MEDICAL REALITY

Emergency Department Death and Its Unexpected Outcome

An emergency physician’s experience with a death that produced pandemonium

The aged gentleman was dead. All of us in the emergency department knew it as soon as we saw him.

“He just didn’t look right.” That was the reason, given later, for the patient’s precipitous arrival in our department.

The lead car, a sagging, faded-green station wagon, contained the ancient patient. Driven by one of the patient’s many sons, it was stuffed with a multitude of others, ranging in age from about 5 to near the century mark. It screeched to a halt in our ambulance bay. Incessant honking alerted us to its presence there.

As we ran to render aid, several other cars, all crammed to over-capacity, skidded to stops nearby. Ultimately 30-plus people, all relatives, spilled out and watched the developing drama.

As I approached the man and began my assessment, his rigor mortis and lividity made it instantly obvious that his demise was irreversible. However, rather than pronouncing him dead outside the emergency department, I directed the resuscitation team to hoist him from his car and begin care. His clustered family clearly expected it. Perhaps, I thought, our efforts will give them time to process his passing. We owed them that much it seemed.

Once our stiff and cool patient was on our gurney we squeezed oxygen into his lungs with a bag and began CPR while running rapidly through the ambulance doors and into the emergency department. The entire extended family trailed us. Security alertly shunted them away from the emergency department entrance and into a waiting area just outside our doors.

Once he was within the ED confines, a plastic breathing tube was positioned in the man’s trachea, IVs were started, medications given and CPR continued … all without effect. Our patient had arrived dead, pulseless, asystolic, apneic, and he remained so.

We gave him, and his family members, every chance.

As the resuscitation team leader and senior resident physician, it was my job to inform the patient’s anxious awaiting relatives of the preordained outcome — death. But due to the magnitude of the assembled throng, no available room would hold them all. Given that circumstance, the best option seemed to be an open area just outside the ED’s swinging doors. Fortunately, it was relatively quiet there with a minimum of cross-traffic, at least for the moment. Unfortunately, only some low desks separated the area from the ED’s jammed waiting room.

My death notification, well-practiced. I ensured that some particularly elderly relatives had seats. Key members of the assemblage were identified and brought forward. Efforts were made to be as inclusive as possible. A hush fell over the group.

Introducing myself as the primary treating physician I explained that all had acted appropriately in rushing their clearly-ill patriarch to the hospital. I assured them that everything possible was done to restore life but that all efforts were unsuccessful. Recognizing the suddenness and the gravity of the events, I offered my commiserations.

“You have my deepest condolences but Mr. (and I used his surname) is dead.”

As the word “dead” left my lips, chaos erupted.

Every family member began screaming, several as loudly as humanly possible. Many wailed while tearing at their clothing, faces, and hair. About half of the group immediately hit the linoleum floor, either tumbling forward from chairs or — alarmingly — crumpling, near-lifeless in appearance themselves, from a standing position. Felled, they continued to sob.

Two heavily muscled and tattooed young men ran at full speed headfirst into a wall, collapsed, and lay motionless.

The rest of the packed emergency department spun around and stared … at me. What has this clearly inexperienced young doctor done wrong? I could hear them all thinking about it.

Seconds later, my supervising doctor (and Department Chair) burst through the ED’s swinging doors and into the area where I stood, momentarily paralyzed. After a glance and a nod in my direction, we set to work, restoring order. We helped the stricken back into chairs or onto stretchers. Hideous shrieking decrescendoed into moans and whimpers. We checked the two who’d crashed into walls. Thankfully, finding no notable injuries.

A collective inhalation and exhalation, a sigh, was breathed. Families, patients, ED personnel and various looky loos resumed their activities. Life in the department slowly restarted and returned to what is considered normal. The chaos ebbed.

Ever since then I’ve planned ahead much more adroitly, realizing that everything and anything can, and probably will, happen. The unexpected is my new normal. I think about that, always.

“Quiet rooms,” with their complete privacy, soft carpets, well-padded chairs, and more-contained spaces are where all bad news is now delivered. Other trained professionals accompany me there. I’m willing to make sure the setting is ideal and the situation optimized for the benefit of all involved.

To my knowledge, I’ve never sparked another emergency department near-riot.

Emergencies I understand, pandemonium not so much.

Dear Non-Physician Readers:

I fully understand that grief, particularly sudden cataclysmic grief, is a horrible overwhelming emotion.

It is also true that we will all die; and before that, we’ll likely have experiences with death and tragedy (that produce grief) in those to whom we’re close. As a well-educated, empathetic adviser (that’s the role filled by many doctors many days) who has been witness to 30+ years of death and tragedy, I’ll offer you these pearls. Consider them carefully, please. They’ll make even the worst situations better.

Before bad things happen either to you or to those near to you, prepare.

Think about what might happen. Talk it over with those nearest to you. Make a plan for what you’ll do and how you’ll react given a life disaster. Realize that plans and thoughts aren’t always predictive of how things may really play out, but the simple act of engaging on the subject of death and serious illness will be helpful. Guaranteed.

Everyone dies.

It is completely unreasonable to think otherwise. Old people, no matter how healthy, loved, needed, and important in a family’s dynamic, die too.

Prepare for this eventuality. Frank discussions and some thoughts, well before life’s end, are helpful. Perhaps difficult, but helpful. I promise.

Don’t make a bad situation worse.

In this real-life story, nothing bad happened to the survivors, but it could have.

By responding in the ways that they did, the group leaders — who suddenly needed to be there to support the other group members — rendered themselves incapable and unavailable.

In similar circumstances, I’ve seen friends and family attack healthcare professionals, seriously damage property, suffer injury, end up as patients themselves, even get arrested. Do your best to avoid all this by doing your best under difficult circumstances. Again, thoughtful planning helps.

A considerably different recounting of this real-world incident was published in 2004 under the title “Pandemonium” by Turner White Communications in the journal “Hospital Physician.”