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Associate Editor Note:

Death in the emergency department, especially of a young patient, and especially when due to violence or self-inflicted injury, evokes a strong emotional response in emergency care providers. These two Reflections essays, one from a medical student at the Alpert Medical School of Brown University, and one from an experienced emergency medicine faculty member at Brown, offer different perspectives on two separate tragic cases. But, their messages are similar—that we do a disservice to ourselves and future patients if we suppress or bottle up the emotions and grief that appropriately emanate from an ED death. Brian J. Zink, MD

I worked my first pediatric code when I was still pediatric myself; 17 and barely out of high school, I had been working in an urban ED for about a month, and I thought I had seen it all. Every day brought in a new onslaught of shootings and stabbings, tattooed patients cursing in foreign languages. The general flurry of the ED blended into a single frenetic, often comical, incursion of chaos and gore, and I loved every minute of it. That was, until TF rolled in.

We weren't used to caring for peds with a children's hospital only a mile away. So, this was a new brand of chaos. Nurses couldn't find the right mask size, the pedi intubation cart had to be extracted from the dusty corner it had occupied for years, untouched. Physicians looked up pediatric doses, estimating the weight for such a tiny being. But it wasn't until we removed her clothes, shearing through pink princess pajamas, that we could comprehend the abuse she had suffered. Bruises of all ages speckled her tiny limbs. The MD looked back over the EMS report to make sure that she was truly a “drowning” victim. Her hair was dry. Everyone in the room realized at the same exact instant, and for a second everything moved painfully slowly, through the thick fog of a nightmare: this is what murder looks like.

And then it snapped back into frenetic reality, an intubation, compressions. Her bruised body bobbed to the beat of too many large hands crushing, desperately trying to get a heartbeat back. Then drugs. So many rounds, we all lost count. It became clear that it was too late, we weren't doing anything other than further abusing a body that at 3 years had already seen too many bruises, too many breaks. When the MD looked around and said “does anyone object to … stopping …” we exchanged glances, eyes pleading for someone to give an excuse to continue, and knowing no one would. And all at once, we shared a collective sigh, and then came the tears. I was relatively new, but I had never seen people cry like this: every person stopped dead in their tracks, trying to figure out how to pull it together and work the rest of their day, or even enough to just walk out of the room. Many snuck off into dark corners, pulling ourselves together where no one else could see or judge our anguish. But not the doctor.

No.

She had to go meet the family, to look into the faces of a father that beat his baby in princess pajamas, and placed her in the bathtub to look like a drowning, and the mother who stood and watched it unfold in silence. She had to tell them that we're sorry that their daughter died; that we had done all that we could to save her, but it had not been enough. That MD had to put away her own sorrow, her accusations and fury, and face that family with her chin up and voice steady. And she did, while I sat in an abandoned corner, knees pulled to my chest, and sobbed. For the first time (but certainly not the last) I thought, maybe I am not strong enough for this.

Now, years later, with thousands of patients and many more sorrows under my belt, I have realized that no one is strong enough. Humans are not meant to absorb the suffering of others in silence, and those doctors that try to, who never learn to unburden themselves, crumble. It is a learned skill to quiet your own mind and heart while giving tragic news, particularly when families litter the silence with screams of injustice or the searing sound of their own pain. We learn to quell our own suffering, to stand tall as we drop to the floor internally, but that does not mean that we don't feel it as acutely as we walk away. Maybe because we can't break down in those first few minutes, we have to learn to break down later. And the strength to let ourselves do that is what gets us through.