Losing your first patient

[whoRyou]

When I was working with patients as a psychometrician it was instilled that I couldn't get close to any of my patients. Administer and score neuropsychological evaluations, document clinical observations, participate in case reviews and give feedback sessions with patients, but whatever I do don't get close. “Never take those feelings home with you” were things I heard often. There were times I felt like a robot. I regret being like that. Do we all have to be unemotional superheroes? The first time you lost a patient was it hard? How did you deal with it and does it get easier? How do you deal with it now? I feel how you deal with it can set the tone for how you deal with all the frustrations you encounter working in healthcare. Can some of you share what you have learned from your own personal experiences?

 

I regret being stoic back then, but I made a promise to myself no matter how great a PA I become, I know there will always be a few which I will not be able to save … and those are the ones I will never forget.

[ilovelost]

As an EMT it's happened. At work I try to stay emotionally detached but still find ways to express compassion and empathy, just in general. When something "bad" happens, I'm better at staying calm in the moment - after a few days I might feel a little sad. It depends on the situation too. I'd probably feel much worse if it were a child/young person or someone I've known for a while. 

 

But I agree with not liking the idea of being a robot. I think it's possible to be emotionally detached (to think clearly), but still build a connection with a patient. 

[jtmathew]

First code I ever worked was a 23yo father who collapsed while watching the birth of his son (dad was later diagnosed with Brugada). We worked on him on the L&D floor, next to his girlfriend who was in labor, for almost an hour before we got him back. I couldnt think straight for days after the event. Every code since has been different and Ive gotten more comfortable, even when the patient doesnt recover. As clinicians, we are still allowed to have strong emotions and being passionate about medicine goes along with being passionate about the people you are helping. At the same time, when its time to go you have to supress emotion and focus on the task at hand. Decompression is for the locker room/break room/commute home/gym/etc. Ive watched my mentor, an IR PA, break down in tears because a patient with advanced stage cancer had run out of treatment options and there was nothing else she could do. It is important to be in touch with these emotions but have enough of a handle on them to still provide excellent care.

[Febrifuge]

There's no right answer. Consider the individual's own type of practice style, and what they need to do to maintain their own emotional health.

 

For some people, keeping the detachment and distance is absolutely critical, because it's a big part of how they think and operate as a clinician, and if the floodgates open they would be less effective. For others, anything they bottle up and don't express in a healthy and expiditious way is going to quickly become toxic. Some will want to send condolence cards, hold family members' hands, keep pictures of favorite patients on a corkboard. Some will go crazy if they don't get to make jokes in the staff lounge, or at the bar later on. Some will want to stay far away from fields where patients can be really sick. Some will live for the chance to fight to get someone back from the brink.

 

I think this is one of the reasons it's so important to have had real patient experience prior to PA school. It's downright cruel to expect some kid to have to figure out how they handle death and dying along with learning how to apply their medical training. I like to joke that if you haven't been at risk of having your scrubs doused with urine, vomit, or blood, you haven't had prior experience; maybe we could take it a step further and say if you haven't been part of both a successful and an unsuccessful resuscitation, you haven't had experience.

 

I was talking to a guy who had necrotizing fasciitis of his arm, after he was helicoptered in. He hadn't taken it seriously until he couldn't move it without 10/10 pain. He was just starting to understand the seriousness of his situation before the Surgery team asked the ED to intubate and ready the guy to go upstairs to the OR. He looked scared, so I held his hand (which helped to steady it for the IV going in).

 

He never woke up.

 

I went up an hour or so later to retrieve our cart from the OR area, and it was behind the doors in the operating suite. It had our portable defibrillator/ travel monitor on it... and the guy's entire arm from the shoulder down. The infection was into his chest wall and he had almost no chance. I eventually got the cart back, and we learned he had died.

 

"But hey," said the charge nurse, "you were holding his hand when he went under." She could see I was bothered by losing the guy, and she was right: it helped when she reminded me.

 

So to answer the question, it depends. For me, it was developing habits and attitudes that try to maximize the chance that the last thing I did before someone died was the right thing medically, but also from a human point of view. You can't predict and you can't plan, so just do what you do, and do it honestly. Feel however you feel. Recognize it for what it is. Then, get back to work.

[ItRainsItPours]

For me, it depends on the patient and the context. When the 85 yo paraplegic with multiple co-morbidities dies in his sleep in his nursing home that reeks of human waste I do not find myself feeling bad for the person's death. I feel worse about the QOL he had in his "golden" years. Many of my partners (I am an EMT not a PA) still find those deaths upsetting so it all depends. I think I'd feel worse if the patient was younger and still fighting to live, havent had one of those yet. Or a dead kid for that matter but I know my day is coming, Im still new into the job..

[EMEDPA]

I lost pts as a medic and er tech due to the typical emergencies.

my first pt I lost as a pa was a lot harder because I got to know the guy over the course of several visits. he was a nice older guy who reminded me of my gradfather. I used to see him for wound checks because he couldn't get in to see his pcp. his bp was always high and I always told him to talk to his doc about upping his htn meds and starting daily asa.

this was when I was a very new pa almost 20 years ago now.

when he had his stroke his wife called me at the er because he identified me as his pcp. in the hospital the pt refused all orders from the hospitalist until I agreed to them. it was a really bad ischemic stroke which likely would have been prevented by adequate bp control and a penny's worth of baby asa/day. I still feel bad about this.I visited him every day in the hospital. after he aspirated and died on hospital day 12 or so his wife came to see me and thank me for all I had done for him. she said I was the best doctor he had ever had.

I thanked her, walked outside and lost it. cried like a baby. I am tearing up right now thinking about it.

I think becoming involved in pts lives is a good thing. it keeps us human. in the moment of the emergency you need to do what is required, but it's ok to be sad later when things don't work out or happy when they do.

[Nonlegit]

I'm in agreement with Febrifuge and E's (edit: and the others) very insightful posts. I might add that the "tough cases" can come and go with a sort of irregularity thats hard to predict. This adds to the difficulty of processing some cases. Station in life (marriage/divorce, you have kids, someone in the family dies from something similiar, etc) and random chance can affect how you respond to each failed case or resuscitation or whatever. Sometimes outright bullsh!t tragedy befalls people. Had probably the toughest case of a 10 year career a weekend ago. Truly barbaric violence, ISIS-like. A true victim in all ways, as well.

 

In the end, we all deal differently. There are often employee assistance programs at work, and while I have never gone, I understand them to be helpful from those that have. I'm sure all of us could name unhealthy ways of coping, but I guess the onus is on you to make sure you have the proper self-awareness. However you do live your life outside of work should be positive and not distructive (ie: booze or apathy or something).

 

In my mind, I know I help some people, and we sometimes even save some people. Its worth it to keep slogging through for the next one.

[EMEDPA]

my way of dealing was writing an article about the experience and how it changed my practice patterns ( I start folks on bp meds and daily asa now in the er if I see them several times with htn and they have no realistic way of ever seeing a pcp or getting this tx any other way).

[SocialMedicine]

personal attachment as an internist is different than a psychiatrist. i do not advocate for socializing and dating patients. I think it is healthy to develop some affection and concern for people you have guided through tragic times. As a mental health provider you must be very guarded. Patients with mental illness sometimes do not see relationships the way you anticipate. Additionally, a friendship can sometimes bias you and create barriers to discussions issues such as sex and alcohol etc.