The Other Side of Patient Care

We respond to save lives. When we can’t, we render a different kind of care to our patient’s survivors.

In my experience, the following components make a successful firefighter wellness program: 

A Strong Foundation
• Focus on taking care of the customer (developing and applying compassion)
• Focus on taking care of self and others (training in  stress resistance, resilience, and recovery) 

Behavioral-Health Program Development
• Peer team and outside resource development
• Operational guidelines Continuing 

Behavioral-Health Education Classes
• How to have difficult conversations
• Maintaining successful relationships
• Dealing with change 

Let’s focus at the beginning— taking care of the customer. For the purposes of this article, our customers are not only our patients but also the loved ones of those we are treating/helping. When looking at firefighter behavioral health questionnaires that I distribute to area fire departments, dealing with family members at the scene consistently ranks among the Top 10 most stressful situations in the field. 

Consider the following scenario: A crew is working in the firehouse one day when a young mother rushes in and hands a crewmember a limp child. She begs the crew to save the child’s life, but the child clearly is dead. How do responders tell her this? We are not taught how to have these types of conversations during firefighter training, nor do we learn it in paramedic school. Yet how we handle these situations can have a tremendous impact on the young mother and on a first responder’s mental health as well. 

Handling distraught family members with compassion and tact is important for everyone involved. Typically, if something happens that a person couldn’t have predicted when they woke up that day (e.g. witnessing a tragedy, someone telling them their loved one is dead, etc.), their brain goes into a crisis response, and what we do as responders during this critical time can not only set the stage for this person’s eventual recovery from the event, but it can also set the stage for healthier first responders. 

If you are unsure how to treat someone during a crisis, remember the Golden Rule: Do Unto Others. Ask yourself how you would want yourself or one of your loved ones to be treated in the same situation, and keep the following tenets in mind.

~ Allow significant others to spend time with their loved one
~Convey caring
~ Allow grief
~ Offer continued support
~ Respect the body

A Gentle, Staggered Approach to Difficult News
Let’s apply these principles to our example. Be truthful: The brain remembers trauma, everything you say will be remembered. Answer questions honestly. If the young mother asks why you’re not trying to resuscitate her child, you might state, “I am so sorry but your child is dead.” 

Dose out the bad news: A jolt of bad news can shock a person’s emotional, intellectual and physical systems—despite the fact that they are designed to withstand enormous stress. Extremely high levels of stress can trigger asthma and panic attacks, and can increase the heart rate and blood pressure to unsafe levels. To keep from overwhelming the mind, body and emotions, we should dose out bad news slowly. Doses are bits of news followed by silence that allow a person to process what they just heard. For example: We may tell this woman while assessing her child, “Your child is not breathing, and her heart is not beating.” If there is going to be an attempt to resuscitate the child, explain honestly what responders are doing and the child’s response, or lack thereof, to the treatment. “We are going to press on your child’s chest to attempt to get the heart started. We are going to put a tube into your child’s throat to breath for her. We are going to start an I.V. (or I.O.) to help give your child medications to help start her heart… If the intervention is not working, be honest in “dosing” the news. “I’m sorry, but your child is not responding to any of our interventions.” 

If there is no intervention, you can go onto the next dose: “It is difficult for me to tell you that your child is dead.” Or  “I am so sorry, your child is dead.” 

Allow significant others to spend time with their loved one: Doing this conjures up all sorts of emotions for first responders. It is time to put your own thoughts aside and “do unto others…” People who are allowed to spend time with their family members at the time of death do better emotionally in the long run. Most of these people will have a strong urge to be beside their loved one, to not let them be alone, to comfort and hold them, and we as responders can certainly help facilitate this. 

Explain what they will see. Be honest. If there is blood, disfigurement or other abnormal sights, tell the family and give them the choice to be with the body. Be honest. “It appears your loved one may have been hit by a car. There is some facial damage, and you may not recognize the person as your loved one.” Ideally, and if possible, cover disfigured bodies; let the family uncover what they choose to see.  In “No Time for Goodbyes: Coping with Sorrow, Anger, and Injustice After a Tragic Death,” author Janice Harris Lord states, “Survivors should be allowed to make a choice about seeing, touching, or holding the body of their loved one.” 

Convey caring: We can’t always change the outcome of an emergency incident, but what we can do is leave the grieving family members with the impression that we cared! We do this by treating people with the same care and respect. Whether or not we ever meet these people again, I can assure you that they will remember your kindness when they reflect upon the incident. 

Offer continued support: What’s available from your organization or community to assist these people? I don’t like leaving them alone. Does your organization have chaplains or other community crisis responders available? Is there a neighbor they feel comfortable with, or do they belong to a church you can contact? If you can’t find someone to sit with these folks, the organizations I have worked for will keep the crews on scene as long as it takes to get support. 

Respect the body: Whenever possible, covering the body shows respect for the deceased and their family. If covering is not an option, explain to the family why it is not possible. If we as responders treat a body with the same care and respect we would want our loved ones treated, we will do better emotionally in the long run.

It’s Not Just Touchy-Feely Mumbo Jumbo 
I was presenting at a large metropolitan fire department several years ago. I had just reviewed an incident where an 18-year-old girl was killed by a drunken driver, and her family showed up at the scene. I took the audience through our interaction with the parents: Being honest, dosing out the news, allowing the family to be with her, conveying caring, allowing grief, offering continued support and treating the body with respect. After we discussed this, a firefighter commented that our stress debriefings must be going through the roof with all that “touchy-feely stuff you guys do out there in Oregon.” I explained that we actually do little stress debriefing. As tragic as it was, we left the scene feeling good about what we had accomplished, and you don’t debrief incidents where you leave feeling good. I explained that my crew realized we couldn’t change what had happened to this young girl, but we could leave the family with the imprint that we cared! That felt good. Did we talk about the incident when we got back to the fire house? Yup! Did we need to debrief? Nope! 

Stanford University School of Medicine has done extensive research on compassion and the human brain. Stanford’s study showed that practicing compassion triggers the pleasure centers within the brain’s frontal lobes, lowers depression and anxiety, strengthens immunity, reduces the risk for high blood pressure and obesity, and contributes to longer life expectancy.  It’s important to note that practicing compassion at an emergency scene does not mean shouldering the grief of others. Compassion is simply the authentic desire to help someone when we see them suffering. 

Doing unto others, i.e. treating others (living or deceased) the way we would want ourselves or our loved ones treated, is neither expensive nor is it complicated. Showing respect and compassion, providing adequate information, guidance and access to the body of a loved one are kindnesses that will always be remembered long after the incident, and a kind and gentle approach to managing tragic scenes will do much to assist the bereaved as well as the responders.