When words fail

I’ve been thinking a lot lately about communication.  So much of my job involves talking with people and trying to communicate complex or emotional material.  So often I feel I fall short of actually making a connection and conveying things like I want to.

Like a couple weeks ago when I had to notify a family of a patient’s death.  I walked into the family room–the little room in any Emergency Department where they shuttle families about to get bad news.  If your loved one is taken to the ED and you’re left in the waiting room for hours on end without any knowledge of what the hell is going on, take heart.  That’s probably a good sign.  But if they put you in the airless, windowless closet-turned-room with cheap paintings of pasture scenes on the wall and boxes of tissue scattered around, prepare for the worst.  A middle aged man and his teenaged son were sitting there.  The man was talking on his cell phone so I introduced myself to the son and then turned to the man.  He put his conversation on hold and then said to me, “This is my brother on the line; he needs to know what happened.”  I was discombobulated–cell phones had never been part of my death notification process before.  But the man put the phone into speakerphone mode and then I proceeded to tell him and his brother that their father had died.  It was so awkward; how can I communicate not just that horrible and stark news but also my sadness and pain for them if I couldn’t look someone in the eye?  How can I reach out and put my hand on a shoulder or a knee if the body I’m talking to is in a car a hundred miles away?  How can I read someone’s body language if I’m talking to a 3 inch box of wire and plastic?

Then there was the night that the attending passed me a chart and said, “Oh, this looks like a good case for you.”  Never something you want to hear.  It’s either a dump–a case the attending just doesn’t want to deal with, or a horribly complicated case that will suck up vast amounts of your time and energy.  As I flipped through the chart I was mostly just confused.   The woman hadn’t had a period in months, a common indicator of pregnancy.  When I calculated her dates, she was right about 7 months along.  The policy at that particular hospital is that anyone past 16 weeks gestation bypasses the ED and goes right to labor and delivery.  We were wicked busy that day so the woman’s workup had been initiated by the triage nurse, which means all of her labs and her ultrasound were back.  I glanced at the ultrasound report–a single intrauterine pregnancy at 26 weeks and 4 days, no fetal heart motion.  What?  Shit.  The baby was dead.  Then I looked at the vital signs sheet–blood pressure 220/115 plus that protein in the urine.  Damn.  The woman had preeclampsia, making her at risk for seizures.  I grabbed the charge nurse, trying to figure out why this terribly sick woman was in the Emergency Department rather than in labor and delivery where she clearly belonged.  “Oh,” she replied, “She didn’t know she was pregnant so we had to wait for the pregnancy test to come back positive and then we didn’t have a good date for the last menstrual period so we didn’t know how far along she was so we didn’t know if she was appropriate for L&D.”   Super.  Now I have a woman who’s unaware of her pregnancy with a dead baby who could possibly start seizing at any moment.  Can this get worse?

In a word-yes.  I walked into the room and introduced myself and quickly realized that neither this woman nor her husband spoke English.  And I was at the hospital where there isn’t a Spanish translator after 5:00 pm.  I took a deep breath and dug in, asking in my suck-ass Spanish when her pain started, where the pain was and so on.  The woman answered everything but then asked if she was pregnant.  Oh dear.  This is what I was afraid of.  “Yes, you’re pregnant,” I said, or at least that’s what I hope I said.  Like I mentioned, my Spanish sucks.  “But the baby is. . .um. . .”  Great, look who doesn’t know the word for “dead!”  “Um, there are problems with the baby’s heart.”  Ooh, that is just too evasive.  Bail out!  Bail out!  I go out to the nurses’ desk and try to find a portable phone, a very scarce commodity in this ED and I call the language line and walk back in, armed with a native Spanish speaker in my hand.  But the communication still falls short.  I hold the phone in my hand, tell the translator what I want to say, then I pass the phone to the patient, the translator relays the information, the patient responds, the phone is passed back to me, the new information is conveyed to me and then we start again.  It’s bulky and it’s cumbersome and it inhibits the natural flow of communication.  Every time I have to use a phone translator I notice that the patient and I make less eye contact.  Theoretically, we’re still the ones conversing, just through a middle-person.  But it just isn’t the same.  So in this far from ideal situation I get to tell the woman that yes, she is pregnant; no, she won’t actually be giving birth to that perfect baby like she always wanted to; and oh, by the way, you’re really super sick and possibly could die as well.  

But sometimes it isn’t the proximity or the language barrier that keep me from being able to effectively communicate with people.  Sometimes, it’s just that there are no words to say.   A “code in progress” is the lingo that we use for someone that’s being brought in by EMS and is in a bad way.  Their heart has stopped or is in a bad rhythm and all the stops are being pulled out.  It’s the scene in ER where they are shouting about “Another amp of Epi, STAT” and shocking people and after 15 minutes of camera shots that pan around the room they magically get a rhythm and things work out.  Except in real life, they don’t.  When we hear code in progress, we get out the resuscitation equipment but we also pull the body bag, because we all know how this is going to end.  Lo and behold, this one was just like all the others.  We intubated the man, breathing for him.  We gave the epi and the atropine and some bicarb, just in case.  We didn’t shock him, because it wasn’t indicated and unfortunately we don’t have the creative license that ER has so we can’t shock him just for effect.  We did it all and after 15 minutes, he was dead.  Technically, he was dead when he got there, but we couldn’t acknowledge that until we tried everything we could possibly do.  I put my white coat back on and asked if the family was there.  “The wife’s in the family room,” the nurse replied.  I made my way back there, my second time already that day.  A short little woman greeted me, smartly dressed, complete with hat and all.  “Mrs. Jones?” I asked.  “Yes,” she replied, already scanning my face, trying to get a clue about the fate of her husband.  I sat down beside her and broke that gut-wrenching, mind-blowing, your world is off its axis news.  “Nooooo,” she cried, “He was my best friend.  He can’t be dead.  He was my best friend.”  She sobbed and sobbed, repeating those same words.  What could I say?  What could I do?  I thought of the brilliant husband, my best friend.  If he should ever cease to live, just kill me there.  I don’t want to live in the world without him, and I’m not sure I even could.  And here was this woman, just six inches from me, having to face that brutal reality.  I knew it wasn’t me that had killed him; it was probably a heart attack or a blood clot in his lungs.  But I still felt responsible, like I was the one that had picked up a cosmic bat and smashed this woman’s world to tiny little bits.  I put my hand on her shoulder and just sat there.  

After all, sometimes words just fail us.