After they'd injected the dying man with IV medications, after they'd pounded his chest, after they'd cut Robert Jackson open and jolted his heart with electricity, there was nothing left for Dr. Carnell Cooper, except to prepare for the moment doctors dread, the hardest job in medicine.
Cooper changed out of his bloodstained scrubs and tried to think through what to say. Then, heavy with the pain he was going to inflict on Jackson's girlfriend, he started the walk downstairs.Cooper and Dr. Steven Johnson came upon Annette Edmonds, 32, in the long hallway. She was standing alone, holding her arms tight against her body, waiting for them. The doctors cleared the other families from Maryland Shock Trauma Center's waiting room, turned off the blaring television and closed the door. The Baltimore woman sat on a small sofa and looked down at the carpet. Suddenly, the only sound that July night was the hum of the fluorescent lights.
"Is there anyone here with you?" Cooper asked. She shook her head no. Cooper pulled a chair close to her, and Johnson sat on her other side. Nurse Joe Larivey stood by. Then, slowly, gently, Johnson began. "Mr. Jackson suffered a serious injury. ... "
It is a painful, centuries-old ritual that physicians and nurses hate. They get little training for this moment, and no matter how many times they break news of a death, it never gets any easier. Many doctors struggle through this devastating conversation. But organized medicine has finally realized its importance, stepping up training nationwide for medical students, residents and even veteran physicians.
Nowhere is this task more difficult than in the nation's emergency rooms, where about 300,000 people die every year. The deaths are usually sudden, with no chance for goodbyes, and without the comfort of doctor and family knowing each other.
At Shock Trauma, part of the University of Maryland Medical Center in downtown Baltimore, the medical team handles 7,000 of the worst traumas in the region every year and manages to compile a 96 percent survival rate. But that still means that about five times a week, doctors and nurses will have to leave behind the science that so often shows them the way, walk into a room, and speak the most awful words in their vocabulary.
"You've just got to open your mouth and say it," said Dr. Thomas M. Scalea, 51, physician in chief of the 100-bed Shock Trauma hospital. "But it wears me down as I get older."
Said Cooper, 47: "My delivery has gotten better, but I don't think it's gotten a bit easier. It's still a family like my family. They feel the same pain that my family would feel. It's much easier to be up all night and operate for 10 hours."
All patients enter Shock Trauma through the Trauma Resuscitation Unit on the second floor. With the nursing station at its hub, the L-shaped unit has large areas ready for 10 patients, but on busy nights, the staff can handle twice that many.
In one four-hour stretch on a Friday night in late June, the trauma phone line buzzed a dozen times, each call announcing a new patient. The onslaught arrived by ambulance and helicopter: a man stabbed in the heart, a 21-year-old whose Mustang hit a tree head-on, a motorcyclist who ran into a guardrail, a Baltimore teen-ager bleeding from more than a dozen gunshot wounds. A routine shift.
Most of the nurses have worked here for years, long enough to have learned certain truths: Don't tell a family that you're calling from Shock Trauma, or they'll get so upset that they'll crash on the way to the hospital. When you spot pale feet on patients, it means they're probably bleeding to death. And when a patient says, "I'm going to die," he's almost always right.
'Don't leave me!'
The night of July 2, Edmonds had discovered Jackson, 38, screaming for help on the front steps of their Sandtown-Winchester rowhouse. Her boyfriend of four years had been beaten by a man with a baseball bat. She cradled Jackson's bloody head in her lap and pleaded with him to live. The couple, who both used heroin, were trying to make a new start: They'd finally found spots in a drug rehab program, and in two weeks, they were to be married. But by the time paramedics arrived, Jackson's heart had stopped.
At Shock Trauma, as Johnson spoke to her, Edmonds kept looking down, twisting her hands together, seeming to mentally block what she suspected he was going to say.
"When he arrived here, we did everything that we could for him," Johnson told her. Then he spoke the words that would be burned into her mind: "We were unable to resuscitate him."
For five long seconds, Edmonds said nothing. She began to rock, back and forth, until the cries burst out of her. "Oh God, no, no, no. Oh dear. Oh. No. No. NOOOOO!" she screamed, curling in on herself, sobbing, praying. "Oh God, don't leave me, don't leave me!"
Johnson put his arm around her, and she fell into him. On her other side, Cooper leaned closer and put his hand on her shoulder. He could feel her screams reverberating through his chest. They sat like that for a few minutes as she rocked herself and gasped for breath. Gradually, the long cries started to fade until she was letting out only small sobs.
It is an outpouring of emotion that the staff must endure. While some shocked relatives react to the news with a simple "thank you" and get up and walk away, most can't hold themselves together. Some women struggle to catch their breath. Other people wail or collapse on the floor.
Sometimes, the grief becomes violent, so the team is prepared: A nurse always goes down with the doctor, and when dealing with a large family, staff members will keep their backs to the door, ready for an easy escape. More than once, distraught relatives have smashed the nearby long glass bookcase. Just recently, a nurse and trauma technician were chased down the hall by an irate man who didn't think they'd done enough to save his relative.
In Edmonds' case, after she calmed down, Cooper told her in a tender voice that Jackson had never regained consciousness, and that once he got to the hospital, he was never in pain.
"We did everything we possibly could," the trauma surgeon assured her. "Do you have any questions for us?"
"No," she gasped, shaking. "No." Cooper told her that if she wanted, she could see Jackson's body soon. "OK," she answered, still trying to hold down sobs. "I'm OK."
Finally, she seemed to will herself into one piece. She looked up at them and said, "Thank you."
The doctors and nurse left, and once beyond the double doors, Cooper called for a chaplain for Edmonds. Then he put his hands on his head and let out a long agonized sigh.