Little white lies in the resus room – St.Emlyn’s

As emergency physicians we are privileged to be present during life changing events for patients and their relatives, but this privilege is not without responsibility. Clearly we must strive to deliver the highest level of medical care, but we must also be aware of, and manage the personal and social needs of patients and their relatives. I think about this a lot, I try and role model good care (I don’t always manage it) and I try and talk to others about it, but I still get it wrong sometimes, and sometimes I just don’t seem to find the right path.

So, what’s got me thinking this week? To be honest it’s the post by Andy Neill over at the emergencymedicineireland blog. Andy has listed some of the really challenging presentations that we as emergency physicians face. At the top of the list is major burns, a problem that always makes me stop and think.

 

I hate major burns.

 

I find them the most disturbing problem in my practice, and whilst Andy is right in that it is something that we need to be competent in it will probably never really be something that I can enjoy.  There are several reasons for this, the potential for death, disfigurement and morbidity make the clinical management of these patients challenging, but not impossible as there are clear guidelines. What worries me, what keeps me awake at night and what takes me back to the various resus rooms and the patients I have seen is the question of last words.

You see, burns are special. There are few other conditions that we face where patients can be critically ill yet with clear consciousness and awareness. Let’s think of a case. It’s hypothetical to protect patient memory, but I can assure you it is typical of the dilemma that we as EPs sometimes face.

It started as a normal day, but at 3pm the standby phone goes and you are put on standby for a serious burns case. Running time is short as the incident is close by. The patient will be with you in 5 minutes. You prepare…………., John arrives in the resus room to your assembled team of doctors and nurses.

John is 36 and works as a car mechanic. He was working in his garage when there is an accident, the details of the accident we don’t really know but he was draining petrol from a fuel tank when there was a spark, a flash and his clothing set alight.  He has major burns. It’s pretty clear that he was not wearing protective or fireproof clothing and the burns are extensive. He has a mixture of partial thickness and full thickness burns over most of his body, with some patchy spared areas on his legs and his head, sheets of burned skin lie over his body, the worst areas pain free and not bothering him, but you know the awful significance of this. Returning to your training you plan to calculate the exact area, but it’s clear that we are talking >60% here with significant burns to his face, hands and with soot in his airway. The injury took place about 20 mins ago and he has come straight to the ED by ambulance, his wife and daughter (15) followed the ambulance and are outside in the relatives room.

John is talking to you and, now that his pain is controlled, he is orientated to what is going on. He is scared in the way that many patients are, making short but not very funny comments about being in trouble with ‘the missus’ when she gets to see him, and that he is out of the washing up duty for the rest of the week. You join in the banter where you can, anything to take you away from the sights, sounds, smells and the inevitability of what is to come.

There is no doubt, there was no doubt from the minute you saw him come through the doors of resus, that he is going to need to be intubated and you start to assemble the people and kit to do it safely. In the next 10 minutes he is going to get an RSI before transfer to the burns centre………, to what?

I know……, you know………, and everyone else in the room knows that this is a life threatening injury. We all know that that John will probably not survive and that the next 10 minutes might well be the last conscious moments of his life.

What do I say to John?

What do I say to his Karen (his wife) and Michelle (his daughter)?

They are anxious for an update on how he is doing.

I’ve been here before, I do have time to have the conversation and we don’t need to RSI right this second so I cannnot use the excuse that I have to act now to avoid it. The questions are being asked, explicitly by the family and in the face and eyes of John himself. They are not stupid, and behind the chatter they know this is bad and….., are they are looking for you to be honest? Others reading this blog will know this situation too. The dilemma of what to say, or whether to say anything? To be honest is surely an option, but it feels brutal, unfair and painful. To find another form of words that avoids the truth is possible ‘we’re just going to give you something to relax and we’ll see you on the burns unit’ is said more in hope than in truth, but it feels kinder. A little white lie to ease the last moments seems kinder..

 

Kinder to whom?

Kinder to the resus team certainly. Maintaining control, being confident and positive help the team, but it’s not the truth, and if John dies then he may have missed the last few moments to say goodbye to his wife and daughter. The white lie that things will be fine and that this is just a process on the road to recovery feels kinder for the family too, for now, but what of later? What of later when memories might return of an opportunity missed to say those final words to those that you love? As a father and husband would I want that? I don’t know and perhaps I shouldn’t put my values on others anyway so the dilemma remains.

We all like to think that we leave work behind, but there are cases and scenarios that you can’t shake off. There are those which return with triggers from a patient, from a blog, a paper or from a new case. This is my recurrent nightmare, my recurrent dilemma that reminds me that for every exciting resus there is a patient suffering the consequences. I remain troubled by the memories of those denied final moments of truth and the questions that linger over those little white lies in the resus room.

So do I do the best for the patient and their family or for we as the resus team. I guess I’ll never know…….., but I will remember them and I just hope that I did the right thing.

vb

Simon Carley

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17 Comments

  1. Natalie May

    Thanks for raising this, Simon. It’s a stark but cathartic reminder that the greatest challenge in medicine is not “getting the diagnosis right” or “giving the correct treatment”, but living with the decisions we make when we consider our patients as people. I honestly don’t know what I would do in your situation: similarly I don’t know what I would want from you if the patient was (god forbid) me or someone close to me. I think we can underestimate the power of hope for both patients and their relatives. I had a similar (non-burns related) experience with a more rapid and imminent but equally predictable outcome where the patient was young; I strongly suggested that if the relative had anything to say, he said it now, and when he said “everything’s going to be ok,” I told him to tell her that he loved her. He did, and it helped me. I wish I knew whether it helped him – or her. I don’t know what’s right or wrong here, but I know it stays with you.

    Reply
  2. Andy Neill

    Cheers for this.

    Diagnosis and treatment matters less than being human and dealing honestly, graciously and kindly with people. Exactly how we balance the two is a never ending task.

    Reply
    1. Simon Carley (Post author)

      Absolutely Andy, whilst we must push the technical and clinical envelope we must never forget the humanity and empathy that underpin our profession.

      S

      Reply
      1. Steve (@SteveGlennie)

        This is a truly touching post. thanks Simon.
        I’m an EM trainee working in the regional burns unit ICU and sit very much on the other side of this discussion. The experiences I’m gaining in the ICU I hope will help to guide my compassion in dealing with the families and patients of such traumatic life altering and life ending events.

        Thanks again for your candid and thought provoking post. I’m quite new to the FOAM network and am living each day right now revisiting the fantastic resources which are right there at our fingertips.

      2. Simon Carley (Post author)

        Thanks Steve, compassion is really important, and really important to value amongst ourselves and colleagues.

        I hope you enjoy the blog and the world of #FOAMed, it helps me learn every day.

        S

  3. Kirsten Walthall

    Fantastic post, Simon. As a trainee, I think it’s important to know that our Consultants still find the emotive aspect of EM challenging. It’s probably the only part of the job (let’s leave exams out of this) that occasionally makes me pause for thought about career choice. Knowledge and technical ability can be learnt and as long as I continue to put the time and effort in I’ll get better. Dealing with the emotions of our patients, their relatives and our own is far more difficult.
    Thanks for sharing.

    Reply
  4. David Menzies

    Great post. I had a similar case but 98% TBSA burns. Intubation was emergent but purely palliative. Just did it. I’m not sure really, that telling pt they’re about to go asleep and never wake up is compassionate, but I do appreciate the importance of maybe saying goodbyes. Can apply to severe sepsis, APO, DKAs, ODs etc too (who may have better survival odds). Depends on individual circumstances I guess.

    Reply
  5. Emcdonald

    Thank you for this candid post

    Reply
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  7. Matteo Borselli

    Found myself in a similar situation… I was in the resus bay with a really old lady with an AAA fissuration, not eligible to surgery. She was awake and aware, especially that she was going to die. Everyone was ignoring her: the vascular surgeon, the anesthesiologist, the emergency physician. You can’t be ashamed to not being able to save someone. You cannot go past this shame ignoring the issue. I took her hand and tried to reassure her that maybe everything was going to improve. Didn’t had the guts to tell her that these were the last moment of her life… From that moment I try to be the most honest and kind I can, without being afraid (but without draining hopes, though!) to tell that these may be the last and most precious moments/days/weeks of their life, because that is a secret too big to keep within ourselves. We’re person before being doctors…

    Reply
  8. KIDocs

    Wow, glad its not just me. Had one of these a week ago. My only solace was in effective delivery of early prehospital anaesthetic for both humanitarian reasons, transport and anticipated clinical course…and spending the few minutes we had pre RSI to discuss loved ones. Onus was then on me to relay that message to family after inevitably succumbing to injuries.

    Reply
  9. tom

    Great post!

    Reply
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  12. Suzanne Owens

    Thanks for this, I’m a fan of witnesssed resuscitation and you wouldn’t be able to keep my outside the resus room. I have shared this with my colleagues to encourage them to think about the issues raised when working in resus.

    Reply
    1. Simon Carley (Post author)

      ThAnks

      Reply
  13. Jennifer Urquhart

    You don’t mention the possibility of palliative care. If the prognosis is so dire, might it not be reasonable to ask whether the patient wants these to be his last conscious moments, or whether he would rather have a few more hours of consciousness (eg. to see family coming from a distance) even at the price of a slightly earier death? It would not strike me as an irrational choice necessarily – so what about giving the patient honest prognostic information as best as you can, then letting them decide whether they want ‘the full works’ to give them every possible chance of life – or not?

    Reply

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