Trauma night call is a bear; something about working overnight just makes it tough. The hours aren’t any longer than the comparable daytime shifts, but the combination of a skeleton crew and the uncertainty of what may come in on any given night at a Level I trauma center conjures a bit of anxiety before the start of every shift. What kind of injuries will I treat? How will I be challenged tonight? Will I have to deliver bad news? Sometimes the anxiety feels unwarranted as the night goes along, unusually quiet, and you are given a few sacred hours of sleep or much-needed time to study for the American Board of Surgery In-Training Exam. Other nights, however, you feel the angst and anticipation build because you know something terrible is coming.
It was a Tuesday. We were in the middle of surgical intensive care unit (ICU) sign-out, poring over someone’s pressor requirements and making our procedural to-do list. As the night chief, I had the “privilege” of being the most senior person in the hospital overnight. I fielded questions from the floor intern, helped guide the second- year in the ICU, and ran the trauma cases with the help of the rest of the night crew.
The pager went off in the middle of sign-out, as it sometimes does, and I let out a sigh of resignation as I thought, “Probably another fall from standing.” However, the page was a Level I trauma, gunshot wound to the head, status posttraumatic arrest. I quickly headed to the trauma bay, my brain racing through algorithms learned in various life-support classes. When I arrived, cardiopulmonary resuscitation (CPR) was in progress on a young woman as the emergency medical services team handed off the patient to the emergency department staff. I immediately inquired about the airway, intravenous access, where we were in the timing of the resuscitation, and if anyone knew what had happened to the patient.
It was all a blur as we continued the resuscitation effort. After several minutes of CPR without gaining a pulse, fixed and dilated pupils, and recognition of a nonsurvivable, self-inflicted head injury, I called the time of death. As a fourth-year surgical resident, it wasn’t the first time I had pronounced a patient, and I knew that, unfortunately, it would not be my last. Death had become routine—an unfortunate result of physiologic failure. The discomfort associated with the loss of life had become fleeting over time, my mind shifting almost immediately to the required postmortem tasks and documentation.
A shocking realization
Per protocol, I asked the nurse if the patient had any identifying information so that we could contact her family. She handed me a paper, and I immediately lost my breath as I realized that I recognized the name. The patient was someone that I knew well and considered a friend. She was an avid traveler, passionate about her career, and loved her family, friends, and community. When I first met her, her smile and silly disposition left a lasting impression. Could this really be her in my trauma bay? I had been so focused on trying to save her life that I had not even recognized her. I found myself overwhelmed with emotion. I felt sad, confused, and helpless. I had more questions than answers, but the fact remained that she was gone.
I cried uncontrollably in the trauma bay over the loss of my patient and my friend. When I was able to compose myself, I looked around to see nurses who knew me well also tearing up with looks of sympathy and mild disbelief at my overt display of emotion. In that moment, I felt exposed and uncomfortably vulnerable. I did not make a habit of crying in public and certainly not at work. I struggled to reconcile my responsibility as a physician with my grief. I told myself to “get it together”—be professional. I’m generally very pleasant but also very focused and direct in the trauma bay—in much the way I had been just moments earlier—to tame the chaos that often accompanies caring for an acutely, gravely injured patient.
In disbelief, I approached her and performed the death exam with silent tears streaming down my face. I spoke softly to her, stating how I wished it didn’t have to end this way. I said a prayer, and I said goodbye. Then the switch flipped. I gathered myself and prepared to be a physician again. I prepared myself to give the news to her grieving family and best friend, who I knew were waiting for an update. I tucked my tears away because these next few moments were not about me but about my patient and her loved ones. After breaking the news to her family with my attending, I walked her best friend into the trauma bay to see her. I watched her grieve and stood by for support, making a conscious effort to stifle my own emotions.
Not long after, the trauma pager went off and continued to go off again and again. There were seven more trauma activations that night. I didn’t have time to grieve because I had to care for my other patients. I had to lead my team. I left the following morning feeling defeated and deflated. Despite the encouraging words and praise from others about how I had handled the situation and was able to move forward to care for the rest of our patients that night, I was in a haze. I had always dreaded the possibility of someone I knew coming through my trauma bay. I wondered how I would handle it. Unfortunately, now I know.
This experience will stay with me forever. I look at every trauma patient’s face, remembering that they are more than their injuries, more than the circumstances that got them to this point, and more than the interventions we perform to prolong their lives. They are someone’s child, sibling, parent, and friend.
Preparing the next generation of trauma surgeons
This is the stuff they don’t teach you in medical school—how to be clinically excellent and resilient without becoming jaded or numb to what we see on a daily basis. How do we make room for our grief without allowing it to consume us? We learn about breaking bad news, but how do we soothe ourselves when we feel we’ve failed our patients? Grief is an occupational hazard for me. I grieve my patients when I am unable to save their lives, and I mourn them again when I have to share the news with their families, realizing that this is likely the worst day of their lives. Are we equipped or trained to cope? Are these the same coping skills that could have prevented my friend from taking her own life? I don’t know, but I’d like to think so.
Perhaps with the inclusion of death and dying Objective Structured Clinical Examinations, simulation, and directed/actionable coping strategies, we can better equip the next generation of physicians. Attending physicians and residents must be intentional about including medical students in these difficult conversations with families and with ourselves, rather than shielding them from the harsh realities that can accompany the art of medicine.
This is beautifully written. It says so much about how the stressful times in medicine can change us. Deepest condolences.
I hope writing about and then sharing the experience brought some measure of healing.
Hi Dr Cobb, Thank you for sharing your experience and thoughts. I’m sure it will help others.
A wonderful soliloquy that came both from the heart and mind. Sincere sympathy on the tragic loss of your friend. I agree that training does not expose you to how to handle death and dying. In 1969 I passed the ECFMG exam in India. Before coming to America I read the book “Intern by Doctor X” and all of Frank G. Slaughter’s books about his residency at Bellevue in New York. He converted his scientific thoughts into prose that was easy to understand.
I do agree that we need to include death and Dying into the curriculum as well that attendings , resident and medical students be involved when the outcome of a case has been unfortunate . I believe that Dr Gahtan has set up a committee with this in mind.