Change of Shift

Invisible Scars Keith Wrenn, MD

Vanderbilt University Hospital

Nashville, Tennessee

A Farewell to an Unidentified Body in the Emergency Department Ralph B "Monty" Leonard, PhD, MD, FACEP

Department of Emergency Medicine

Bowman Gray School of Medicine

Winston-Salem, North Carolina

Invisible Scars

[Wrenn K: Invisible scars. Ann Emerg MedMay 1994;23:1141- 1142.]

Standing in the doorway of the trauma room, all I could see of the patient was a pair of small feel They were immobile and dirty in the way that only a 4-year-old's feet can get in the summertime. The rest of the child's body was obscured by several doctors and nurses working at the bedside. One doctor was obviously doing chest com- pressions. Everyone looked competent and professional. The orders were given in a calm, almost detached, fashion and carried out seemingly without effort. A little epinephrine here, a little atropine there. You could hear the in-and-out noises of the bag-valve being pumped by someone at the head of the bed.

To a casual observer, I'm sure it would have seemed like business as usual. In fact, I was little more than a casual observer, not intimately involved with this resusci- tation effort. I had been drawn into the room because of my curiosity. I'd heard the ambulance call on the radio about the 4-year-old accidental hanging victim who was coming in.

The feet were arresting to me. I have children, and their feet get dirty in the summertime, too. These feet had been having fun; they looked alive. I couldn't take my eyes off them, so small there on the adult-sized stretcher. How could these happily dirty feet be attached to some- thing lifeless up higher?

I don't know how long I stood watching, probably not more than 30 seconds, before I began to feel myself crum- pling. Tears were going to come. I had to leave because it wouldn't have been appropriate for me, a senior faculty member, to start sobbing in the middle of this resuscita- tion that was being run so professionally.

As I left the room, a medical student, curious also, approached and asked me how it was going. A remarkable thing happened. Almost like an electric window in a car, an invisible shield came up, and I reverted to one of my professional roles, that of teacher. The tears went wherever

MAY 1994 23:5 ANNALS OF EMEH6ENCY MEDICINE 1 1 4 1

CHANGE OF SHIFT

unreleased tears go. I began to speak of asystole and EMD and brain death. The emotion was drowned in a sea of words. My face was saved, but was my soul?

I got busy again and forgot those feet. It was much later, as I prepared for bed, that they came back to me. While picking at a particularly chronic callus on my big toe, I peeled away too much skin and blood welled up. As I watched the drop form, I suddenly remembered those small, dirty feet. Almost like the pus released from an incised abscess, I could feel tears letting go.

Perhaps this emotional release was healthy I wonder, though, if I don't harbor a residual scar somewhere inside, just as if I'd had a boil incised. What happens when you don't release the emotion at all or don't even allow the emotion in the first place? How many times can you put up the shield or play a role without being consumed by it?

We're fond of talking about reduced ejection fractions in ischemically scarred hearts. What about the emotion fraction in hearts scarred repeatedly by exposure to such tragedy? Is this what happens to idealism and empathy-- scarring and, eventually, emotional failure? Is this why we're often perceived as arrogant and uncaring by patients? Are there effective and acceptable ways to afterload-reduce sadness, frustration, and anger or should we put more emphasis on preload reduction? Have we been good role models for students and residents in this area?

My hope is that someone smarter than me will begin to look into these questions so that the next generation of doctors and health care providers will not have to hide continually from their feelings. Maybe those feelings and the energy they consume can be harnessed and channeled in a positive and useful way.

A Farewell to an Unidentified Body in the Emergency Department

[Leonard BB: A farewell to an unidentified body in the emergency department. Ann Emerg Med May 1994;23:1142.]

I'm sorry I don't know your name. You were a child once, Long ago, Happy, Innocent, Your whole life before you.

All now forgotten, Erased, Forever to be unknown.

I must go now, Others wait, Demanding, Impatient, To make their way to where you are now.

I'm sorry I don't know your name.

Reprint no. 4711/54753

Copyright �9 by the American College of Emergency Physicians

Reprints not available from the author.

Reprint no. 47/1/54963

Copyright �9 by the American College of Emergency Physicians

Reprints not available from the author.

1 142 ANNALS OF EMERGENCY MEDICINE 23:1 MAY 1994