This week we were shocked and horrified when we heard the reporting and saw the images coming from Nashville in the wake of yet another school shooting. This time the lives of 3 young kids and 3 school staff at a private Christian School were prematurely snuffed out by the actions of a deranged individual who's motivation are not yet know.
All accounts of school shootings are tragic. But for me personally, this one hit particularly close to home. Though geographically distant from me, I have young children who are of similar age. And my kids attend a similar school. This story could just have easily been written about our school and my kids. I have the greatest confidence in our school administration's preparation, foresight, planning, and commitment to security. But the reality is that anyone intent on doing harm will seek to find a way to inflict evil on this world. That is a terrifying prospect as I entrust my precious children to the care of the school and its staff.
As we take a step back from the tragedy of this event and look at the broader landscape of medicine, we can see that healthcare is a career filled with tragedy - particularly in certain specialties like my own. We are daily faced with the morbidity, mortality, and sufferings of fellow human beings. We are daily confronted by the personification of groans of creation. And we are left with the question, how do we make sense of the tragedy that we see all around us? How do we read about Nashville then look at our kids without completely dissolving into paralyzing terror that this too may be our experience? Turning our faces and plugging our ears is neither feasible nor advisable - tragedy will find you. And allowing our hearts to become calloused by repeated inoculation to tragedy is an even worse option. As I reflect on these questions, 4 strategies come to mind.
Grieve
If there is one thing that we don’t do well in health care, it is to grieve. Grief is a deep sorrow following a significant loss or tragedy. We, as healthcare providers, are constantly exposed to tragedy. Either as a protective mechanism or out of necessity due to the business of a shift, we are forced to repress our emotional response to the pain and suffering of our patients somewhere deep and out of the way. We attempt to immediately move on as if nothing can phase us. In fact, early in my career, took pride in the thought that I was resilient enough to be able to stare tragedy in the face and remain steadfast. But for anyone with an ounce of humanity, this is just a fragile shell.
Several years ago, I was working a shift on our air-medical helicopter service. We were dispatched to the scene of a horrible car accident where we were to transport a young child to the hospital. For the next hour, my crew and I devoted all of our mental and physical resources to caring for this comatose child. On my way home from the shift, I found out from the medical team in the ED that this particular child later died caused by a substantial head injury from the crash.
For some reason, this particular encounter profoundly affected me. I couldn't stop thinking about the whole situation. I reviewed every step in the care that I gave. I thought about the precious life that was lost. I thought about how this kid's future was gone, how there was now an empty bedroom at their home. I thought about the grief that the family was experiencing. And added to all that, I just felt bad for reasons I couldn't fully understand. It felt as if I had lost someone close to me. For a couple days I couldn't sleep. So, I called one of my colleagues late at night and over the next 45 minutes or so we talked about the case.
I told him, that I felt horrible about the situation. But I also felt horrible that I was devoting so much mental attention to myself when I suffered no loss, but the parents of this child now had to process through the death of a child and the lingering effects of a now empty chair at the kitchen table. I said, "I feel bad that I feel bad." Over the course of our conversation, my colleague responded that it's ok to feel this way. As I look back on this scenario, it is now more evident that this experience was part of the grieving process. It is part of the process of making sense of a loss and finding healing.
There has been much written about the idea of grief. One of the famous models of dealing with grief is the Kubler-Ross model - otherwise known as the 5 stages of grief. It suggests that individuals going through grief pass through 5 stages: denial, anger, bargaining, depression, and acceptance. Subsequent research has suggested that this model is not entirely accurate. But whatever model we employ, it is evident that grief is not just a state but a process. It is the process of dealing with a loss and finding healing. It is the process of catharsis.
While grief is a process that we all go through in response to tragedy, the presence of grief also highlights several important ideas.
1. Grief is the recognition of the value of someone that is lost. We grieve because all humans have inherent worth and value. Even though I may not have a long, prior relationship with my patients prior to pronouncing the time of their death, that aching and emptiness I feel as I leave the room is a reminder that laying on the bed is the body that remains of a person - a person who had likes and dislikes, friends and family, a past and hopes for the future.
2. Grief recognizes the resulting void left by the person that is lost. Except for the people who are alone in this world, death leaves a large hole in the lives of others. A mother who is no longer there to care for her children. A daughter who will never walk an aisle with her father to be given in marriage. And even those who don't have family or friends to mourn, the tragedy of death is not diminished. When we emotionally feel the loss of these individual, though not in our own close circle of family or friends, recognize the impact that each individual has on others and on this world.
3. Grief is a representation of empathy over the fragility of life. Empathy is an important aspect of human-to-human connection. It frees us from the selfish pursuit of our own interests and allows us to enter into the experiences of others. Far from being inappropriate, self-absorbed, or narcissistic, my struggle with the loss of the young child was a reflection of empathy. It was a reminder that I am not some robotic and soulless automaton but a fellow human being. As healthcare providers, if we lose empathy, we lose the very soul of who we are. And we lose the greatest tool of healing that we can provide to our patients.
Cherish those around you
Every moment is a gift. Everything and every person around us is a gift. If you think about it, we did nothing to call our existence into being. And we do very little to practically maintain our existence on a daily basis. Sure, we eat, sleep and exercise. But we can't keep our heart beating, our kidneys filtering and our neurons firing. The tragedies that we encounter are a persistent reminder that nothing is secure, permanent, or guaranteed.
Frequently, as I put my children to bed, a fleeting thought crosses my mind that something might happen in the middle of the night, and they may not wake up tomorrow. While I try to mitigate as many potential and foreseeable threats to their existence, I have encountered too many tragic events in the lives of my patients. And I know that some things are out of my control.
The same thought applies to me as well. While I try to make good decisions, not place myself in harmful situations, and take care of my physical health, I have seen many young and otherwise healthy patients present with sudden and catastrophic health conditions. As I am wrapping up patient encounters, discussing the diagnosis and talking about what to expect, I frequently tell my patients that to the extent that I can predict the future, they will ultimately be fine. However, nothing is guaranteed. Theoretically, I quip, I could be hit by a bus on my way home. Life is fragile.
So, as we ponder the fragility of life, and allow ourselves to be affected by the gravity of tragedy, it is important for us to cherish the people that we hold dear. When I read articles about the tragedy in Nashville and see the faces of those affected, or when I experience a tragic patient encounter at work, my natural reaction is go home and hold my kids and spend time with them.
In the last several years, we have experienced and weathered a trying, worldwide, viral pandemic. This invisible pathogen caused a profound degree of morbidity and mortality and left a path of devastation and destruction in a social interaction that we have with one another. Whether it be the loss of a loved one, fear of contagion, or idiotic public policy, based more on virtue signaling than legitimate scientific merit, COVID has tragically pushed us apart.
However, these moments of tragedy give us the opportunity to reorient our perspective. They can remind us of what and who is truly important in life. The most important things aren’t the next big promotion, raise, or even the accumulation of stuff. It is the relationships that we forge. They are the exuberant welcome home from little voices so excited to greet me every day. Make every moment count as if it might be your last.
Mitigate manageable risk
To live is to experience risk. We live in a world of limits and entropy. We live in a world where suffering is a probability, not a just a possibility. In fact, it is probably not a matter of if you will suffer tragedy in your life, but a matter of when you will suffer tragedy.
That being said, a lot of the tragic things that we encounter are a result of decisions that we or others make. We have the opportunity to be careful or careless, wise, or foolish. We have been given a mind and a memory to be able to observe and think. We can anticipate that B follows A. And if B, then C might happen. We have the ability to anticipate risk. As we go through life, we develop experiences. We watch the experiences of others. We begin to develop a model of where risk may hide.
As the child of an ophthalmologist, safety glasses were a ubiquitous part of life's PPE. I was constantly being reminded of the need to protect my eyes. This risk mitigation requirement was borne out of numerous patient encounters where the final diagnosis was ocular foreign body. Early in my career, I wondered what unusual forms of risk mitigation I would impose on my family based on my clinical experiences as an Emergency Physician. And there are ways that my clinical experiences have informed opportunities for risk.
I mentioned earlier that I routinely think about the health and safety of my children. While I don't spend an excessive amount of time worrying about things outside my control, I am constantly looking out for things that my potentially cause harm. I have had one of my kids get his finger tied so tight in a hole of a knit blanket that he began to experience an ischemic digit. Another son choked on watermelon at the table requiring a 911 call. These experiences inform my understanding of risk. I don't leave my toddler unattended in the bath, I don't put my daughter to bed with a hair tie. I employ the safety locks on the windows of my son's second story window.
The tragedy in Nashville reminds us that we cannot foresee and mitigate all risk. Sometimes there are going to be things that are beyond our control. But in many ways, and in many situations, through a combination of clinical experience and a healthy imagination we can anticipate and mitigate manageable risk.
Live!
Finally, don’t live in fear, rather - Live! That's right, take time to grieve and hold close that you love and manage your risk. Then get up and live! Go out into this world and pursue your dreams, engage in the lives of those around you, seek meaning, and live in service to others. One of my favorite scenes is right after a bad storm. Even though foreboding clouds are still on the horizon, the sun begins to reemerge. There may be damage from the storm that just past, but there is also a sense of renewal. Though things got rough, we survived.
It is true that life is fragile. Tragedy happens. And suffering is an inevitable part of the human experience. But life can also be filled with a profound sense of joy, meaning, and fulfillment. In fact, these aspects of life are often most clearly seen when viewed superimposed on the backdrop of pain and suffering. We honor the memory of those who have suffered by grieving with them and for them, and then resiliently getting up and living boldly and in the service of others.
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