Thursday, December 14, 2000

When Bad Things Happen to Good People

This column is dedicated to the memory of Richard C. Wuerz, MD who in life reminded me of the joys of teaching and in whose death reminds me of the subject of this column. Still early on in a career as an Emergency physician academic, view the summary of his work with the Emergency Severity Index and for those with access to Academic Emergency Medicine[1], his legacy is summarized in Ron Walls' superb editorial about the emergency severity index.

All of us practicing in emergency medicine have experienced death in our practice. This month, I’d like to briefly describe a useful resource for helping all ED staff manage the aftermath of a patient death, but then I’d like to go on and discuss Critical Incident Stress Debriefing (CISD) and its role when death strikes closer to home.

Patients die in the emergency department or before arriving and we perform in the role of the "failed" healer and announce to those assembled that indeed their family member or friend has died. In this role, more akin to that of the ancient Roman "temple priest" who led the worship of Aesculapius than to Hippocrates who founded scientific medicine, we physicians struggle to inform the patient’s loved ones and yet move on to care for others in our busy emergency departments.

I’ve recently had the chance to view some of Ken Iserson’s materials published under the imprint of Galen Press. Ken, a faculty member at the University of Arizona Emergency Medicine Residency Program, and Director of the University’s Bioethics Program has produced favorably reviewed texts, videos and training programs that are useful in teaching death notification to physicians. He also now includes a pocket guide that is convenient memory jogging device to carry in your white coat pocket—or waist pack—during a shift. If you or your staff has ever struggled with death notification—and who has not—some formal training is useful and if all are trained to a single approach, then you will have more confidence in accomplishing the difficult, but necessary and timeless ritual.

Sometimes though, death and clinical crises strike closer to home. In the past six-months in our emergency department we experienced the sudden unexpected death of one nurse found in her bed by her teenage son, the near-death of another nurse in a motor vehicle crash on her way to work, the motorcycle crash death—observed by his wife—of the son-in-law of one of our emergency physicians followed shortly thereafter by that physician’s hospitalization with unstable angina and most recently the hospitalization for pneumonia with mild hypoxia of one of our patient care technicians that turned into an ICU stay when he developed respiratory failure from which he has fortunately recovered.

These events, drop into our lives as just one more stressor in what all of you know is already a stressful time for all of us in emergency medicine. Every hospital confronts fiscal uncertainty and emergency department volume continues to grow, adding the sudden unexpected death of a colleague, co-worker and oft-time friend can cause even the most "normal" of people to collapse or respond abnormally in the crisis. As a leader, how might you respond?

In a well written piece on the Prehospital Perspective site and supported by an extensive bibliography of scientific evidence on his own website, Bryan E. Bledsoe, DO, FACEP, EMT-P debunks critical incident stress management in a rationale that resonates for me.

Critical Incident Stress Debriefing (CISD) is a technique that has increasingly been deployed in the EMS community over the course of the past decade. Many community EMS providers are aware of trained CISD practitioners in or nearby to your community. Oft-times, EMS providers themselves have been trained. I first became involved in the early practice of CISD while I was Philadelphia’s EMS Medical Director in the 1980’s. At that time, in this fire department based service, the death of a firefighter while on duty was a near apocalyptic event marked with all sorts of elaborate, formal ritual. Yet, little beyond the ritual was offered to the members of the fire company who may have worked alongside the one who perished. "Survivor guilt" was common and was manifested at times in a variety of inappropriate and personally destructive means. My first exposure came when a firefighter on-duty died from a medical catastrophe in a firehouse that housed a paramedic squad, which had tried, but failed to save their colleague’s life. Was that ever a bleak time in that firehouse. At a closed meeting, I sat in the firehouse kitchen along with the rest of the company and discussed the events, the hopelessness of the resuscitation efforts and yet confirmed the appropriateness of the efforts. I’ve since met firefighters, years later, who remember the debriefing and thank me for it.

The Critical Incident Stress Debriefing (CISD), developed by Jeffrey T. Mitchell, Ph.D.[2], , is a group meeting or discussion about a distressing critical incident. A critical incident is any event, which has a stressful impact sufficient enough to overwhelm the usually effective coping skills of either an individual or a group. Providing crisis intervention and education, the CISD meeting (lasting approximately one-to-three hours) may reduce the impact of a critical incident.

Critical Incident Stress Debriefing as described by D. G. Mitnick.:
· Is not therapy or substitute for therapy
· Should be applied only by those who have been specifically trained in its uses
· Is a group process, group meeting, or discussion designed to reduce stress and enhance recovery from stress. It is based on principles of crisis intervention and education.
· May not solve all the problems presented during the brief time frame available. Sometimes it may be necessary to refer individuals for treatment after a debriefing.
· May accelerate the rate of "normal recovery, in normal people, who are having normal reactions to abnormal events."

Following the motor vehicle crash which nearly took the life of one our nursing staff—she was resuscitated and stabilized at our emergency department—we held CISD meetings for the staff taking advantage of the CISD team that was staffed in part by members of one of our community’s volunteer ambulance services. Separately, we had also supported the ethnic rituals of co-workers and friends of the nurse who had died earlier in the year.

Perhaps because I’m in mid-life and these events pile on me more frequently than ever before, I’m ever more aware of the effect on my colleagues and myself. Inevitably, we aging baby-boomers will experience these losses ourselves, not just with our patients. As a leader, you can yourself learn and then teach the best ways to notify others about the death of a loved one and reach out for help for yourself, colleagues and ED staff when that moment comes into your own lives.

[1]Walls RM: Dr. Richard Wuerz's Emergency Severity Index. Acad Emerg Med 2001 8: 183-184.

[2]Mitchell, J.T. & Everly, G.S. (1995). Critical incident stress debriefing: An operations manual for the prevention of trauma among emergency service and disaster workers. (2nd ed.). Baltimore, MD: Chevron.

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