Death in the family: Endings also hit hard at doctors
“A patient died today.”
Death is inevitable, often in hospitals, sometimes during surgery. Loss of a family member strikes hard at survivors. It also takes a toll on healthcare providers who struggled — yet lost the battle — to keep their patient alive.
In the course of their careers, doctors will lose many patients, but there is always the first one. Dr. Helen Madamba has lost her first patient in the operating room. The hurt and shock still linger. Yet, there are more patients to treat and — with skill and perseverance — keep alive.
Madamba is an obstetrician gynecologist and infectious disease specialist at Vicente Sotto Memorial Medical Center in Cebu City, Philippines, and executive director of the Share A Child Movement.
She talked with other healthcare professionals about death, dying and moving on, but first the “social media enthusiast” posted “A patient died today” on Facebook and later blogged about her experience with the details painfully fresh:
A few days ago, I experienced my first OR table death. I am still in shock.
A patient bled to death during surgery while we tried to remove a ruptured bleeding tumor. Hypovolemic shock. It was a traumatic experience to struggle with suturing to complete the surgery during external compression of CPR.
When I scrubbed in, the estimated blood loss was already 2 liters — hemoperitoneum from a ruptured tumor. Our usually cool anesthesiologists asked me at least four separate times in different ways: “Doc, have you controlled the source of bleeding?” or “Doc, have you ligated the bleeders already?” or “Doc, have you successfully clamped the bleeding tumor?” and “Doc, is there any active bleeding?” Just as calmly, the team of anesthesiologists informed me that the patient was bradycardic (heart rate slowing down) … then that the patient was almost coding … and finally that someone should initiate CPR because she flat-lined.
All these events seem like a flurry of events happening before my eyes. We struggled to remove the uterus and suture close the stump and ligate all bleeders with all the movement of somebody else doing CPR to revive the patient. We heard someone say that there was blood coming out of her nose and through the oral tube. Blood was being pushed through the IV for faster transfusion. People were running to the blood bank to get more blood. People were calling for help. Residents and interns were taking turns at external compression.
We stapled the skin (OBGYNs almost never use a stapler for skin closure) just to finish the surgery as soon as we could. We continued with CPR for more than one hour, administered two shocks and gave eight doses of epinephrine. With somber faces, the whole team wordlessly accepted that the patient was gone, despite all our heroic efforts. Mental shock.
I had to face the patient’s life partner to show the tumor that we had removed, and to explain that the patient’s heart stopped because she had lost so much blood. Even before I had finished speaking, the husband started sobbing. It was heart-breaking, and all I could do was to offer him my condolences. I could not give support because I was in shock, too. Emotional shock. As soon as we showed him the ECG reading showing a flat line, I returned to the operating room and had my own cry. It felt a part of me died with the patient.
My friends told me that it is alright to grieve and to mourn the patient “because you are human. That was a woman who died. Someone’s wife and daughter. So yes, you should grieve.”
In our hospital, maternal mortality is high. There are several mothers who die of pregnancy-related causes every month. How does a health professional keep emotionally divorced from death and dying, especially if you wonder if the deaths could have been prevented? Writing this blogpost may be cathartic (therapeutic) for me as a doctor, but I honestly wish to discuss with others out there who may have experienced these challenges and difficulties, so that we can help each other cope with patient deaths — so that we can serve our patients, but not at the cost of our own emotional and mental health.
“That was a milestone in my career as an OBGYN,” Madamba said. “Not at all easy, but we survive and hope that the experience makes us a better doctor for it. Patient deaths are part of being a doctor, so we need to learn to cope. We deal with maternal mortality too often for my taste.”
Call for help
Amid the emotional stress, she said doctors should not try to deal with their emotions on their own: “Calling for help is a surgical humility trait.”
Dr. Jaifred F. “Jim” Lopez researches health policy and has been a “doctor to the barrio” in the Philippines. That is where he encountered patient deaths.
“In my rural practice, the deaths I had to deal with were my hospice patients, and the occasional coded patient brought to the health center,” he said. “The buzz generated in a rural town can be unsettling, but when they know you did what you could, they are grateful for your service.
“Dealing with it with faith helped me, and I learned it from my seniors,” Lopez said. “Life-and-death situations truly bring out the faith in many people. In each patient death, I learned I had to grieve, while also moving forward to serve the rest. This cannot be ignored; emotions build up.”
Dr. Teddy Herbosa is executive vice president of the University of the Philippines. He has extensive experience in trauma surgery and emergency medicine.
“That’s a difficult one,” he said, referring to patient death. “I operate on cancer patients, take care of them, and after many years it’s at the end of the road. You journey with them … attachment. Senior physicians should help teach in dealing with unexpected and difficult deaths of doctors’ patients.
“We do our best and improve, but we also learned to be ‘jaded,’ or else we burn out,” Herbosa said. Coping with spirituality is one of the methods. We all learn to use many techniques. Each one finds their own unique coping.”
Dealing with grief did not come easy for Lopez.
“I used to just pass by the chance to grieve,” he said. “Then a few years ago I had the chance to go on retreat. I did not realize I already spent a whole day crying the accumulated emotions out. Lesson: It’s OK to cry when it happens. You may choose to do it in private. It’s nice to have these retreats once in a while.”
Dealing with patient death depends on perspective. A relative expected to be in charge after a patient’s death might put on a good face before, during and soon after the inevitable passing. A few days later — alone — comes the time for a good cry. On the other hand, doctors are expected to move on regardless of their mental state.
“There were days when I would not be functional at all the next day, grief was debilitating,” Madamba said. “During residency, I lost a gravidocardiac patient to severe pneumonia. The baby was delivered safely, but the mother did not survive. When I faced the sister, I was the one they comforted. I guess I am an empath, not knowing how to hide emotions.”
Delivery room deaths strike Madamba particularly hard.
“We are trying our best to reach out to referring institutions to find ways to reduce maternal mortality,” she said. “We don’t want mothers to die giving birth to new life.”
She also seeks spiritual help.
“Praying is holding on to a higher being to lift up everything that happens, believing that everything happens for a reason beyond what our eyes can see or what our hearts can understand,” Madamba said. “My Uncle Juju also advised methods to help me relax and empty my mind. Physical exercise is a great way to de-stress as well.”
Lopez looks for help anywhere he can find it.
“I spend at least a half hour in chapel,” he said. “I talk to a friend or a mentor. I go home and spend time with family. I play my guitar.”
Herbosa finds relief getting away on his own.
“Meditate. Quiet time. Solitude. Empty my mind. Breathe,” he said. “Talking to the patient’s family is hard. I remember senior surgical residents made us first-years talk to the families. Brutal! I also had my share in mass-casualty incidents. I remember going home after and just hugging my daughter. One of the casualties was her age.”
Experience has helped Lopez a lot.
“It can be difficult to balance between the need to be compassionate, and the need to be realistic with one’s emotions,” he said. “It takes practice.
“It is like Ignatius beset with internal strife, or Benedict withstanding the onslaught of demons,” Lopez said. “Just as when the death happens, the surgeon is left to him or herself to reflect on what happened. Intense, but the emotional struggle is necessary. It builds skill.”
Madamba said healthcare providers should make a conscious effort to breathe in and breathe out.
“It is difficult, but I think each person would have a unique way of coping with patient deaths,” she said. “I tried alcohol, but it doesn’t drown our despair. I tried more work until exhaustion, but it compromises relations. I use quiet mindfulness, meditation and prayer as well as expression.
“This is why there is a high risk for depression and suicide among healthcare professionals — when coping mechanisms fail,” Madamba said.
Healthcare provider or family member, it’s difficult to cope with patient deaths. You shouldn’t keep things bottled up inside — and least not for long. It’s understandable to keep a compassionate yet strong face in front of next of kin, but you need time and space to let everything out before you burst.
“Sometimes there’s no time to process because it’s on to the next case,” said Dr. Iris Thiele Isip Tan. She is a professor at the University of the Philippines College of Medicine and a consultant at the Philippine General Hospital Section of Endocrinology, Diabetes and Metabolism.
“I’ve been in practice for more than a decade, and I’m losing some of my elderly patients who have been with me since I started practice,” she said.
Lopez advised getting away from the hectic pace.
“Take a rest,” he said. “If it is impossible, suggest something that can give a semblance of rest: lessened tasks, a moment in prayer or meditation, a day off, maybe swapping a duty day.”
Reality, however, might not be so forgiving.
“The question is how to do that?” Madamba said. “Just like in a romantic relationship, is there a way that you don’t get hurt from breaking up or losing one another? Is there a way of distancing oneself emotionally?”
“That is actually difficult,” he said. “It needs self-knowledge. What makes me clingier than usual? What makes me compassionate? How can I ensure that I can move on from hurt? One thing’s constant though: Hurt will always be there.”
Herbosa said administrators should do their part to help physicians deal with their emotions.
“We need to institutionalize and make available coping methodologies for docs,” he said. “We watch out for each other. Solidarity. We also identify burnout.”
Madamba reminded the others that everyone is different.
“Sometimes watching out for each other will mean not needing to ask for help — being sensitive enough to know that your fellow healthcare provider needs help and offering it voluntarily,” she said. “When it gets too difficult or too painful to overcome, it might be a good idea to quit. There are a lot of other ways to be functional after grief.”
Amid the trauma, could social media help healthcare providers cope with patient deaths?
Social media can be good or bad, depending where you seek information. For inspiration, it can be good, especially with support groups. Steer clear of haters ready to jump on what you and other providers should have known and did wrong — in their opinion.
“We need to exercise caution in using social media when discussing these matters, since it also harbors unfortunate elements that bully instead of reassuring people,” Lopez said.
Herbosa had a final thought: “Death and dying are as biologic as hearts beating and lungs breathing. We really need to talk more about this topic, and mentoring is way to go.”
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