The husband and wife were brought in on a weekday morning. The smell was overwhelming. Despite their years of experience, the horror in the eyes of those around me — firefighters, paramedics, nurses, physicians — was striking. She was completely burned, unconscious and barely alive. The pink cotton underwear that I helped remove outlined the only area spared from full-thickness burns. Her husband had been doing renovations when a chemical exploded. The neighbours told the firefighters that he had originally escaped, only to go back into the engulfed house to bring out his wife.
He was in the next bed with full-thickness burns over ninety percent of his body, evidently in pain and very aware of his surroundings. The darkness of the burns contrasted with the whites of his wide, scared eyes.
There was a different pace in the room than I'd experienced in other trauma cases. The words “palliative now” were whispered. There was an odd quiet as a femoral line was urgently placed. The paramedics had been unable to get a peripheral line, so the patient had yet to receive sedation. The only mercy of a full-thickness burn is that the pain receptors are also destroyed; however; the pain was still so evident in his eyes.
I reflected afterwards that I do not remember anyone telling the patient about the horrific prognosis for him and his wife. We all knew as we sedated him with heavy narcotics that he likely would never wake up. I carry a powerful memory of looking straight into his eyes in those last moments of his conscious life — they were so white, so questioning.
In medical school we are instructed in the art of breaking bad news. We learn to prepare adequately, to allow sufficient time, to gauge how the patient is feeling, how much the patient wishes to know and can understand.
Little of this applies in the trauma suite where more than once I have looked into someone's terrified eyes, only to realize afterwards that I was one of the last people to make contact with that person. I struggle with these memories, and with the question of whether I have the right to tell or not to tell the patient that there is no hope.
Carolyn Snider PGY-2, Emergency Medicine University of Toronto Toronto, Ont.