ER: White Cloud

I am what they call "a frickin' white cloud." I've been an active EMT for five years, but never worked a cardiac or respiratory arrest call (I responded on one years ago in Brooklyn, but was in the second ambulance to the scene, so I watched as the other crew did CPR and used the defibrillator). In four years of medical school, I've never seen one of my patients die in the hospital, although many of my friends have gone through this experience (one, I would argue, that changes your whole outlook on medicine and is a sort of rite of passage). When I'm on the code blue team, either no code blues are called, or everyone is brought back to life. In the ICU, my attending predicted, gravely, "She's gonna die tonight," about one of my patients with fulminant colitis and a tenuous grasp on life; the patient lived to leave the hospital two weeks later. I have never performed CPR.

Today, I rode-along with the EMS Physician who responds to ALS calls from our dispatch center. As I chowed down on my chicken parm at lunch, I lamented my white cloudiness with my usual incredulity at the fact. It's something I find entirely unbelievable, that someone with as much exposure to the shit that could go wrong could possibly never accidentally land in it. Something totally inexplicable, bewildering, awesome, and awful. I wondered whether, when I have to run my first code as a real doctor, I will actually be ready for the task without past experience. The EMS Physician told me that patients should love to have me as a doctor.

Shortly thereafter, we responded to a call at a dialysis center for a patient with "hypotension." According to the doctor there, the patient had a number of issues apart from her renal failure, including aortic valve stenosis which is inoperable due to her poor performance status and dependence on dialysis. For the past several months, she had been slowly decompensating. In the lingo, she was "circling the drain." At the dialysis center, her blood pressure was barely 80 / --, and her heart rate was incredibly slow, coming down to 20-30 beats per minute; these numbers, combined with the patient's medical conditions, seemed worrisome. Yet, with an IV infusion of a few hundred mL of saline, she felt pretty comfortable, was alert and talking to us, and was asymptomatic. The medics joked that she had seen us coming and perked up because the doctor was so good looking. We got another call for a car accident two towns over, so we directed the medics to transport her to the hospital, start a line if possible, and give additional saline if the patient became symptomatic. We then left the scene.

The next time I saw the patient, she was intubated and stripped naked in the critical care room in the ER at the hospital.

The paramedics told us that they had loaded the patient into their ambulance and started driving. Out of the blue, she coded into an episode of VT's (ventricular tachycardia) and became unresponsive. They began CPR, shocked her back to a normal rhythm, rushed, and intubated. Here she was, naked on the bed, and Dr. E was mashing around in her groin trying to get a femoral line. It felt surreal... only half an hour ago, I had been making small talk with a LOL (little old lady), and now she looked like a piece of meat on the table.

I couldn't help but wonder... how large is the shadow cast by a white cloud?