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Death After Life

I had a pretty terrific childhood, thanks to my family and friends like Gary and Joel. We came of age during the ’60s, when generations of civic values were challenged by social instability. That should have mattered more to us, but we were too busy testing limits imposed by parents, teachers, bosses and bartenders.

Last autumn, Gary and I visited Joel at his home in Kansas. Joel had been sick. I didn’t know much about his condition until I saw him for the first time in 37 years. Joel, whose size and physical prowess as a young man had been equal to Gary’s plus mine, was gaunt and stooped, like so many patients I’d seen. I felt myself sliding into medic mode, despite my reluctance to turn our reunion into a house call.

I wasn’t surprised when Joel died in May. I wasn’t anything. According to my hardwired Kennedy-era sensibilities, mourning was a luxury neither John Wayne nor I could afford. Both of us had to keep our heads clear to deal with the next indignity, or rescue, or Indian uprising. Death, to me, had become just another outcome, declared and documented whenever time, training or technology wasn’t enough.

I’ve written before about the dangers of red-bagging emotions. Lately I’ve tried taking my own advice, so easily dispensed in the abstract: Feel, speak, heal. I omitted the part about which button to push to make that happen, possibly because I had no idea.

Since the American Heart Association literally wrote the book on critical care, I went back to my ACLS text for answers. The only guidance I could find about dealing with death is to accept pronouncement as the end of life. I’m fine with that—when I’m the one doing the pronouncing. It’s different for families of the newly dead.

Psychiatrist Elisabeth Kübler-Ross wrote that grief often presents in five stages: denial, anger, bargaining, depression and acceptance. I didn’t sense any of those when Joel died. Maybe I wasn’t supposed to. Kübler-Ross eventually downplayed her theory, and conceded “There is not a typical response to loss, as there is no typical loss.” I’d say Joel’s death was “atypical” for me; he was a close friend, not a patient. Shouldn’t that have made it easier to grieve?

Years of censoring sadness often leave us spiritually tongue-tied when facing tragedy away from our 9-1-1 worlds. It takes time for sentiments to spool up, even at a safe distance from EMS. Some of us never regain a desire to feel. That’s a big sacrifice, just to stay numb to the random horrors of rescue. Stoicism looks good on tape, but compromises health and home life when no one is watching.

Some colleagues present with reactionary, rather than repressed, feelings. To them, everything is funny and everything is sad. You’ll find their punch lines about human frailty in the chat room of your choice. Take the high road with those folks; they’re hurting too.

EMS alters our death perception. Unlike the public, we react more to the dying than the dead. Our jobs require as much, in the absence of advance directives or family decisions to the contrary. When patients die in our presence, that’s as hard as it gets. I try retreating to a safe corner of my psyche to sidestep the emotional static of end-stage living, but that doesn’t always work. I think most coworkers respond as I do, although Kübler-Ross says, “Our grieving is as individual as our lives.” Perhaps that’s true outside of EMS; there isn’t much room for individuality in an industry driven by protocols and peer pressure.

The best approach for me has been to differentiate between death as an outcome and death as a loss. The former is unpleasant business, the latter is personal. It’s taken me a long time to recognize a sense of loss as something to build on, rather than something to avoid.

I realized what I miss most when I lose someone close is the link between that person and my past. I began to visualize my life as a wheel, with me at the hub, and spokes representing connections between people and memories. When death intrudes, spokes break, and the wheel becomes wobbly. The only way to stabilize it is to replace old spokes with new ones; make fresh memories with friends and family. To dwell on broken spokes—connections that no longer exist—is to accentuate, rather than accept, loss.

The patient-provider relationship in EMS shouldn’t qualify for hub-spoke treatment. That doesn’t mean we don’t care about outcomes; we can be sympathetic and conscientious without vesting in memories.

Thanks, Joel. I think I get it now.

Bibliography Coping with grief and loss,
Henry M, Stapleton E. EMT Prehospital Care, 3rd ed. MosbyJems, 2004.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at

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