A Picture’s Worth

Touching fists (the “high-fives” of the 2000s), punch lines to jokes, recapping last night’s sporting events, and catching up with life’s goings-ons. It seems more like the dialogue heard around the water cooler or at a place of leisure rather than a place of life and death. Welcome to the emergency department (ED). As emergency medicine specialists, our ability to separate ourselves psychologically from the pain, fear, and stress that lace nearly every patient contact is often described as a survival technique. This technique is important as we endeavor to help the many patients who present to the ED on, literally, the worst day of their life. This defense mechanism is also easily and deceptively rationalized as “a shield” that protects us from the all-too-common rude, thankless, or downright hostile behavior of some patients. In other words, “Don’t let them get to you.” But at what cost? Could this protective “thick-skin” that is seemingly so desirable for maintaining our psychological well-being filter too much? Another day at the office. It was a weekday morning in the area managing the highest acuity patients at our county-model Level 1 urban trauma center. In such an environment the patient demographic spectrum is wide. It is common to care for a patient of a different race, religion, and or socioeconomic background, which adds to the challenge of personally relating to every patient. Like any typical ED surge, in an instant my slow-paced morning suddenly morphed into a Grand Central Station–like afternoon. The simultaneous arrival of multiple critical patients heralded a familiar chaos. My middle patient of three consecutive resuscitations was Mr. D, a 62-year-old African American male who presented with abdominal pain. Upon entering the shock room, I saw a pleasant Redd Foxx look-a-like with the jolly smile of Saint Nick. As “emergentologists,” the first branch on our decision-making tree is “sick or not sick?” and from the doorway this gentleman did not look sick. So why was he in the shock room? Just seconds into the data collection I felt a spike in my organic gestalt meter to a level breaching the dentate line. The criticality of the situation became clear after laying hands on an abdomen that was clearly tender out of proportion to the exam. Along with a blood pressure low enough to be mistaken for the score of a high school basketball game, I responded “Fluids, antibiotics, stat CT—abdomen/pelvis, and get me a surgeon on the phone!” Shortly after expediting the patient to radiology, I received a call from the reading room that confirmed my fear. The voice on the other end of the phone simply said “This is the worst case of mesenteric ischemia I have ever seen, he’s got pneumatosis everywhere and a ton of portal venous gas … these guys die in hours, not days.” I knew this patient was gravely ill, but he certainly did not look like he was going to be dead in a few hours. “What does the radiologist know?” I thought to myself. He cannot see the patient; my surgery colleagues will surely be able to help this patient. Unfortunately, the report from my surgical counterparts was equally as grim “He’s had symptoms for greater than 72 hours, he has peritoneal signs and catastrophic CT-scan findings, we have nothing to offer this patient … he’s going to die . . . and soon!” A surreal moment came upon my return to the bedside. My therapies were working. Mr. D’s blood pressure was now above 100 mm Hg, along with other normal vital signs. His pain was almost undetectable thanks to a dose of pain medications, and he was alert and joking with his family. “This looks like a guy that is too healthy to be in the ED, not like someone who is on death’s doorstep,” I whispered to myself. Reality sank in, for me, when I entered the room to hear the surgery team deliver the mortal prognosis. The surgeon explained to the patient and his 80-something-year-old mother that his disease was “too extensive” and that there “are no surgeries or treatments that would fix the problem” or “help him to live longer.” The chief resident, to her credit, sat down and held Mr. D’s hand when she said that he would not “survive this.” The next thing that happened baffled me. After receiving the catastrophic news of her son’s inevitable death the patient’s mother quipped, “I think this is because of all that alcohol, now you REALLY have to stop drinking.” Mr. D immediately dismissed the implication acting like he had heard his mother’s counseling before. He inquired to the chief surgical resident, “Well, if there’s nothing to do, I guess I can go home right?” Mistakenly thinking that Mr. D was requesting hospice, the surgery team agreed that this was an “acceptable decision” and they would “make arrangements for pain control” and for him to be comfortable so he could “be at home at the end.” It became clear to me after 10 minutes filled with delicate speak and death euphemisms that neither the patient nor his mother understood the gravity and impending doom. Right at that moment another urban youth made the near fatal mistake of combining “standing on the corner” and “minding his own business,” which inevitably results in penetrating trauma. The surgery/trauma team leapt up and followed in the wake as this nascent stabbing raced by the shock room occupied by Mr. D. As the surgeon’s voices faded down the hall, they reassured Mr. D and his mother that they would discuss his care further and figure out the “best plan.” Although it was 90 minutes after my shift, something kept me from walking down the familiar path to the freedom of the ED’s exit. After hearing my surgical counterpart’s attempt to deliver terrible news tactfully, only to be prematurely pulled away, I realized that Mr. D and his family still had no idea of how little time he had left. I entered the room to try my hand at the sympathetic delivery of bad news and realized I was retracing many of the same missteps as the surgical team. I thought of how many times I had done scripted bad news notification, such as a diagnosis of cancer, or informing a room full of family members that a loved one had just died. However, this situation was so drastically different. Mr. D’s death had not occurred yet, but was certain and near. After the patient’s mother reiterated her earlier mandate to stop drinking, it became clear that neither Mr. D nor his family realized that his precious few hours left on this planet were slipping away. The remainder of his life could be literally half over by the time the surgery team finishes with their trauma patient and returns to make palliative care arrangements. Like an episode of “60 Minutes” I had a mental stopwatch ticking away in my head and I finally realized I could not leave. These people should not waste one more minute. They need to fully understand right now. And that’s when I let go. I told Mr. D that he was dying and he was dying right now as we spoke. I held his hand and apologized for such horrible news, but I said that he has an opportunity that many people do not get and that is to say “goodbye.” I told him that if there was anything that he ever wanted to say to someone … now is the time to do it. At that moment Mr. D’s daughter entered the room and quickly acclimatized to the circumstances. She simply asked “How long?” I said, “I don’t know for sure.”“How long?”“It’s hard to …”“How long?! Please!”“Most people with this severity of disease don’t live beyond a day.” She teared up, but miraculously said thank you. She kissed her father, took out her cell phone, and stepped out of the shock room. Mr. D’s mother, true to her nurturing role inquired, “Is he allowed to eat?” I told them that he could (and should) eat anything he wants! Mr. D, who looked so at peace that I still was not sure that he accepted the truth, made a joke that made his family break up their tears with a short lived chuckle and smile. The transition from ambivalence to opportunity was palpable. Slowly, I could see mom and daughter maximizing the little time they had left. I was so moved by their circumstance, I wanted to capture it. Just like encountering a bizarre trauma or rare pathology, I thought, “why is this any different?” Slowly reaching for my camera I hesitated, uncertain how it would be received, but then I said to myself just ask. “Mr. D would you guys like me to take your picture?” Mr. D said “Yeah, that would be great, maybe you could send it to my daughter since it’s probably gonna be my last photo.” He said it so matter-of-factly that it was like he had accepted his fate a long time ago. After taking their picture, I told him that I would pray for him and his family (another thing I probably do not say or do enough), and I departed to leave him some time with his family. Six hours later he died. In the ensuing days, I could not stop marveling at the overall positive feeling I had about this patient encounter. I truly felt lucky to have participated in his care. How weird to feel this way, because I did not fix him, and he died. Naturally, we have all felt little victories in the clinical setting, but it usually follows more tangible success. Completing a difficult procedure, making a “zebra” diagnosis, or stopping pain in its tracks, are the more obvious wins. The truth is, the success in this case was at a level that we usually do not measure, a level that we fail to measure in part due to our own protective mechanisms. Looking back, I could have easily just left after my shift, and the patient’s organic outcome would have been the same. However, once I saw the “countdown” in my head, and I started envisioning the opportunity at hand, it made me think of my own life. I laughed at what extreme measures I personally take to get a latté before the end of a Starbucks’ business day. Comparatively, what would I want to do before the end of the day if it were to be my last? This serendipitous opportunity to “walk in my patient’s shoes” made that extra investment in time an obvious choice. There is a lot of evidence that we as a profession have substantial potential for improving a patient’s (and family’s) end-of-life experience.1–3 Professionally there needs to be a balance, of course. Undoubtedly if we were to completely forgo the so-called “thick skin,” we would be at risk for mental fatigue, burnout, and ultimately an early end to what should be a tremendously rewarding career. However, if this thick skin is so impenetrable that it prevents us from honestly empathizing, particularly in pivotal points in life and in death, then we have lost something vitally important to our patients … and ourselves. The art of properly balancing emotional investment with the requisite psychological shielding is a skill that must be developed over time. As such, the importance of this skill cannot be overstated and we should actively seek out opportunities during patient encounters to refine its practice. If not, our “balanced compassion,” just like any other neglected skill set, will succumb to atrophy. Finally, by consciously embracing the need for genuine empathy with the patient’s (and family’s) circumstances, we will be taking a simple but important step toward ensuring a successful experience for the patient and a fulfilling encounter for us, even if it is a healing of a different kind. Thanks, Mr. D.