The debriefing

Humanity

CJEM 2008;10(1):81-83

The nurses asked for a debriefing. A level 1 trauma: the activity has been intense and now that there is a lull they have asked for this time out. They need to talk about how they are doing and what could have been done better; and for some, the time out is to gather the strength to go back and finish what is left to do.

3:10 pm

The air was cool and crisp with the taste of approaching winter. With Raffie firmly in hand, Sophie began the short walk from Raffie's school to his parents' grocery store, which was nestled on the edge of 6 lanes of roadway beneath an elevated highway traversing the city. Sophie had been with the family for so many years that the older children called her Auntie. Now it was the baby's turn to be holding her hand. Raffie would be 7 the next day, but he was still her baby until the Alivas decided to have another child.

As the driver approached the intersection, the traffic light turned yellow. Raffie approached the corner, saw the little man in the crosswalk signal flash green and pulled sharply away from Sophie's firm grip. He was small, no higher than the car parked at the curb, and by the time the driver saw him dart into the road, it was too late. No matter how hard he pushed on the pedal, he couldn't stop the truck. The sound of tons of metal hitting a child's body was no match for the screeching of a truck's tires. The irony: the truck was delivering caskets.

Jose Aliva, hearing that terrible sound, looked through his store's front window and saw Sophie across the street. He knew. He knew!

3:20 pm

There were no more than a few minutes between the time of the accident and the arrival of the ambulance that had been stationed a few blocks away. The paramedic didn't respond to a call. He responded to what he had heard and the traffic that was now at a dead stop. Raffie's lifeless body lay on the roadway. His face was bruised and there was some blood, the only physical signs of what had happened just moments ago. The paramedics secured him to the board and, with a police escort, they raced to the nearby hospital. They were so close and acted so quickly that the hospital's trauma team activation call went out as the ambulance pulled into the ambulance bay.

The emergency physicians were in the ambulance bay when the ambulance door opened and Raffie, on the stretcher, emerged from the back. By the time he was wheeled into the trauma bay, the team was already assembling: trauma surgeons, an anesthesiologist, trauma nurses and pediatricians. Everyone who needed to be there was there and then some. When the patient is a child, the mechanism of injury so violent and the injuries life threatening, it somehow is different, even in a trauma centre.

4:10 pm

The fight was over. Forty minutes after Raffie entered the trauma bay, the physician in charge called it. Only moments before, more than a dozen people surrounded the gurney, working seamlessly, a unit of one with economy of words and actions, all directed to assessing, stabilizing and, when traumatic arrest was the diagnosis, fighting to find and nurture any sign of life. They walked silently from the room. As difficult as it was to leave their patient, there was nothing more to do. They walked out in silence, each alone, not even exchanging glances. Whatever they felt, however they felt it, they kept it to themselves, at least for the time being.

The senior surgeon had one last thing to do — to tell the waiting parents that their son was dead. He told them that when Raffie arrived at the hospital his heart had already stopped beating. The team had done everything that could be done to bring him back, but nothing worked. The injuries were too massive. He offered his condolences and told them they could see their son if they wanted to.

5:10 pm

An hour had passed and the trauma surgeons were gone. They would meet the next day in morning report, an educational conference, to review what they did, and see if there was anything they could have done better.

Raffie had been moved to a quiet corner in the emergency department (ED) where the family was gathering. A hospital chaplain was with them. The nurses and social worker who were involved in the trauma asked for a debriefing. They needed a few minutes with a facilitator to go over what they had been through; a few minutes to meet and catch their breath so they could be available for this family and for the steady stream of patients still arriving at the ED.

The debriefing began in silence. It was hard to know where to begin, how to start. The facilitator framed the possibilities. We had all been through an intense experience, and part of a family's tragedy. For some, it might resonate with past experiences and feelings about the loss of a loved one, of a child. For others, we were here doing our job. This is an emergency department; this is why we are here.

The nurses began.

First anger. ... There were staff lingering nearby who had nothing to do with the trauma and just had to take a look. They had no business being there. An uninvolved Emergency Medical Services crew was in the trauma bay. Why? The rest of us were there because we had to be. "If I was assigned to the general ED rather than trauma," said one of the nurses, "I'd stay away and just do my job." The voyeurs and gawkers — they hated them.

Then, recognition and appreciation. So often when doctors get anxious they begin barking orders, impatient with even momentary delays, as if those delays will influence the outcome. But there was no barking, no impatience this time because of the doctors who were there. The anchors. The senior attending, who happens to be the chief of trauma, was calm and in command. The senior resident, a fifth-year seeking a trauma fellowship, was at the head of the gurney directing the surgical residents and the medical student in the tasks that had to be done — also calm and in command. And the anesthesiologist. There is technical complexity in intubating a child. There are times when there is only 1 shot; the tube must be placed correctly on the first try. He, above all, was calm and in command. There was no anger here today. The nurses knew when the team was working right. This team worked right. The nurses, 3 in all, 1 assisting the medical team, the other documenting what was given so no mistakes would be made, and the third, the nursing administrator for the ED, at the door of the trauma bay dispatching aides for anything that might be needed.

Finally, the pain.

The facilitator modelled by speaking of his own personal reaction to being part of this tragedy. It was the intensity that he knew would come from the grieving family, their seeing the lifeless body after it was over. He thought of his own children and how, in one capricious moment, everything that is dear to us can be taken away. A nurse spoke of needing a few moments alone when it all became too much. The nursing manager talked about going into her office and feeling the anger of a senseless moment that changed everything for a family. A nurse, the mother of a 6-month-old, had a sudden heaviness in her chest, the fullness of grief at the possibility that we can all lose a child. And the social worker spoke about thinking of her nieces and nephews as she stood by the side of the child's parents.

Finally, the nurse who may have felt some of this but said only that we did our job and we did it very well. Yes, this was a tragedy over which we had no control. What we did have control over was how we functioned as a team and that's what we did very well.

The debriefing ended. For some, the job was finished and they went on to the next patient. For the social worker and a nurse, there was still work ahead. The hardest work: being with a family whose grief is palpable and consuming.

7 pm

The mother, inconsolable, stood at her child's side; the father, more contained with his emotions, stood next to her. Two stunned children, Raffie's 12-year-old sister and 8-year-old brother, sat in folding chairs at the foot of the gurney. Other friends and relatives had already gathered to lend support and grieve with the family.

It was time. Raffie had to be moved. There were now at least 30 people at the bedside, including the parish priest and the police from the local precinct, a captain and 2 community affairs officers who had been with the family for hours. They were kind, committed, responsive and professional. The newspapers are filled with stories of police using excessive force. Who will read this story? Who will read about them?

The priest said the final prayer and told the mourners it was time to leave. There are many hard moments a parent must endure when a child is lost. This moment of separation was such a moment for Raffie's mother. The family gathered around her, supporting her trembling body, as she was led from her baby's side.

7:30 pm

Four hours before, as the ambulance arrived, the ED had exploded into a pulsating frenzy. Now, as the last family member departed, it returned to an eerie calm. The night shift would start in a few hours and Raffie's story would be just another piece of the trauma centre's history.