You have to create a disconnect from death. Not indifference, in fact, it’s your duty to combat it. But as an emergency medicine physician, you lose that battle often. I encounter death on a near daily basis as a resident in the emergency department, and despite all my years of training, there’s often nothing I or anyone can do to prevent it. Health care workers in such an environment often develop defense mechanisms against the devastation of death. If we didn’t, we would become so overwhelmed with grief and gloom that it would be impossible to continue caring appropriately for our other patients, who need our sharp focus. I’m no exception to this. Perhaps it’s no more than a protective wall, but I believe the blunted sadness is also deeply fortified by my faith in a hereafter. But at times the wall crumbles.

I recently came to work a shift in which I would be responsible for the department’s resuscitation bay (for the critically ill) and trauma bay. Within in the first 15 minutes of my shift four new critically ill patients come through the door. As a silver lining, the influx happened at the time of shift change, so we had two teams of residents and attending physicians there to help divide and conquer. The setting was chaotic, but in a busy inner-city county hospital, we’ve adapted to be comfortable with chaos.

Our combined initial efforts settled the scene, and things looked to be on the right track. An elderly man in status epilepticus (uncontrolled continuous seizures) had stopped seizing and was starting to wake up, an elderly woman in cardiac arrest had her heart beat restored and seemed to be stabilized, and a severely chronically ill elderly woman with multiple menacing infections was placed on a ventilator, and the appropriate treatment was initiated. The other residents and off-going attending did their part to help then left me to continue caring for each of these critical patients.

There was also a fourth patient who was brought in that didn’t receive the same attention as the other three. In fact, I was not even made aware that she was there until the dust started to settle on the other patients. Unlike the other three, she was middle aged, awake, breathing on her own, and able to have a normal conversation with me. After an initial exam and some screening studies, it was clear that she likely had something constituting a surgical emergency brewing in her abdomen. A surgery consult and confirmatory imaging were ordered, and treatment commenced.

The CT scan confirmed our suspicion of a small bowel obstruction that was cutting off blood flow to the bowel, a life-threatening condition, and the surgery team was informed. There was some delay in getting the patient to the operating room, and both my attending and I reassessed her, and she seemed to be maintaining enough stability to make it until the OR was ready. In the meantime, another patient arrived who required immediate attention, and having found her stable enough we turned our attention to him. Just a few minutes later the nurse called out that she was not responding.

I rushed to the bedside and found only a thready pulse that soon disappeared. CPR was initiated, and we did everything we could to try to save her. After some time it became clear that any further effort was futile. The attending physician had begun to lead the family (who had been witnessing all of this) away to the quiet room. Having decided to call off the resuscitation efforts, I called to him and motioned for him to bring the family back to the bedside so they could be with her in her final moment. I called out the time of death and the team dispersed, leaving the patient’s distraught family alone by her side.

I have witnessed and been a part of countless other similar deaths, but this time, as I walked away I was stung more strongly than I had been in recent memory. I don’t know whether it was seeing the family witness her sharp decline and death, her relatively young age, the steep slope of the decline which created a measure of unexpectedness, or a sense of “what if” when considering if her care could have been managed differently, but I suspect the sting was probably the sum of all of those.

As I walked away, my eyes began to well and I became consumed by sadness and contempt — sadness for the grieving family and contempt with myself and the consultants for not preventing this, finding no solace in the reality that we probably couldn’t have. The despair seemed to boil inside of me until its climbing pressure seemed like it would cause my blood vessels to burst. Not wanting to lose my composure in front of my co-workers, I continued walking down a corridor into another part of the ER. The emotion must have been visible on my face, and one of my colleagues quietly said “I’m sorry” as I walked by.

I walked into a quiet room where I stood only briefly, tears streaming, trying to will the emotion to course through and out of me knowing my remaining patients required my full mental investment. After a moment, l lifted my head with dry eyes and began back toward my station where new patients were waiting for me, the weight of their own expectations bearing down on me.

Andrew Martin is an emergency physician.

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