‘This guy doesn’t look good.’

There are phrases in emergency medicine that mean pure, smoldering badness. The best-known is, “I don’t feel so good …” To hear a patient say the phrase and give him your undivided attention makes you worth the stitching on your scrubs. This comes from the experiences of watching many patients begin to die minutes later.

“Patients just know it’s coming,” we say, fully believing that people in extremis foresee their upcoming demise. When my physician assistant said, “This guy doesn’t look good,” I tensed involuntarily, mind and muscle mobilized for combat. This was my faith in a trusted colleague with a track record of great clinical judgment. I was in the room seconds later watching a pale, sweaty man grimacing as if an alien within was trying to burst out, burrowing to the surface.

Frank, our clinical care technician, handed me an EKG, and I could see the monster’s face through the pink gridlines.

A left bundle branch block with QRS – concordant ST depressions in the precordial leads. The EKG computer read the cardiogram innocuously as, “Interventricular Conduction Delay,” but I saw an acute myocardial infarction, a wolf in sheep’s clothing. The monitor beeped ominously and a couplet of ventricular complexes sailed across the screen. The beast growled at me, showing fangs.

I always bring friends into the room. They are those who worked so hard to teach me skills, judgment and presence, which I rely on in every battle. They started with a nervous novice, knowledgeable but confused, curious yet resistant, overconfident yet often paralyzed with indecision.

They believed I was worth the effort. They had faith in me. So through their unforgettable lessons they contribute whenever it matters. “Understand the patient” (Lewis), “understand the process” (Neal), “understand the logistics,” (Jeff), “anticipate” (Suzie). Having faith in the wisdom of my pantheon, I followed their advice that day. Amiodarone infusion, though not technically necessary, was begun, while the Code MI team was activated and the cardiologist was awakened and persuaded to come in. Only minutes passed as I completed the routines. Suddenly, a loud alarm demanded attention.

Rate of 250 on telemetry, commotion in the room, and I ran there, which is rare at work. He was dead, blank ceiling stare, gray skin. Ventricular tachycardia. I thumped his chest with my fist, for old-time sake, and began CPR. People piled into the small room and Frank took over compressions, freeing me to think and command. The body stiffened under Frank’s hands, the patient’s implanted defibrillator going off with no success. We exchanged glances, and I reassured him.