Sunday, 15 March 2009

The Worst Job in the World

Tonight was not easy.

I was called to a car which had lost control and flipped off the road, coming to rest on its side. I was informed by Ambulance Control that there was 1 fatal and 2 trapped, so I knew this was a serious accident.

I wasn't too close, so I arrived in about 9 minutes. The crews had already been working on a gentleman on the ground near the car for a short while. He was not breathing, and had quite severe chest and facial injuries. As I approached him, I could see a young lady still in the car, trapped. And now comes the dillema; the difficulty of having multiple casualties, and only one doctor to deal with them all. Do I carry on with the man on the ground, in a vain attepmt to revive him, or do I move on to the one in the car, who is clearly, from a distance, still very much alive? And, how do I make that decision, in full view of the girl in the car? I don't have much time to decide, either - the one in the car may be severely injured, and prevarication could prove fatal for her.

I told the ambulance and fire crews to move the man to an area a little distant from the car, and out of direct vision of who I found out later (and suspected at the time) was his daughter. Meanwhile, and with little time to spare, I made a rapid assessment of the daughter. She had a broken leg and some facial injury, but looked fairly stable. So, giving some quick advice to the paramedics (get an intravenous line sited) I went back to the father.

My assessment of him was unchanged - this man had already died. I pronounced life extinct. I looked at my watch to give an accurate time of death - 3 minutes had passed since I had arrived on scene.

This act of pronouncing life extinct on scene is very important for two reasons. It means that all resources can now be turned to help the person who still has a chance of survival, thereby increasing their chances. It also means that the person who has died is spared any further indignities at the hands of the medical team who would otherwise be receiving him into their A&E department - something that I feel very strongly about.

I then turned my attention to the daughter. It is quite amazing, when I think about it now, how all of us on scene can switch so rapidly from one patient who has not survived to one who needs all our care. Our only access to her was through the front windscreen. She was sitting on the front door - the car had rolled on to its side - with her left leg curled under her in a very un-anatomical way. She had clearly broken her thigh-bone, and was in severe pain. But that was not going to kill her, so I had to check her lungs and pelvis, to make sure she had no life-threatening injuries. I then had a discussion with the fire crew, to ascertain how we were going to get her out. I was all for cutting away part of the roof, so that we could have some more space. The worry was that this was a new car, and there are umpteen airbags and safety curtains built in to the roof fixtures, and these may go off with an ill-placed cut. An airbag is like a controlled explosion, and there were two people in the car - the patient and one of the ambulance crew.

So, back to Plan A - removal through the front windscreen. To do this I had to sort out her pain, as we were going to have to move her leg straight. There are various options, but in this circumstance I always use a drug called ketamine. It's more commonly used as a horse sedative, but, in much smaller doses, is an excellent pain killer for the pre-hospital patient. Within about 30 seconds she was asleep, and we quickly, carefully, pulled her out and on to a spinal board for transfer to the ambulance stretcher.

And then it's all done. Load her on to the ambulance, connect up the monitoring equipment, a quick chat to the fire crew (letting them know how well it went) and the police (she was going to be ok) and then it's a short journey in the back of the ambulance to the local hospital. Collect my thoughts while I sit there, making sure that I have all the information for the receiving Trauma Team.

But what of the third passenger, the one I haven't mentioned yet. She had been in another ambulance by the time I arrived on scene, with only very minor injuries, and I had not seen her. She was, unsurprisingly, the wife of the chap who had died on scene. And there she was, in the hospital, waiting for news of her family. What to do? She needs to know, and soon, it is only fair. So, I have the job, the worst job in the world; to tell someone their loved one is dead. She sat there, quietly, taking it in. No hysteria, just silent tears. Her family, many of them, soon arrived, and sat by her side, supporting her. "Did he suffer?" the only question she and her family wanted answered. I could at least reassure them on that one.

When I left the hospital, about an hour later, I had to pass through about twenty of the man's family. I am now left with the memory of these people, standing or sitting in the entrance to the Department, all quietly grieving, stunned at the devastation of their family.

And as I drive slowly home, I mentally add this man to the list of those who I was unable to save, whose injuries were too great.


  1. It might make you feel helpless but don't under-estimate the power of sympathy. Those of us on the receiving end of bad news remember a kind word and a sympathetic demeanor for many, many years after and it's not meaningless.

  2. Thank you for your comment, ShelaghG. I never underestimate the importance of breaking bad news. As you have said, the impact of the way in which such news is imparted will last for years to come. When someone dies, it is the last act that a doctor has to perform. both for the patient and for their family, and the care and attention that the doctor should put to this, the worst job in the world, should be no less than he puts to any other of his or her tasks.

  3. Too true - only recently my 90yo Granny told me how the kind doctor broke the news that her husband had died of a heart attack - it happened 33 years ago and her mind is slowly failing now, but that one she does remember. It's a story I've heard from her before, and every time, while she touches on the devastation of the news itself, she also always mentions the doctor's words of comfort.

  4. Have just discovered you courtesy of Tom. Excellent reading so far.

    I am an ambulance technician, and nowhere in our training does it prepare us for going downstairs and saying: "I'm so sorry, your husbands passed away". I had to do it in my first week on the road and I had about 15 seconds to prepare myself for it. It was to tell a daughter her mother was dead after we'd broken into her house. I'd made a rapport with her whilst we'd been waiting for police assistance to get through the hardwood door in the block of flats, and got her settled with one of her mother's neighbours. As I walked in I suddenly realised I was about to say something that was going to change this persons life forever. I silently said a prayer hoping I'm going to find the right words, but how can I know? I've had to do this a number of times since then, but each time find myself equally at a loss.

    Following this thought, does anyone know where it is possible to get training or guidance on this kind of thing, so I don't break the next heart any more than I absolutely have to.

  5. Hello Ambusam, and welcome. Thank you for your comments.

    The answer to your question is a definite yes: there is excellent guidance for how to break bad news. It is within you! How would you want to be told? What matters to you is what matters to the patient's relatives.

    My basic advice is as follows:
    1. Don't beat around the bush, get to the point quickly.
    2. Don't use ANY jargon. Even saying that the person has passed away is possibly not appropriate. They have died.
    3. Give the person time to absorb the information. Sit quietly with them, saying nothing, for a minute or so after telling them.
    4. Give them a chance to say whatever they need to.
    5. Don't hide your emotion. If it's a child, and you are affected, let it out too. That's not to say that you should wail louder than the parents, but a tear or two is not inappropriate.
    6. Learn, from every one you do. Think about what went well and what should be changed.

    I do hope you continue to enjoy the blog.

  6. That is definately the hardest part of being a Paramedic for me. Although I've done it many times in all sorts of circumstances it still doesn't get any easier. Another problem is Ambulance services don't give adequate advice/training on how to break bad news. Like Ambusam said these few words will be etched in memories for years to come.