeding looked at me, face pale and afraid. I see these patients over and over again and feel flashes of heartbreak. I won’t forget them. I can’t.
Corresponding Author: Diana Halloran, MD, Department of Emergency Medicine, Northwestern Memorial Hospital, 211 E Ontario St, Ste 200, Chicago, IL 60611 (email@example.com).
Conflict of Interest Disclosures: None reported.
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Very powerful and unsettling depiction, Dr. Halloran.
It looks like physicians are fighting these waves of trauma understaffed and underfunded. The training programs should provide more support, with more time away from the carnage, and more mental health support. They need to refocus attention on the staff rather than building ever more grandiose buildings and funding a few dozen VPs.
Halloran D. We Are Drowning. JAMA. 2022;327(18):1763–1764. doi:10.1001/jama.2022.6759
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