“He’s in here.  I went in and he just wouldn’t get up and . . . ,“  The woman’s frantic voice seems distant as I scan the home for hazards.  “My husband wasn’t feeling well when he went to bed last night and when I woke up this morning he wasn’t breathing.  Please help!”  I hear the ambulance announce its arrival over my radio as I arrive at the bedroom door.  I immediately notice lividity (gravity starts to pool blood to the lowest point once the heart has stopped and after time has passed makes that part look purple and bruised).  The body’s been down for some time but I cross the room and check for a pulse anyway.  There is no pulse and rigor mortise has started.
    “I’m sorry ma’am.”  I say turning towards her.  I see the tears in her eyes as I pick up my radio.  “Paramedic 8-2 to headquarters, priority 4.  Hold response to units on location.”  I stand and cross over to the dead man’s wife.  “There’s nothing we can do for him ma’am.  He’s been down too long.”
    “But can’t you shock his heart or give him some drugs or something?”
    “No, ma’am.  I’m sorry.”
    Medical providers, from doctors and nurses down to EMT’s and paramedics in the field have to constantly use the social communication concepts of role negotiation, role distancing, and role exit during their interactions with patients and their families.  I have been part of scenarios like the one described above time and again.  The patients view dramatic rescues on the TV and expect those same rescues to happen in real life.  Their expectation of our abilities and the roles we “should” play is often unrealistic.  The first few minutes of most of my encounters with serious patients involves me giving them a quick overview of what I can and can’t do.  I need to negotiate the role I will play.
    In the scene played out above, I knew the woman expected me to save her husband.  I also knew that in our rural area the chances of surviving a cardiac arrest are less than 5% unless there is a crew standing next to them when it happens.  It simply takes to long to arrive at the patient’s side (another reason I advocate more push for bystander CPR).  I know my role will usually be either pronouncing the patient dead or following the motions of working the arrest:  CPR, heart monitor, defibrillation if needed, giving medications, and driving the patient to the hospital where the doctor can pronounce the patient dead.  The roles of miraculous rescuer and “death pronouncer” are exclusive of one another.  I doubted that she would understand that I couldn’t save her husband.  I planned my role exit.  I was not going to meet her expectations of my role at all.
    Sometimes I don’t have to be so abrupt.  I can negotiate an understanding of my role in a patient’s care.  When I transport a patient who is in a lot of pain, I have to negotiate my role in lessening that pain.  Often the expectation is that I can get rid of it entirely.  I have to impress upon them that I can only give them enough morphine to take “the edge off” their pain.  I demonstrate that I understand their need for pain management and explain my role in that management program.  I use multiple resources to assist in the performance of that role like morphine, cold packs, splinting, reminding the driver to slow down, etc.  All of which lets the patient know that I’m the guy who cares about their pain.
    More role negotiation takes place when I show up for what the patient thinks is a minor problem and I diagnose a more serious condition.  For example, a wife notices her 50 year-old husband has been complaining of indigestion for several days.  She knows he doesn’t like to see the doctor but is worried about him.  When she notices he’s pale one afternoon, she calls 911 just to check him out.  The husband is very angry with her.  When I arrive on the ambulance he smiles and apologizes for our inconvenience.  “It’s nothing.”  He says.  “My wife is overreacting.”
    Time for me to negotiate.  I offer, “Well, sir, since we’re here why don’t we just check you out and then if you don’t want to go to the hospital you don’t have to.”  This is a true statement.  I’ll say so if I find no indications of any problem.  I have negotiated with him to let me play the role of care provider and that he play the role of patient for “just a little while”.  When I find that he has signs and symptoms of a cardiac problem, I can say that he should get a thorough check at the hospital.
    “Sir, you have all the signs and symptoms of a heart problem and even though I can’t see clear evidence on my monitor, I recommend that you come in to the hospital and get checked out.”  Usually this is enough to convince him that his expected role for the day of work or relaxing around the house has changed to a role of ambulance and hospital patient.  Role negotiation plays out all through most interactions with medical personnel.
    Role negotiation, role distance, and role exit are also involved in the process of grieving and terminal illness.  The 5 stages of grief as described by Elisabeth Kubler-Ross are all about the way patients interpret the roles they will play.  Denial and anger, the first two stages of grief, are our way of distancing ourselves from these roles we don’t want to play and our attempts to exit from the roles by refusing to play along.  By first refusing to admit that we even have a part to play and then raging against the other players, we attempt to distance ourselves from the loss we are facing.  By the time we reach the third step, bargaining, we are negotiating our role.  We have realized that we cannot escape the role forced on us.  Depression is our realization that we cannot negotiate our way out of it but we have not yet moved into acceptance, the final of the 5 stages.  This signals the end of our negotiations with life, God, our caregivers and family.  We will play the role.
    Health care providers also use role distancing.  We are often accused of being insensitive, but it is my ability to distance myself from the tragedies I witness that enables me to go out to the next one.  In the opening scenario of this article, I use role distancing several times.  I refer to the man on the floor as the “body” and I don’t pronounce him dead but call him “priority 4” or say he has been “down too long”.  This is just one of my ways of distancing myself from the death and dying I come into contact with on a weekly basis.  Euphemisms are one way we distance ourselves from tragedy. Another method of distancing is my usual coping mechanism for bad or disturbing situations.  It is humor:  sick, disgusting, and usually inappropriate humor.
    I have always been one to use humor in my daily interactions.  A former class clown, I easily fell into the gallows humor of emergency medicine. Ever wondered about the term “gallows humor?” It refers to the way the condemned would use humor to distance themselves from their impending death.  I have seen doctors use this as well.  A very large woman with extreme body odor came into the emergency room where I worked a few years ago.  She was having chest pains and after working her up, the doctor decided to admit her to the hospital on a heart telemetry or “Telly” unit.  The nurses and I had all made quiet comments about her weight and smell since it was quite overpowering but I hadn’t heard the doctor make a comment even though she had certainly overheard ours.  I was filling out the paperwork for the transfer upstairs and I asked the doctor, sitting next to me, what the official diagnosis would be.  She leaned my way and in a very quiet voice said, “Telly Tubby”.  We both started chuckling and she apologized for the comment, but the point had been made.  She needed to distance herself from the patient’s condition as much as the rest of us did.
    I use role distancing humor all of the time in the field.  In fact, it has been the patients where I couldn’t use role distancing effectively that have given me the most problems.  These calls have haunted me for weeks until time dulls the painful memory.  Usually, however, after a particularly gruesome accident scene I see something that strikes me as funny and I mention it to those around me.  They laugh and slap me on the back calling me “sick.”  I have changed the mood from one of somber seriousness to one that will let us get back to our lives and families in a few hours without too much difficulty.
    It’s 5:32 PM and I have just spent the last hour climbing all over a dead teenager trapped in the front seat of an overturned automobile while treating the live female passenger in the back.  After the firefighters cut the car away from her and we fly her out to the trauma center, I stand on the side of the road watching them extricate the boy’s body.  A few of my colleagues are with me talking about the patient we just flew out and her good chance of survival.  It is a very clinical though gruesome conversation.  I look down at my rescue gear.  I see bloodstains in several places including a big blob of blood and tissue stuck to the side of my shoe.  The words slip out before I even know I said them aloud.
    “Damn!  I’ve got dead guy on my shoe!”  My crew bursts out laughing along with me, all the tension of our last hour, broken by my inappropriate comment.  As I wipe the tears of laughter from my eyes I notice the parents of the boy still in the car, standing and watching as the firefighters remove his sheet draped body under the watchful eye of the funeral director.  Embarrassed, I walk away.

--------------------------

For more of roles, the presentation of self, and Goffman's theories of self go to the next page.