John Graham-Pole

Professional Grief

Show me the data that solemnity ever cured anything, Patch Adams, MD

 There’s a term for it. For the grief that caregivers experience when we lose one of our patients. We call it “professional grief”—a phrase that in its clinical dryness captures the all-too-rare acknowledgment of its very existence. We may be trained to help the immediate family of one who dies, but few if any of us are taught to deal with our own often-confused feelings of sadness and helplessness. My friend, Patch Adams, once challenged me: “Show me the data that solemnity ever cured anything.” And every so often, I have been witness to a healing dose of humor in the presence of such tragic situations.

This story recalls a gathering of pediatric intensive care unit (PICU) nurses I was invited to sit in on. I call it Marshmallows.

“So why’d you ask me?”

“Well, you’re up here a lot,” Edith, our PICU nurse manager, responded.

True enough. Pediatric oncologists spend a good bit of time on the Intensive Care floor—and things don’t often go too well.

“You’re a good bit older, too.”

“Is it that obvious?”

“Oh, you’re still a kid to me. But they don’t know that.”

Edith was referring to the seven nurses who were about to descend on her office. We both giggled—she was maybe in her late thirties and I wouldn’t see sixty again.

“Yeah, I guess I’ve been around the block a few times. And I’ve probably got twenty years on any of the PICU docs.”

“I haven’t invited them, by the way. Just the nurses and you. They’ll think you’re here because of Ella.”

Ella had been one of my patients. End-stage glioma—and the most recent child to die on the unit. She had lapsed into a coma before she got transferred up from the pediatric ward. If I’d had my druthers I would never have moved her to intensive care, but I’ve learned what hills to die on. The little girl hadn’t been feeling much of anything when they put out yet another code after she had already taken her final breath.

“So they don’t have to know you’re really here to hold my hand if the going gets tough,” Edith added.

I knew what she was getting at. A couple of the senior nurses could be hard to handle. Edith had told me earlier that they had lost five patients in the last two weeks. She’d called this meeting because of the tensions building between the nurses and ICU doctors. Rose—the nurse caring for Ella when she died—had come close to boiling point with the attending doc—Dave, I’ll call him—and his over-heroic efforts. Her opinion, anyway.

A brief knock on the door and the nurses started filing in. There were only two vacant chairs, so the rest sat on the carpet and leant up against the legs of the ones in the chairs. There was some friendly jostling as the room filled to capacity. I knew all seven nurses by sight, several by name. I sensed they all knew me, the way nurses know all the docs who work on their unit. Things settled to an expectant silence as Edith looked around at each of us in turn.

“It’s been real hard here lately, we all know that. So this is just a place for you to vent, share your feelings, anything you want.”

Rose spoke right up. “Too right it’s been hard. Some of those kids were never going to make it. But the docs just can’t seem to get it sometimes.”

Annie picked it up. “Yeah, with that last code—as soon as Dave finally called a halt, he just went straight back on rounds. Like nothing had happened. Left it to the intern to break the news to the mom. Jeez, he’s an unfeeling brute.”

Her outburst gave everyone permission to blow the lid off.

“I never thought it could get this bad …”

“Five deaths in—what, a week and a half …”

“Some of those guys just don’t know when to stop …”

“Maybe we should have called an ethics consult …”

“My boyfriend’s getting pissed at me, crying every night …”

“Mine took off. I’m about ready to quit …”

The cacophony went on for several minutes. Two nurses were crying freely, feeling the unspoken permission, venting feelings too long held in check. A sense of release began to surface around the room, but Edith let things run, knowing they needed to do this. As things quieted, she stretched out both hands to the two closest nurses, and the rest took the cue, hugging and holding hands. Tears gave way to brief grins. I laid a hand on the shoulder of Mia, whose back was propped against my knees. She freed her own hand, raised it to grasp mine and return my squeeze. My throat thickened. I grabbed at a handy box of tissues and blew my nose, then offered the used tissue to Mia. Grins became guffaws. Edith took time to embrace everyone with her beaming smile.

“Thanks for coming—all of you. And feeling you could say your piece. We’ve all got a lot of crying to do. So to hell with boyfriends who can’t hack it. There really are some good men out there!” More giggles. “Hey, maybe Dave could use a few hugs. Can’t hurt, might help!”

Rose looked at Edith like she was about to nix the very idea, but she stayed quiet. Maybe she was even picturing the scene?

“Just be sure you don’t blame yourselves,” Edith went on. “Like things could have turned out fine if you’d done things differently. Second-guessing can keep you awake all night.” She paused to take in everyone in turn. “Just know you did your best. I’m real happy you all decided to work here.”

Which got the sniffles going once more. I realized none of the nurses had launched any more attacks on the doctors after their first salvos. The anger had surfaced fast and hard then quickly opened up to expressions of grief. Like everyone knew that that was the core thing, this big knot of helplessness and heartache. That shedding it was what this precious time was for—not for blaming absentee doctors for their decisions and actions.

Rose freed up a hand to open a couple of packs of marshmallows. They made the rounds along with someone’s flask of Gatorade—no one seemed bothered about drinking from the same container. People grabbed handfuls of candy like they hadn’t eaten for a week. After a bunch of face-stuffing and munching, one suddenly flew through the air and caught Rose full in the chest. Someone yelled, “Marshmallow fight!” cuing Rose to hurl several back in the general direction that the first missile had been launched. Everyone began scrambling for larger handfuls and slinging them in random directions, tears fast giving way to screams and guffaws. After several minutes of bedlam, the energy started to stall.

Rose finally yelled out, “Okay, you can eat them up now!”

There were no takers: most of the marshmallows had gathered a coating of rug or been ground under knees or butts. The brief feast over, we set about working with damp cloths from the bathroom, wiping off bits of goo from chairs and rugs.

“Anyone need their butt wiped?” Annie offered to more releases of laughter.

As I left, I checked my watch. Less than an hour—not too long out of a 168-hour week. And nobody was going to burn out today. Someone’s  boyfriend might even get a big grin and a kiss tonight.