The Death Spectrum: A new(ish) ER nurse's perspective
This is an article describing a few different patient death scenarios experienced in the emergency department. This is from the perspective of a relatively new nurse, who is even newer to the ER.
As 2015 was nearing its end, so too was my final semester of nursing school. My mood was good. I already had a job lined up, and I felt fairly confident that I would do fine on my final exams. Some time in those final weeks, however, a surge of anxiety came upon me. The cause of anxiety:
The ever-present beings that hung in every patient room, scrawled with beautiful calligraphy of the (mostly female) staff nurses. And yet here I was, with handwriting that resembled a cross between a serial killer's manifesto and a ransom note.
This was my fear. This was my anxiety. But I'm not really here to talk about handwriting. I'm here to talk about something that I think is probably a much more prevalent fear, especially among nursing students: the death of a patient.
I think one of the reasons the thought of death wasn't really at the forefront of my mind is because, as a student, I never saw it. Sure, my classmates and I were sometimes assigned sick patients. But they were mostly fairly stable. Any death that did occur during my rotations did so quietly, and behind closed doors.
My first nursing job wasn't much different. I worked on an orthopedic floor for six months. While complications can and do occur, all of the hip and knee replacements weren't leading to the demise of my patients. The most action I ever saw is when one of my patients oxygen saturation dropped to 86%.
She also had COPD. And she made it through.
Like I said, I only worked this job for six months. And while I normally stay with my employers for much longer than this, at some point during my time there, I caught wind of a job opening at another hospital in the emergency department. And that's where I really wanted to be.
I remember my first patient death pretty well. I'll call him Mr. Gonzales, which was not his real name. He wasn't too old, maybe in his 50s or 60s. He came in to the emergency room in cardiac arrest, his heart being mechanically stomped by the Lucas machine that EMS had placed him on. I was new at the time, maybe in my second month, still in orientation. I had no idea what to do (thankfully, everyone else did), so I tasked. I hooked him up to the cardiac monitor, placed a blood pressure cuff on him, then pretty much just observed. We didn't code him for very long before he was pronounced by the physician. His wife and daughter were outside of the room, and were called in. They were Spanish speaking, but the stillness in the room by both the patient and the staff told them all they needed to know. They started crying. The doctor instructed my bilingual preceptor to inform them of what happened. As if by magic, my preceptor pulled a box of Kleenex out of thin air and handed it to the patient's wife. He expressed his condolences (I think). I stared at the floor and uttered a "Lo siento", and my preceptor motioned to the door.
Back to business. I had to do all of the code charting. Phone calls were made to the coroner's office, the local organ procurement agency, and the funeral home. More code charting. Put a call in to the chaplain. Charting. Check on the family. Try to tidy up the room, bring in chairs, bring more Kleenex. Charting.
The chaplain came down and spoke with the family for the while. Then she came to me with a pink bag that contained a condolence card, a pack of Skittles, and a candle that the other nurses instructed me to never light because if I did, someone in MY family would be on that stretcher. Who knew nurses, with all of their anatomy and physiology and pharmacology, were such a superstitious bunch?
I was honestly a little confused by the latter gesture. Why was the chaplain offering ME condolence? I didn't know this patient. I never heard him speak. At the time, I honestly probably didn't even remember his name. I felt terrible for the family, of course, but even those feelings were muted by all of the charting and phone calls that I had to make. The whole ordeal had a very much "part of the job" feeling to it.
If there's some sort of macabre spectrum out there of "good patient deaths" and "bad patient deaths", then working in the ER probably falls more toward the left. We typically don't get to know our patients very well, especially the ones who ultimately die. If a dying patient comes to us, they're either stabilized, or they die within a short period of time. It's probably a cliche, but most of the death-related sadness that ER nurses experience is more for the family than the patient himself. And that can be hard. And it can stick with you. Luckily, there's always someone or something to help distract you behind the curtain next door.
I work in a busy but small facility, and it's not a trauma center. That's not to say that we don't get traumatic death, too. A few months after my first patient death, a 16 year old patient was brought into the ER. He had been shot. Many times. EMS was en route to the nearest trauma center, but had to divert to us because his condition was rapidly deteriorating. All of the doctors and all of the nurses rushed into the room, hoping against hope that there was something that we could do to be useful. It didn't work. He was pronounced about 20 minutes later. And it was devastating. What seemed to be his entire family was in the waiting room, and upon hearing the news, they (understandably) lost it. There was screaming. There was crying. There was punching walls. And our hearts broke for the family. But there was more. It was quickly determined that this was a gang-related shooting. And the patients friends began showing up en masse. As a result, the hospital was locked down. Triage was now taking place not in the waiting room, but in a vacant patient room behind the locked doors of the department. There were police and security guards everywhere. Our focus quickly shifted from the loss of the patient and his family members to the safety of all of the other patients.
Mr. Gonzales's family was beginning to file out. I was starting to think (hope) that his wife had cried as much as she could, but leaving him at the end of the night proved me wrong. After she left, my preceptor began instructing me in the ways of post-mortem care. He had been cleared by the coroner, so we were able to extubate him, wrestle the IO from his leg, and remove his IVs. I still hadn't really had too much of an emotional response to the ordeal. We got to the point where we were placing him into a body bag. I began zipping it, and stopped when I got just below his chin. And that was my moment. That's when the finality of it all finally struck me, after hours of calling and charting and cleaning. I began to feel that warm, stinging feeling behind my eyes. My preceptor was still present, though he was in the far corner of the room doing some other task. I wanted to make a joke, anything that would distract me from the emotions I was finally feeling. Instead, I looked down at the floor, uttered one last "Lo siento", and zipped the rest of the bag.
About rldubz, ADN, RN
Joined: May '13; Posts: 19; Likes: 48
Specialty: 3 year(s) of experienceFeb 12Death is inevitable. Don't take the Grim Reaper personal. Many more to come.
Take care of YOURSELF.Feb 12Your article uncloaked many memories from my days in the pedi ER. Images I haven't "looked" at in a long time. It's inevitable, working in a ER, you will come face to face with death, see its arrival, hold it, smell it, and witness the horror and agony it causes. From swaddling infants for they're parents to hold for the last time, to being accompanied by detectives to radiology for a skeletal survey on a toddler beaten to death, to cleaning blood from underneath the fingernails of a teen for his parents to hold until eternity, to that final moment when you seal the shroud. The Death Spectrum, ER nursing; well written, "Lo siento."Feb 12I think on the spectrum of good to bad, ED deaths tend toward the bad.
They're often messy and often unexpected, and more likely to have been someone who was healthy and functional shortly before our encounter with them.
All successful ED nurses learn to grow a shield about them, separating "them" from "us"... and "us" includes our families. We usually come up reasons why "we" can't become "them," even though we know how easily we can. One needs to learn how to keep the face of your loved one from superimposing itself on the dying person in front of you.
I've never gotten a pink bag of goodies but I have received some of the most heart-felt hugs from men and women who viscerally understand just what I've been through.
You're never the same after your first peds code.Feb 13Beautifully written. And like another poster said, brought back some memories for me, too. Our first death as a nurse is never an easy one, and I, like you, wrote about it to help Move on. I'll never forget her, or her name, or how I felt as we performed post mortem care. Even if all we can do is give the patient a final moment of dignity through extubation and a gentle bed bath, it matters. Good job. You should be proud. ❤️Feb 14While the 16 year old was a peds code in the technical sense, I have yet to be involved in a code of a younger kid (if that makes sense). We don't get a ton of them where I work. A few months back we had a child, age 5, who was brought in following a car accident. He didn't make it. As a father of a 7 year old and a 2 year old, I'm glad I wasn't there that day. I don't know how I would handle that.Feb 17In 29 years of EMS, Paramedicine, and now nursing, I have been present for more deaths that I can begin to remember. Do they affect me? Yes and no, honestly, mostly no.
The important thing to know and to keep yourself well is to talk about it. ANY time you think you may be even slightly affected by a death, even if you aren't sure, find peers to talk to. A more experienced peer will always know what is needed and that we are all there to help keep each other's mental states in good health when it comes to these scenarios. It will get easier, but it never goes all the way away.Feb 18You sound like you started nursing with a level head and a degree of maturity. I'm guessing your co-workers appreciated your lack of drama. I managed well with the death of elderly med-surg and ICU patients, but my first newborn death I sobbed in front of everyone.
Our education about death and dying is a gift. We appreciate the finality from having seen a cold, lifeless form. We respect life more. We've also seen things worst than dying, someone suffering, with no hope for recovery, someone comatose with multi-system organ failure, someone abandoned, immobile and alone in a nursing home, etc...
We are uniquely qualified to be Healthcare Power of Attorneys for our families and hold their hands when they go. We can guide them with Advanced Directives and Living Wills, not make decisions for them, but help them understand the terminology and what to expect.Feb 19I actually found the best part of working the ED was the womb to tomb aspect where you could see anything and everything. Kinda kept me balanced. Being part of a death is never cool, but then you're helping some lady deliver. To me it was a Yin and Yang kinda thing.
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