Annals of Medicine: Some Days

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In my line of work I have to break a lot of bad news. One of my professors once defined Emergency Medicine as the “bad outcomes business” and some days it does feel that way. Other days I witness lives saved and bad outcomes avoided. Some days I bounce from tragedy to hope like a pinball in a machine, energy expended and replenished with each new bounce. It is hard to tell if I am strengthened by these emotional challenges or worn down, but overall I feel richer for being present at some sacred moments in my patients’ lives.

On a recent day an elderly but still vital gentleman came into the ED in V-tach, our slang for ventricular tachycardia, a disturbance of heart rhythm and rate. In V-tach the ventricles, the main pumping chambers of the heart, overdrive the heart much faster than it can stand. There can be many causes for this including heart attacks. Occasionally V-tach can be a stable rhythm, but mostly it is unstable and rapidly progresses to death. This man was somewhere in the penumbra between stable and unstable. His blood pressure was dangerously low, but he was wide-awake, thinking clearly and denied any pain or distress. His heart rate was around 190 beats per minute. Yours is probably around 72 as you read this.

The treatment for V-tach depends on whether it is stable or unstable and the two treatments are dramatically different, so we had to decide “how unstable” this nice, witty man was. The definitive treatment for unstable V-tach is a strong electrical shock to the chest wall (cardioversion), but this is difficult to tolerate if the patient is wide awake, and this patient’s low blood pressure made safely sedating him a challenge.

Rare and life threatening events in the ED require significant manpower, and we are very good at spontaneous teamwork around these cases. We had two pharmacists, three nurses, three EMTs a respiratory therapist, several EM residents, a cardiology fellow and resident and, of course, me and the patient. This was a lively and knowledgeable crowd, and a vigorous debate about the right course of action flowed around the room. While we were still deciding, I had the pharmacists draw up a smallish dose of sedative so we would be prepared to move rapidly if need be.

In the end, the patient decided the issue by slumping over, vomiting and moaning, barely conscious, finally in distress. A small dose of sedative was given and a 200-joule shock was delivered to his chest. His entire body stiffened in a massive spasm that lifted him off the bed slightly.

“Whoa, that was a good one!” he declared before passing out completely as the sedative took full effect. His heart stopped briefly from the shock and then restarted, this time reset into a normal rhythm.

The dozen or so team members collectively exhaled a deeply held breath and grinned. The acute crisis was over and a much smaller team would see him through the recovery of what turned out to be a small heart attack.

While the staff was still celebrating, I moved on to another patient, a middle-aged lady whose cancer likely had returned. Her oncologist (cancer doctor) who had seen her through a year of treatment and six months of remission, was out of town and she was nervous and scared. I consulted our oncology service to come down and examine her to see if the cancer had returned.

Leaving her worried husband in the room she approached me privately and asked me to cancel the oncology consult.

“My doctor will be back next week. He knows me and has been with me through all of this. I would just rather he be the one to … well, you know, be the one to…” and her voice trailed off.

“Yes, of course,” I answered, as she clutched my hand.

The intern gave me a quizzical look when I told him to discharge her, undiagnosed. I explained her request but he was clearly confused and disappointed by this ending to the encounter.

“Why did she come in then?” he asked.

“Sometimes it’s a process,” I told him, knowing no explanation I gave him would make sense to his young, technically focused mind.

As the patient and her husband passed me on the way out they both shook my hand in deep gratitude and I wished them well.

Some days are like that.