Fail, fail, fail, fail, succeed

When Death Becomes Routine (Part 2)

This post was written as Part 2 of a series on how ER health care providers (e.g. MD’s, RN’s, and ERT’s) process their active participation in death on a daily basis. This internal processing can take place on a conscious or subconscious level, but make no mistake: it can not be ignored. Failing to actively create an internal narrative in response to one’s experience can result in early burnout and the manifestation of negative coping strategies. (Part 1 can be found here.) This essay was an attempt to explore this process – to try to understand what does this mean to me?

I have always been fascinated by this topic, in part because it always seemed like the 800 lb. gorilla in the room that no one acknowledges. Very early on in my career as an ER nurse I became aware that taking an active part in death was starting to feel normal, and I immediately sensed that this didn’t seem like the correct response – the death of another human should never become routine. And yet it never seemed to come up as a topic of conversation.

So these two essays were my attempt to explore this subject. What follows is Part 2.

Where do you put your grief?

She came in as a notification, which in ER speak means “critical emergency.” She was only 14, and would die in the trauma room near the end of my shift. Afterward, on my way home was the only time I wept in almost nine years in the ER. It was also the only debriefing I ever took part in. She was just a kid, I remember cutting her clothes off with my trauma shears, and we modestly draped her lower body to at least attempt to preserve some shred of her dignity. A 14-year-old girl, her life ended splayed out on the trauma room stretcher like a grotesquely cruel reminder of just how quickly life can change – one minute she was a teenager with her whole life stretched out in front of her. Now she was a 14-year-old who would never make it through high school, never go to college, never get to pick a career, fall in love and get married, or have children. She was dead because she forgot to bring her asthma inhaler with her to a sleep over at a friend’s house.

Welcome to the ER – it’s not for the faint of heart.

All nurses and doctors in the emergency department are constantly engaged in a delicate balancing act. How do you care for people and not become emotionally involved, yet somehow remain human and compassionate? This isn’t something they teach you in school. If you’re lucky, you might have a professor who is experienced in real-world practice with a developed sense of humanity who will touch on this subject in an attempt to help prepare the student for what they will encounter. But nothing, except life experience, can ever truly prepare you for the death of someone whose care was your responsibility.

This seems like a good place to make a few hard-won observations. First, to state the obvious to those of us do it every day: the act of administering emergency health care, or health care of any kind, is not an exact science. Nursing and medicine are symbiotically related and inextricably entwined – they are two halves of a whole – so I am including both in this statement. For the layperson, this point is not always obvious, which is where honesty and sincere compassion go a very, very long way when dealing with loved ones after a death. As long as they understand that those administering care were competent and did everything in their power to resuscitate their loved one, and that the doctor and primary nurse looked them in the eye and expressed their empathy and sorrow at their loss – only then do they begin to understand this concept. We are humans, just like them, albeit highly trained to administer care in these extreme life and death situations. The importance of this simple act of human connection cannot be overstated.

Let’s assume that this exchange of human connection and acknowledgment of loss has taken place with the family. Often, this conversation happens in an environment of extreme expressions of emotional grief. Crying, wailing, fainting, out of control behavior – all normal and to be expected. Yet the doctor, nurses, and emergency room techs who have just worked to save this patient, sometimes for a considerable amount of time, must now either absorb or deflect this palpable sorrow over the death before moving on to their other patients, some of whom may also be actively dying.

Again, I ask the question: Where do you put your grief? Where do you carry the unspoken psychological weight of unacknowledged death? Repeat this situation over and over for a period of years, perhaps decades, and it can become an existential crisis for the practitioner. Where indeed?

Here is what I have learned: It is critical for the practitioner to forgive themselves over perceived shortcomings that may or may not have led to negative outcomes. This is easier said than done, but I believe that as long as one has applied themselves to mastering their profession as best they can, and know that they administered care to the utmost of their ability, they then must forgive themselves, learn from the experience, and move on. This is how one achieves the highest level of professional, compassionate practice. Unfortunately, the capacity to absorb grief and sorrow is part of the bargain.

So the answer to where do you put your grief is: nowhere. Instead, you must release it by first acknowledging it and then making it part of your internal narrative. It is only through this process that we can pay our respect to life, turning what might have been unacknowledged grief into an act of self-knowing. Instead of burning us out it becomes a catalyst for a greater understanding of life and acknowledging our own transitory place in it. What might have been dysfunctional if left unacknowledged, and over time grown toxic, now becomes functional and provides an opportunity for growth and a greater capacity for compassion.

In our first world culture of western medicine, we have somehow learned to treat death as a failure. It is something to be avoided at all costs, whether as a layperson or health care professional. This lack of ability to see death as a natural part of life takes a particularly hard toll on the health care professionals who have to face it on a daily basis. The western view is to simply not acknowledge it, not discuss it, and if it is discussed at all it is within the framework of failure. A personal failure on the providers part for not being able to “save” this person, a failure of the system for having no mechanism for dealing with death as an inevitable part of life, and a spiritual failure of the surrounding society for its inability to acknowledge death as a celebration of life.

For most of human history, death was a natural part of living. The death of animals and humans were woven into the very fabric of our existence, experienced up close. Today, society has become so removed from death as a witnessed, transformative experience that what once was a normal part of daily life has now become remote. We now experience death as an abstract phenomenon that has no meaning to us on a personal level. Toxic expressions of violence resulting in mass casualties have become weirdly mundane, with no real emotional understanding on a visceral level of the consequences.

It is only through our acknowledgment of death on a deeply personal level that we become more in touch with our own humanity. Fail to acknowledge and process this at your own peril.