Ideas | Dr. Jay Baruch

I’m an ambassador from nightmares. My medical training didn’t prepare me

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I’m a physician, a husband and dad, a guy who tries to live by the golden rule. But sometimes I’m an escort into sadness and despair, plunging families into the darkest emotional depths with the news I must give.

One particular case from years prior stands out. Mary (whose identifying details have been altered) would have been starting college in a few weeks. Instead, the car in which she was a passenger collided with a truck. My emergency department team couldn’t resuscitate her. Right after we called the time of death, a nurse gasped. With a shaking hand, she pointed to Mary’s cellphone, which we had removed from her jeans when we cut off her clothes. “Where are you!!” the text message said. It was from Dad.

Later on, as I sit in the windowless family room packed with a chair, two small couches, and space enough for knees, telling Mary’s parents that their daughter is dead, I am acutely aware of my role in their nightmare.

Nightmares are vivid, disturbing dreams that elicit fear, anxiety, and sadness. They can jerk us out of sleep. I traffic in nightmares made real, sit with families as they shake themselves in a desperate attempt to prove they’re not awake. As I talk with Mary’s family, I’m feeling sick myself. My son will be driving in a few short years. When my grief mixes with theirs, it’s as a physician and as a parent.

I strive for sympathy and absolute clarity, sensitive to the weight of what I’m saying and who I’m saying it to. I use the word “died,” not “passed” or some other euphemism ripe for misinterpretation. My chest aches as I watch their eyes glaze over and their faces crinkle with disbelief.

Mary’s family eventually emerges from the shock. I detect suspicion, which isn’t unexpected. I lack any history with them or trust to draw on. Their expressions ask, “Could a better doctor have saved their daughter?” It’s hard to meet their eyes.

There isn’t a “right” or “expected” response at moments like these. I’ve witnessed grief so aggressive that I feared for my safety. The adult daughter of a patient once charged at me, ready to hit me, only to collapse at my feet. Another time, an adult child grabbed my white coat, pulled me out of my chair, and demanded that I leave the family room and do more for his now dead parent. I’ve also sat before dull nods, as if the family had been awaiting this heartbreak but didn’t know when it would appear.

Death from trauma such as car crashes — events that are sudden, unexpected, premature, violent, and potentially avoidable — is painfully disorienting for those left behind. “Why couldn’t you save her?” says Mary’s sister, tossing in a few insults under her breath. “Isn’t this a hospital?”

I can’t argue. Though Mary suffered severe multi-system trauma with no signs of life at the scene of the collision, that doesn’t dampen the appetite for miracles. Studies show that the public is overly optimistic when it comes to predicting recovery after cardiopulmonary resuscitation. The media contribute to this dreamy misinformation. On TV, people whose hearts stop recover more often than in real life .

I give Mary’s sister room for her rage. All grief is specific and private and tangled up in relationships. Mary had been trying to get her life together, her father says. No, she was getting her life together, her mother insists.

As a medical student many years ago, I didn’t receive any formal training for situations like this one. That wasn’t uncommon at the time. These days, it’s often folded into teaching modules bearing the name “breaking bad news” or “difficult conversations.” The medical literature is rich with conceptual thinking on the subject.

Despite the best efforts to understand and train for these encounters, they never feel right. Mary’s day began as any other. Her parents expected her home in the evening. Until they received the call, they had enjoyed the luxury of being upset at her for staying out so late.

In situations like these, the family members become victims themselves. Researchers have recommended that they be considered patients for the immediate time, and suggest that skilled interventions may help reduce pathologic grief responses. The loved ones of people who die in car crashes are particularly at risk for complicated bereavement and even post-traumatic stress disorder. Sometimes I worry that a death in the family might signify a death of the family.

As I emerge from the room where Mary’s relatives grieve, the hospital hallway appears too bright. I want to yell at two nurses innocently laughing as they return from break. I can’t imagine what laughter sounds like to Mary’s family.

Her father calls after me. He looks me up and down, runs his fingers through his hair. Then he shakes my hand, his grip firm, as if to brace from collapsing. Words feel like the husks of empty seeds in my mouth.

I’d rather not be an ambassador to nightmares. There’s no hiding behind a white coat. Through the years it hasn’t become easier. And I hope it never does.

Dr. Jay Baruch is associate professor of emergency medicine and director of the Medical Humanities and Bioethics Scholarly Concentration at Brown University’s Warren Alpert Medical School. This piece was adapted from STAT.

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