How to approach your first traumatic death in the ED

Danielle Andrews, MSIII - Loyola University Chicago Stritch School of Medicine

EMRA MSC Great Plains Regional Representative, 2021-2022

Let's face it. Emergency medicine physicians are the experts at handling emergent medical crises, so traumatic events will inevitably occur, and sometimes, someone dies. And as people who willingly choose to handle those situations in their careers, there is an expectation that EM physicians must be almost immune to the impact this can have on a person's psyche and emotionally detach themselves to preserve their ability to continue serving patients. Personally, this has been a source of a lot of angst lately because I consider myself an empath and can easily absorb the emotions of others when I see someone suffering. To add to my worries, I also have yet to experience death with any of my patients and am dreading the thought of how I'll handle it. Especially while being evaluated for SLOEs, I frequently wonder how I should respond to the situation that won't raise a red flag about whether I can handle the challenges of this specialty. While I know that not every death will cause significant turmoil, I'm aware that at some point, at least one will hit a little different, force me to pause, and might be a little harder to shake off. If it happens during my EM rotations, how will my natural reaction be perceived if I struggled to cope with the loss? How fast should I move forward so I can continue seeing subsequent patients during my shift? What, if any, resources are present to help me get through that experience?

These are some of the many questions that run through my head as I start my first EM rotation. Much to my relief, I realized I wasn't alone and was widely validated with my concerns. After asking multiple residents to get their perspective on how they handled their first traumatic death in the ED, I compiled a list of recommendations for students who may encounter this during their rotation.

1. Pause, breathe. By the nature of the ED, the events leading to the death likely are a blur as the patient is crashing. Your brain might still be running around a million miles a minute trying to process everything, and your adrenaline might be understandably sky-high. Students tend to feel shocked or in disbelief at what just happened. If you do, that's OK and a natural response to a traumatic situation. Before you do anything else, pause, take a few deep breaths to collect your thoughts.

2.   Remember the patient. Whether the patient's death severely impacted you or not, taking a moment to acknowledge what occurred and giving a moment of silence to honor the patient's life creates a space to process and give yourself room to determine how you feel. Many programs have this built into the sequence of events where an attending or resident leads a moment of silence for the entire team. If this isn't something that automatically happens, giving yourself that moment to honor the patient can also be helpful to keep you grounded and maintain empathy for the lives impacted by the loss to prevent complete detachment or disregarding the situation.

3.   If you need additional space, take it. The most consistent advice I received is to not be afraid to take additional time if you need it. This isn't considered a sign of weakness; it's an acknowledgment that you are human and are experiencing a difficult situation that most doctors have dealt with at one point or another. Taking a slow lap around the ED to clear your head or giving yourself a few minutes in the bathroom can be easy and subtle ways to create some separation from the scene and give yourself a mental break. Especially as a student, your attending will understand that death in this setting is a new and often challenging encounter. Of course, timing is vital to consider if more steps are required for the patient who died. For example, if the patient's family needs to be updated, that's something not to miss or step away from. Sometimes this part can be even more challenging to handle than the death itself, but it is a crucial part of patient care and an expected responsibility of physicians. Once all is said and done, if you need the extra time to regroup, take it before seeing the next patient, and communicate with your attending. Your attending may have already checked in with you to gauge how you're doing. But if they don't, it's likely because they have experienced this situation numerous times and may not actively think about how it affected you as a student. Communicating with the attending to ask for a few minutes to process can serve as a gentle reminder of this fact, and they will usually happily support you.

4. Use your support group. The ED will not be where you sort through the full extent of your feelings and fully reflect on the experience. At some point, the day must continue because more patients need your help and deserve the same care and attention in their treatment. That doesn't mean the grieving or emotional turmoil will magically disappear. It may take a while to process, and it shouldn't be abandoned altogether. Many residents stated that in those challenging moments, they heavily relied on their friends, family, meditation, or outside resources such as counseling to further unpack the emotional burden they carried. Most of them who did this said that it was beneficial to cope and prevent them from forming unhealthy habits of repressing their feelings or becoming disillusioned in medicine. 

The death of a patient is one of the most difficult encounters in medicine but is an inevitable reality of this career path, especially in emergency medicine. Being a good doctor doesn't mean that we need to be unphased by death. Those emotions are part of what keeps us empathetic to our patients and remain connected to the humanistic experience of medicine. What we do after someone dies can shape our perspective and have lasting effects on our emotional and mental wellness, so it's important to not dismiss or take it lightly. If you struggle to cope with a loss in the ED, you are not alone, and you are not weak. On the contrary, your struggles may help define you as an even stronger physician-in-training.