The Look

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Dear Editor:

I saw the look again yesterday. There was a copy of the Journal of Emergency Nursing in the break room of our emergency department. On the cover was a photo of a young Army nurse holding an injured Iraqi child. The child was swaddled in blankets but the exposed face and leg bore the marks of an IED explosion, peppering as we called it. I pointed out the picture to Chris, one of our nurses and said, “This picture speaks volumes.” “Yes,” she agreed, “that poor child. It isn't fair.” But I wasn't talking about the child. The nurse was what drew my attention and the expression on her face took me right back to an ER tent in Iraq. Her eyes were open wide with a deep and profound sorrow and I knew I'd seen that look before. Our nurses, techs, and docs all displayed it at some point during my 2-month deployment to the Air Force Theater Hospital in Balad, Iraq. It's not the brief expression of horror one has upon viewing a tragedy such as the Indonesian tsunami or a violent car crash on the side of the road. Those are too distant and impersonal. “How terrible,” is all the mind can muster and we quickly return to whatever trivia occupies our days. No, this was the look of one whose tragedy was intimate. She held this tiny child and her gaze told me that her defenses were down and she was sharing, no, absorbing, pain from her little charge.

ER types, we pride ourselves on our clinical detachment and coolness under fire. “Nothing works up an appetite like a good Code! I've seen worse. Ain't no big thing” We wash off the blood or whatever bodily fluid of the day has stained our hands and press on. Steady strain, no problem. I was surprised while in Iraq, that despite the horror of the situation, I seemed to be doing rather well, …steady strain, no problem. As I trained my replacement, a terrified Family Practice doc drafted to the emergency department at the last minute, he asked how I could be so calm in the midst of all this mayhem. Well, no use getting upset at every little thing, …steady strain, no problem, it's what we do…right? We talked trash, planned jokes on each other, and played Texas Hold 'em right up until the Blackhawks landed on the pad. Anything but admit that we were taking emotional hits every time another victim rolled through the door. It wasn't until I got home and started to sort through my pictures that it struck me. There's the look. “E,” one of our techs staring sadly at a dying soldier. His chest was opened in the emergency department in a valiant but futile effort to save his life. Her gaze is fixed on his pale face and the look says, “I'm here, I'll share your pain, help you shoulder that unbearable load, bear witness to your sacrifice. Part of me will go with you.” Next picture. Ken, an ER doc, sizes up an unseen patient and he has the look. Shields down, the misery goes straight into the soul. Without our knowledge, it wounds and reworks our psyche but the damage assessment must wait. Steady strain, no problem. Flash back to my last patient at Balad. As the radio announced their imminent arrival I remember saying, “please, no kids.” But there were kids, there were always kids. He was riding in the family car; Mom had just picked up big brother from the main gate when a car full of insurgents pulled alongside and showered them with AK-47 rounds. He was an 8-year-old, just like my first patient there, and his right femur was shattered by a bullet. As I replay the scene, watching from my out-of-body perspective, I have the look. Its OK little one, we'll help you, share your pain, comfort your mother. And then it's gone. Back to work, clean up, prepare for the next wave, get some food, have a laugh or two… steady strain, no problem.

I remember seeing pictures of Viet Nam vets with “the thousand yard stare” but this is different. Our look is not that of the used up or hollowed out. We weren't burned out by the experience…but we were burned. We've held and stood next to the victims of unspeakable violence. We lined the hall and saluted our flag draped brothers at the start of their final ride. While on duty, we bore the steady strain and accomplished the mission, no problem. Now I'm safely home and back with the wife and children I love, back to work, back to church, back to everything as it was before. Yet, I am briefly lost in thought as I return the look to the nurse on the journal cover, and I know I am forever changed. Soldier on Captain, you do us proud. Keep your eyes open and soak up some of that pain from your young patient, you're strong enough. There will be time when you get home to sort it all out, steady strain, no problem…

Shakespeare's Henry V tells his men on St. Crispian's Day, just before the battle of Agincourt, “He that outlives this day, and comes safe home, will stand a tip-toe when this day is nam'd, and rouse him at the name of Crispian. He that shall live this day, and see old age, will yearly on the vigil feast his neighbours, and say 'To-morrow is Saint Crispian.' Then will he strip his sleeve and show his scars, and say 'These wounds I had on Crispian's day.' But we medics have no scars up our sleeves. If you would know us as part of that few, that happy few, that band of brothers (and sisters), watch our faces and you may catch for a fleeting second, our scar; the look.