Our job as emergency medicine specialists requires a certain mental toughness. We spend years learning the ropes, understanding the incredible complexity of the human body and its extraordinary ability to recover from harm if given the right treatment.
Trauma – when someone suffers significant physical injury, often due to a violent event of some kind – can be challenging. People can arrive at the emergency department in a real mess, but you learn to deal with it. You run the program for that scenario, you stay focused and you don’t get emotionally involved.
If you have to tell someone that their loved one has died, that requires a different approach. That’s when the emotional part of you switches on. You connect with the person or people you’re talking to and let them know in however small a way that you cared about the person too, because they were your patient.
To inform someone that their wife has died is very hard. You build yourself up to it. You need to be present and vulnerable but at the same time professional and responsive. It’s very challenging. To do it once is hard enough. To have to do it more than once, in fact to have to deliver that news to the same person many times, is not something I ever expected to do.
In the early summer of 2014 four German tourists were driving back from a trip to King’s Canyon in the Northern Territory about 300km Southwest of Alice Springs where I work. They were two couples, husbands and wives in their mid-forties who were great friends and had been planning their trip to Australia for a long time. The day at the Canyon had been perfect and they were excitedly discussing where they would go next. The men in the front seats were wearing seat belts. The women in the back were not.
Somewhere along the Stuart Highway the driver lost control of the car. The family sedan they had hired flipped at high speed and rolled several times, ending up on its roof.
In this type of accident the car generally flips between three and seven times and at the speed they were going the damage was extraordinary. The car was a write off.
The problem is speed. If you’re going too fast and drift off to the side of the road, the instinct is to quickly turn the steering wheel to correct your course. But the roads out here aren’t like the highways that predominate in and around cities, with broad shoulders and roll guards. There’s a dirt patch where the shoulder should be and when you try to correct at high speed, the dirt catches the tyre rim and can flip the car. That’s what happened here. We see a lot of it in the NT.
The first we heard of the accident was a call saying there’d been an incident with four people on the Stuart Highway. The police were setting up a control area at the scene and a nurse from the clinic at Kings Canyon was on her way out there. I arranged for two emergency registrars who were doing a retrieval term with us to fly out on a PC-12 with the Royal Flying Doctor Service to meet the patients at the airstrip at Kings Canyon. They brought them back to the Alice.
Both women were dead. One was ejected from the car and had died instantly and the other died on impact when the car rolled over. Unlike the men in the front seat, neither had been wearing seat belts. The man in the passenger seat had a broken leg and some cuts and bruises but was otherwise fine. The driver had suffered a minor head injury and was concussed.
We laid him out in the resuscitation bay and went to work doing the ‘trauma work up’, checking him over to establish his condition.
He opened his eyes and looked around, confused.
“Where am I? What’s happened?”
I explained to him that he’d been in an accident. He and his friend were at the hospital in Alice Springs and were being cared for but his wife and her friend had both died.
He looked uncomprehending. Then the realisation hit him. His face crumpled and he began crying. No matter how often you see this, you never get used to it. As emergency medicine doctors we have to be able to deliver bad news but it’s not a part of the job you ever really get comfortable with.
Having delivered my awful news, I resumed working with the rest of the team, following the standard operating procedure for trauma cases. The man had stopped crying. Probably in shock, I thought.
“What – where am I? What’s – ?”
He was looking at me, clearly disorientated.
In concussion type events you sometimes see people repeat the same question because they haven’t been able to take in what’s happened. It’s called perseveration. The brain has taken a knock and can’t process an experience, so the patient has to be told about it – and relive it – all over again.
No-one had stopped working but I could feel my entire team was on edge, waiting to see how I’d deal with this situation.
I explained to the man that he’d been in an accident. I told him where he was and what had happened. That his wife had died.
It wasn’t any easier the second time.
The man’s response was almost exactly the same. A look of blank incomprehension, then a moment of awful understanding and tears. He was understanding that his life had changed irrevocably, that he had been broken in a way that was deeper than any physical wound.
The business of the trauma procedure took over once again. I concentrated on the task at hand, treating the man’s injuries so he would at least be able to walk out of my emergency department in a reasonably fit state.
“What – what’s happening?”
It was the man’s voice again.
I met the eye of the resus nurse. No, it can’t be.
It happened over a dozen times.
Each time was horrendous. Each time felt like handing someone a live hand grenade that was about to go off. Each time the surreal horror of it spread a little deeper into me and the rest of my team.
Eventually the news seemed to sink in. The man grew quiet and lay there staring into space.
We supported him and his friend as best we could over the following days, helping them contact family and friends, deal with insurance companies and arrange for their return – and the transport of the bodies – back to Germany. After four days they were able to leave.
Each traffic accident is like a stone thrown in a pond. At the centre is the victims – the driver and passengers who are killed or injured. Then come the family and friends who lose people they love or have to deal with their physical and emotional scars. Then there’s the police and emergency services teams who have to visit the roadside.
Then there’s the emergency medicine staff.
We often see traffic accidents like this in the Alice Springs ED. Speed is almost always a factor. The fact is that every high speed traffic accident could be mitigated or even avoided if the vehicle was travelling at a lower speeds. In this context, having an open speed limit – as is the case now on sections of the Stuart Highway – is madness. People say there hasn’t been an accident yet, but that doesn’t mean it won’t happen. If it does happen, the lack of speed limit is likely to play a factor in making the accident worse than it would otherwise have been. Comparisons to the autobahn in Germany are frankly ridiculous. The German roads are far superior to those we have in the NT and don’t have camels and kangaroos running across them.
And wearing seat belts should be a given.
The impact that these accidents have on emergency medicine staff is only a shadow of the pain and suffering that is experienced by family and friends of the victims, but it is an impact all the same. My entire team was deeply affected by what that man went through. I know I will never forget his face. Having to tell him again and again that his wife had died was one of the hardest things I’ve ever had to do. Had the car not been going so fast, it’s possible that I wouldn’t have had to do it. His wife and her friend might still be alive. It all might never have happened.