After they'd injected the dying man with IV medications, after they'd pounded his chest, after they'd cut Robert Jackson open and jolted his heart with electricity, there was nothing left for Dr. Carnell Cooper, except to prepare for the moment doctors dread, the hardest job in medicine.

Cooper changed out of his bloodstained scrubs and tried to think through what to say. Then, heavy with the pain he was going to inflict on Jackson's girlfriend, he started the walk downstairs.

Cooper and Dr. Steven Johnson came upon Annette Edmonds, 32, in the long hallway. She was standing alone, holding her arms tight against her body, waiting for them. The doctors cleared the other families from Maryland Shock Trauma Center's waiting room, turned off the blaring television and closed the door. The Baltimore woman sat on a small sofa and looked down at the carpet. Suddenly, the only sound that July night was the hum of the fluorescent lights.

"Is there anyone here with you?" Cooper asked. She shook her head no. Cooper pulled a chair close to her, and Johnson sat on her other side. Nurse Joe Larivey stood by. Then, slowly, gently, Johnson began. "Mr. Jackson suffered a serious injury...."

It is a painful, centuries-old ritual that physicians and nurses hate. They get little training for this moment, and no matter how many times they break news of a death, it never gets any easier. Many doctors struggle through this devastating conversation. But organized medicine has finally realized its importance, stepping up training nationwide for medical students, residents and even veteran physicians.

Nowhere is this task more difficult than in the nation's emergency rooms, where about 300,000 people die every year. The deaths are usually sudden, with no chance for goodbyes, and without the comfort of doctor and family knowing each other.

At Shock Trauma, part of the University of Maryland Medical Center in downtown Baltimore, the medical team handles 7,000 of the worst traumas in the region every year and manages to compile a 96 percent survival rate. But that still means that about five times a week, doctors and nurses will have to leave behind the science that so often shows them the way, walk into a room, and speak the most awful words in their vocabulary.

"You've just got to open your mouth and say it," said Dr. Thomas M. Scalea, 51, physician in chief of the 100-bed Shock Trauma hospital. "But it wears me down as I get older."

Said Cooper, 47: "My delivery has gotten better, but I don't think it's gotten a bit easier. It's still a family like my family. They feel the same pain that my family would feel. It's much easier to be up all night and operate for 10 hours."

All patients enter Shock Trauma through the Trauma Resuscitation Unit on the second floor. With the nursing station at its hub, the L-shaped unit has large areas ready for 10 patients, but on busy nights, the staff can handle twice that many.

In one four-hour stretch on a Friday night in late June, the trauma phone line buzzed a dozen times, each call announcing a new patient. The onslaught arrived by ambulance and helicopter: a man stabbed in the heart, a 21-year-old whose Mustang hit a tree head-on, a motorcyclist who ran into a guardrail, a Baltimore teen-ager bleeding from more than a dozen gunshot wounds. A routine shift.

Most of the nurses have worked here for years, long enough to have learned certain truths: Don't tell a family that you're calling from Shock Trauma, or they'll get so upset that they'll crash on the way to the hospital. When you spot pale feet on patients, it means they're probably bleeding to death. And when a patient says, "I'm going to die," he's almost always right.

'Don't leave me!'

The night of July 2, Edmonds had discovered Jackson, 38, screaming for help on the front steps of their Sandtown-Winchester rowhouse. Her boyfriend of four years had been beaten by a man with a baseball bat. She cradled Jackson's bloody head in her lap and pleaded with him to live. The couple, who both used heroin, were trying to make a new start: They'd finally found spots in a drug rehab program, and in two weeks, they were to be married. But by the time paramedics arrived, Jackson's heart had stopped.

At Shock Trauma, as Johnson spoke to her, Edmonds kept looking down, twisting her hands together, seeming to mentally block what she suspected he was going to say.

"When he arrived here, we did everything that we could for him," Johnson told her. Then he spoke the words that would be burned into her mind: "We were unable to resuscitate him."

For five long seconds, Edmonds said nothing. She began to rock, back and forth, until the cries burst out of her. "Oh God, no, no, no. Oh dear. Oh. No. No. NOOOOO!" she screamed, curling in on herself, sobbing, praying. "Oh God, don't leave me, don't leave me!"

Johnson put his arm around her, and she fell into him. On her other side, Cooper leaned closer and put his hand on her shoulder. He could feel her screams reverberating through his chest. They sat like that for a few minutes as she rocked herself and gasped for breath. Gradually, the long cries started to fade until she was letting out only small sobs.

It is an outpouring of emotion that the staff must endure. While some shocked relatives react to the news with a simple "thank you" and get up and walk away, most can't hold themselves together. Some women struggle to catch their breath. Other people wail or collapse on the floor.

Sometimes, the grief becomes violent, so the team is prepared: A nurse always goes down with the doctor, and when dealing with a large family, staff members will keep their backs to the door, ready for an easy escape. More than once, distraught relatives have smashed the nearby long glass bookcase. Just recently, a nurse and trauma technician were chased down the hall by an irate man who didn't think they'd done enough to save his relative.

In Edmonds' case, after she calmed down, Cooper told her in a tender voice that Jackson had never regained consciousness, and that once he got to the hospital, he was never in pain.

"We did everything we possibly could," the trauma surgeon assured her. "Do you have any questions for us?"

"No," she gasped, shaking. "No." Cooper told her that if she wanted, she could see Jackson's body soon. "OK," she answered, still trying to hold down sobs. "I'm OK."

Finally, she seemed to will herself into one piece. She looked up at them and said, "Thank you."

The doctors and nurse left, and once beyond the double doors, Cooper called for a chaplain for Edmonds. Then he put his hands on his head and let out a long agonized sigh.

"I can't cut out her pain. I can't give her something to relieve her pain. I can't do what I normally do to help my patient," he said. "Your only saving grace is that you know you've done everything you possibly could have done to save that patient. That's your only comfort."

Faith and Oreos

Deep down, though, many physicians feel that when a patient dies, they have failed. Doctors and nurses try to tell themselves they did everything they could. They try to encourage each other. Some want to believe it was the patient's fault - for driving too fast, or dealing drugs, or being careless at home or work. Others rely on faith or cope by munching on Oreos and gumballs at the nurses' station, sharing ghoulish jokes or even adopting a lost doll and performing fake operations on her. A few claim they've grown hard.

But when a staffer at Shock Trauma meets with a mother or a brother, the patient turns into a person. Nurses and doctors see someone die, and they realize it could have been anyone - their wife, their son. One trauma tech, Monica Nashan, instinctively sits by a child who has died, to hold a hand until parents arrive. When another tech, Julie Hall, gently cleans a body, readying it for the family to see, she finds herself whispering, "I'm sorry," to the dead. The staff is haunted by relatives who ask, "Why?" They don't have any answers for the families, or for themselves.

"In the end, it doesn't matter if I did everything I could; the kid is still dead, and you get really sad when someone dies," said Scalea. "Why did a drunk driver jump the curb and hit that kid? Why didn't that person buckle their seatbelt? A bunch of these people didn't have to die."

Some of the deaths have inspired him to do research, studies in geriatric trauma and the physiology of blood loss, which have saved lives. He tries to compartmentalize, he knows he needs to let go, but at home, he'll find himself thinking about a patient he lost, making a private farewell.

"Most of the time, you've never even spoken to them, yet you still feel that connection," Scalea said. "But it has to matter to you. You have to be able to hurt with the families."

Injury is the most common cause of death in people younger than 44, and experts say delivering bad news is the most important communication skill a surgeon can have. Yet very little research has been done about what families want in these situations. A 2000 study by Dr. Gregory J. Jurkovich of Seattle's Harborview Medical Center found the clarity of the message, privacy and the doctor's knowledge of the case were most important to families. So were sympathy and time for questions.

Unfortunately, doctors and nurses don't always heed that advice, especially when they're rushed. The Seattle study found that a third of the time, hospital staff delivered news of death in a hallway or other public space. Some physicians ramble on with vague, confusing medical terms or make an abrupt announcement and walk out. At the moment family members most need to let out their emotions, many nurses and doctors don't do what Cooper did; instead, they cut the relatives off with a slew of medical details.

But how this is handled matters a great deal.

First, people whose relatives die in a sudden accident or trauma struggle much more with coping, as well as depression and suicide, than do families who have time to say goodbye, studies have found. And when the news is broken in an insensitive way, research shows, these people suffer even more.

"When doctors handle it badly, families remember that for the rest of their lives," said Dr. Robert Shochet, an internist at Sinai Hospital and president of the American Academy on Physician and Patient, a medical group dedicated to improving communication among doctors, patients and families. "It's a flash point of trauma that they really have a hard time getting past."

Except for certain terminal illnesses, though, there has been little attention to breaking bad news. Within medicine, it has always been considered a gift, an innate skill - like a musician's perfect pitch, something that couldn't be taught. Typically, new doctors get little more than a lecture or a few hours of training on the topic and then watch a veteran do it a couple of times before they take the plunge themselves.

But that is beginning to change. Across the country, a cultural shift is under way in medicine as doctors realize the value of communication in everything from patients sticking to treatments, to fewer malpractice cases, to families dealing better with a death. Soon, before medical students graduate, they will have to sit down with actors and show they can break bad news with compassion. In hospitals, medical residents will be graded on these conversations. Even veteran physicians will have to prove they can do it appropriately.

At Shock Trauma, Scalea and other attending physicians make a point of bringing young doctors in on these talks. He teaches them to find a private space, to sit, hold a hand, be direct and skip euphemisms such as "passed on," or "expired," and instead use the verb "died." To give more support to families and staff, the hospital also wants to make permanent a successful pilot project in which chaplains were posted there overnight on weekends.

"Taking care of the family is part of taking care of the patient," said Scalea, who, as does Cooper, makes a personal phone call to the family a few weeks after a death to answer questions and see how relatives are doing. "What's more important than that?"

'Hanging crepe'

Sometimes, that means preparing a family for the worst possibility. Within medical circles, the practice is called "hanging crepe," a reference to the black fabric that drapes funeral homes. It is a delicate job, dealing with relatives who have been at work or asleep thinking their world is safe, when they get that terrible phone call, or a police officer knocking at their door. They arrive teary, trying to catch their breath after running down a hallway as long as a football field to get from the main lobby to Shock Trauma's waiting area.

At 3:20 a.m. on a July day, charge nurse Gael Whetstone left the busy unit, her mind clicking, worrying about what she would say to the mother and stepfather of a 22-year-old Baltimore man who had been hit in the head with a brick. For the past hour, Whetstone, Cooper and the rest of the team had been trying to stabilize the patient, Ben Galvan. His heart rate was dropping, and bleeding was putting pressure on his brain.

Whetstone found the Perry Hall couple in the waiting area and sat down with them. "Let me tell you what I know," she began, explaining that Galvan had been rushed into the operating room for brain surgery.

His mother, Veronica Tsitakis, put her hand on her forehead, gasping and starting to cry. Questions spilled out of her: "You're going to drill a hole in his head? Is he knocked out? Does he know it happened?" Tsitakis was trying to make sense of it all, but finally, it hit her. "Is he going to make it?"

Whetstone looked into her eyes. "He is critical," she said carefully and slowly. "Does he have brothers and sisters? You might want to give them a call."

Those words seemed to knock Tsitakis over. She fell against her husband, leaning on him until she could gather herself. At the end of the conversation, Whetstone promised she'd bring them up to see their son as soon as possible, and she gave the mother a long hug.

"If you speak from the heart, you'll always say the right thing," the nurse said later. "But you have to be able to go down there and sort of bare your soul, and then come back up and shift gears."

(In this case, the family recently got good news: Galvan was upgraded to stable condition and is in rehab.)

When there is no doubt that the patient is dying, the staff tries to give the family a chance to say goodbye. Sometimes, that means nurses must blurt out the news and then rush parents to the CT scanner or even into the operating room. Once, nurse Cheri Carver ran downstairs to bring up the parents of an Eastern Shore teen-ager who was in a bad car accident on her way home from the beach.

"I told them: 'She is not going to make it. But I need to bring you up if you are going to be with her,'" said Carver. She started to run, the parents tailing her up the stairs and through the Trauma Resuscitation Unit. It was midnight, the unit was full of patients; but the place seemed quiet, sad, respectful, recalled the girl's mother, Vivian Taylor. They reached the bedside, just as their daughter Dianna was taking her last breaths, enough time for the Taylors to tell her they loved her, that they would see her again. Enough time to notice someone had brushed out Dianna's long, blond hair.

"It was like she knew they were coming, and she was waiting for them," recalled Carver. The nurse reached into her backpack and pulled out a worn thank-you letter the Taylors had sent her a few weeks after Dianna's death in August 1997, along with her senior portrait. Dianna had dreamed of becoming a nurse at Shock Trauma.

"I always cry when I tell families. You think, 'What a waste,'" Carver said, wiping away tears. "She was a beautiful girl."

Patients not forgotten

From the housekeepers who mop up the blood to X-ray techs, nurses and the most senior physicians, staff members all have cases that stay with them. They remember the faces and the injuries and the last words, and years later, can point out in which bed a certain patient died. The team reviews every death to see whether there was anything else they could have done. They also talk about cases that bother them, and when one of the staff gets discouraged, a colleague will put a hand on his shoulder and remind him, "You can't save them all."

Sometimes, though, nothing can make the staff feel better. And all they can do for a family is be there in the final moments.

For one young nurse in particular, Amy Bositis, that case came in the early hours of Easter morning. Two patients arrived about the same time, and as often happens, they were from the same car crash. Within a few hours, word started to spread: The woman driving one car was not badly hurt, but the 30-year-old driver of the other car, Don Meadows of Crofton, had one of the worst brain injuries doctors had ever seen.

When the neurosurgeon went downstairs to talk with family members, the doctor found Michelle Desrosiers, 28, pacing, in a cold sweat. She and Meadows were to be married in one week. Desrosiers knew it must be serious for Meadows to be in Shock Trauma, and she realized there wouldn't be any big dance at their wedding, but she had hope - until she saw the physician's face and heard the words: "It doesn't look good."

Bositis, 25, the nurse who handled much of Meadows' care, knew the injury was fatal. But a part of her believed Meadows might have a chance, and she quickly found herself drawn into the family. They showed her pictures of the handsome, athletic salesman and told her stories about how he made friends everywhere and planned to raise children in the house he'd grown up in. Even tougher, the nurse noticed Meadows' fiancee had a Tiffany-setting engagement ring just like the one she was wearing. Then the nurse learned the Crofton couple's date was just one week before her wedding.

Twelve hours a day for three days, Bositis watched over Meadows, meticulously checking the pressure in his brain, managing his ventilator, talking to him, thinking what it would be like if this happened to her fiance.

On Thursday, the director of neurotrauma, Dr. Bizhan Aarabi, told a hushed room packed with family and friends that Meadows wouldn't survive without machines. The family didn't debate much: The day of the accident, Meadows had told his brother, Jason, that he'd never want to be kept alive like that. But before the final decision, the family talked with the nurse.

"They invited me in," Bositis said, "as if I was a part of their family."

On that last night, doctors removed Meadows from life support. Then, with Irish music playing, relatives and friends jammed his hospital room. Meadows' mother stood on one side of him, with Desrosiers on the other. Directly behind his bed were the nurses, Meadows' mother remembered, lined up in their pastel uniforms like a row of angels, with Bositis in the middle, keeping vigil.

Slowly, the room emptied out, and Desrosiers leaned close, giving the man who would have been her husband her last words, her last kisses. She clung to him until she felt a touch on her shoulder. It was the hand of the nurse, comforting her, giving her the strength to stand up and leave.