The Policy of Truth

One summer afternoon, as a light rain coats a winding two-lane road, a father with his three children in an SUV overcompensates on a turn. In the subsequent accident, they are broadsided by a minivan traveling in the opposite direction. As the vehicles come to rest, the aftermath involves two adults and four children — three noncritical, two critical…and one fatality.

Arriving with the second-due advanced life support (ALS) unit, the first thing that strikes me is that some of the EMTs and firefighters on scene are crying. Everyone is moving around in that tightly contained chaos of a major accident scene, with tears freely streaming down their faces. The cause of their dismay is in the SUV: the macerated remains of a little girl entangled in the remnants of her seat, a grim-faced firefighter attempting to cover the sight from bystanders and responders alike. Where is her family?

We check in with the ALS unit already on scene. One medic is already enroute to the landing zone with one of children from the SUV, a little girl with a traumatic brain injury. The weather is starting to turn; we have enough time to fly just one before the skies close up on us. The other medic is in the ambulance with the passengers from the minivan: a father and his son, both secured to backboards. The medic directs us to a third ambulance, indicating that the remaining passengers from the SUV, the father and his young son, are in it. Before walking away I ask him, "What does the father know?" The response is, "Nobody's told him yet."

My partner and I enter the ambulance. A young boy is secured to a long board on the stretcher, crying hysterically. His father sits on the bench seat, trying to console him with litany of soothing phrases that do not wholly disguise the panic and fear in his voice. The volunteer EMT who had been left to care for them is overwhelmed and glad to see us.

The father is obviously injured, but absolutely refuses any attempt at intervention or care — he is focused solely on his son and, ultimately, all his children. He begins asking about his daughters — what is happening with his girls? My partner and I look at each other in dismay. What should we tell him? "I'm sorry, sir, but one of your girls is on a helicopter, and I have no idea how badly her brain is injured. Your other daughter is practically cleaved in two in what's left of your vehicle. Oh, and because you and I have never met, I have no idea which daughter is who."

We know what this information will do, how it will devastate him and undermine any chance we have at an appropriate level of care for him. But how do we not tell him what he wants to know? Do we lie? Do we ignore it? What if you were the parent? All these things jumble together in a Gordian knot that tongue-ties you and leaves you flailing for answers.

"What About My Girls?"

As a personal rule, I do not lie to my patients. I may omit, I may reword, but ultimately, if you ask me a direct question, I will answer you with the truth as best I know it. I think there needs to be an inherent trust between patient and care provider. Once violated, that is never recovered. And not just on a personal level, but with all providers to come after you. They won't remember your name, they won't be able to pick your face out of a line-up, but they will absolutely remember what you said to them and how it made them feel.

"How medics relate to survivors is vital, since at this pivotal moment, memories are seared into their minds and their behavior patterns may be radically altered. Even years after the event, many survivors recall not only the tone of voice and manner of speaking, but also the exact words medics said to them…Sometimes, EMS personnel don't have to say anything. Their attitude and non-verbal behavior say it all. This is especially true during rescues or body recoveries."

—Kenneth V. Iserson, MD
Grave Words: Notifying Survivors About Sudden, Unexpected Deaths