May 13, 2023

Chair’s Corner: What (a) Difference

Beside her is her husband, leaning onto the gurney, holding her hand, and resting his head on her arm. She is holding her lower abdomen, with her neck flexed toward her chest and her eyes over-filled with tears that run down her cheek. She is holding her breath through the cramping. You knew before you walked into the room that this would be hard and emotional after reading the chief complaint: “6 weeks’ pregnant with vaginal bleeding.” Everyone in emergency medicine knows where this visit goes; it frequently ends with the finite and unforgiving news of a loss. It is a painful and confusing loss for any of us that have lived through it. A loss of what? Potential. Future. Hope. Reproduction. Infinity. Lasting lineage. Influence.

You obtain a history, and it is tragic: two prior pregnancies that both ended similarly with first trimester miscarriage. Your exam does not distract from your leading differential diagnosis of threatened abortion. After discussing your concerns with the patient and her husband, you gently hold her forearm and pause for a moment to be with her and her husband in silence. In your shared silence, you empathize, you mourn, and you dare to hope for the future for this family attempting to blossom.

While walking out of the room toward your work station, you take a deep breath and focus your mind on the medicine. You order the necessary labs and the ultrasound, which you suspect will confirm your leading differential. As you start working on her note, the ambulance radio interrupts you with a blaring report on an incoming patient with a short ETA, and just like that…you are onto the next patient.

After the chaos of the ambulance patient settles and you get back to your work station, you realize you have the ultrasound results on the woman in room 24. “Findings consistent with fetal demise.” You read it twice, then sigh and read it again. First trimester miscarriage is all too familiar, both personally and professionally. You check the labs and make sure the rest of the workup is okay for discharge to home, then you pause a moment. You reflect on your life, your experiences, and your prior discussions with similar patients and those who have led you through this discussion.

It was just three months ago when you were pregnant. You were 8 weeks’ along and feeling it: nausea, swollen breasts, bloating, and don’t forget the fatigue — who knew that would be so significant? Or was it the coffee withdrawals that drove the fatigue? Who knows, it was three months ago.

Three months ago, you woke with the familiar cramping and bleeding. Three months ago, you cramped, bled, and breathed your way through the night until you delivered the miscarriage. Three months ago, you took yourself to work your 12-hour ED shift the next morning, knowing you feel best when you’re helping others feel better. Three months ago, you endured your third first trimester miscarriage.

Our patients may see us as invincible, perfect, strong, and conquering. In some ways, we are, but our personal experiences impact our ability to care for our patients. How could it be any other way? We are all people. We are all human. We are all getting through “this thing called life,” as Prince so eloquently put it.

As you walk toward room 24 to deliver the news to the worried couple, you gather your experiences (both personally and professionally) and your emotions and construct a conversation plan. The woman hears you. She nods along and cries silently while holding her husband’s hand. He turns his eyes from you to his wife and back to you as the conversation develops. He is heartbroken — you see it on his face, in his posture, in his caring glances at his wife. You sit with them and just breathe. Silence can be so comforting sometimes. After a sit, you offer your sympathy and again review follow-up plans and return precautions. You wish them well and turn toward the door. The wife speaks up, “Thank you…really, thank you,” she continues, “This has been so hard, but you have been so wonderful. I’m glad it was you here to help us through this. Thank you.” What? You just broke both of their hearts, and she thanked you? Did she completely miss the conversation? Were you dreaming and the whole thing never happened? It is 03:00 in the morning and your third consecutive night shift, so maybe you’re over-tired. You look at her. Her eyes are puffy from crying, but they are…grateful. She is sincere and appreciated your bedside manner. She appreciated you as a fellow woman, you as her ED physician, you as her guide during this sadly familiar loss. You.

What a difference you made! Keep your head up and your heart grateful. You make a difference each day, each shift, each hour, each patient interaction. You make a difference.

Alecia Gende, DO, CAQSM, FACEP
Mayo Clinic Health System
La Crosse, WI



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