‘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.
‘Awakenings are rare. It is almost never possible to be this perfect in the chaos of the emergency department.
The stars on my team were aligned and working in perfect accord.’
“Continue good compressions. It is safe,” I said. With faith in me, he maintained the rhythm, and the monitor registered excellent pulse oximetry, a marker of great CPR. The pharmacist was getting the drugs, the intern prepared for intubation. The nurses ran to get the code cart. Until the push drugs were available at the bedside, I squeezed the amiodarone bag and encouraged Frank to keep up perfect compressions. Though he must bench-press over 300 these days, the steady rhythm of much lighter pressure was exactly what this patient needed. At this moment, Frank was my best weapon and I had faith in his ability to keep the patient’s brain alive.
As two minutes passed, the equipment was assembled, and the intern got ready to intubate. As if sensing the laryngoscope approaching, the patient’s eyes opened wide and he took a spontaneous breath. We all froze in surprise, watching a ghost.
“He just got another internal shock,” Frank reported. I asked him to stop CPR. Steady rhythm on the monitor.
“Wha…wha…what happened?” the ghost asked, staring back at all of us. It was only a miracle. We did everything right, no delays, with enough amiodarone on board early enough that the internal shocks began to work. He received multiple therapies upon arrival as part of a sophisticated protocol. The telemetry did its job. Impeccable CPR perfused the brain and bought time. As if every push on the sternum added yet another month of productive life to be savored and shared.
Awakenings are rare. It is almost never possible to be this perfect in the chaos of the emergency department. The stars on my team were aligned and working in perfect accord. Losing my composure, I faced the ghost, with one question I’ve always had and only he could answer: “What did you see?”
The room was dead silent while the living centerpiece struggled with a response in front of a dozen strangers.
“Nothing … I saw nothing … I was talking to my wife, and then you were all here, just like that … What the hell happened?”
He looked incredulously around the room and smiled in disbelief.
“You died,” I said. “Welcome back. Please don’t do that again.” Somehow, blunt honesty felt appropriate. And in the room where someone just died, everyone laughed – including him.
I ordered meds and connected the pacer just in case, as the cardiologist walked in. I took a moment to reassure the wife, who displayed a mix of joy and terror. The patient was whisked away to the Cath Lab, to get a stent and keep on living a life that from this point on would be one long miracle.
I got my answer. And my faith became stronger and broader than ever. Many emergency providers enjoy organized faith. Nearly all of us feel faith present in our crude and pragmatic, yet mysterious and supernatural work. When we give it our best we have faith in each other, in our desire and ability to shine when it counts. We have faith in the team.
On those days, we deserve the faith of our patients.
Dr. Veysman is an assistant clinical professor at Rutgers-Robert Wood Johnson Medical School in New Brunswick, N.J. You can reach him at firstname.lastname@example.org