Expecting the Unexpected

Due back to work this month, I have been feeling anxious about my return during the pandemic and after being away for so long. This has been the longest break I have had from medicine ever. I was worried about how I’d transition back. 

Being an attending was really hard for me. Much harder than I expected. I left residency confident in my practice and ability to tackle any case in the emergency department. Yes, some cases are easier to manage than others, and some I enjoy more than others, but I knew that, regardless, I could handle them all. 

But when I walked into my first shift as an attending it felt like my mind was blank, void of the last 8 years of medical training. It probably didn’t help that the first patient I saw as an attending was unexpectedly critically ill. Looking back, I laugh at “unexpected” because the epitome of my job is to expect the unexpected.

Since I was brand new as an attending and also to the hospital system and electronic medical record, I picked up a triage ESI level 3 patient to orient and ease myself in. For context, ESI stands for emergency severity index and is used to triage patients presenting to the ER based on their presenting concern (e.g., chest pain), vital signs, like heart rate, blood pressure, and oxygen saturation (called vital for a reason!), and brief evaluation by a triage nurse. ESI level 5 is a less urgent complaint like a mild rash or medical refill and an ESI level 1 is a patient who requires immediate attention by a physician to live, such as a patient in cardiac arrest or with a severe asthma attack. In the emergency department, due to the time sensitive nature of different presentations with some being more emergent than others, patients are seen in order of their ESI (Level 1 and 2 being highest priority) not the order in which they arrive at the ER. 

So back to my first patient as an attending, who was a young gentleman presenting with a simple complaint of a cough and had normal vital signs (ESI 3). From the triage note it sounded like a straightforward case of an upper respiratory infection or URI. Before seeing him, I reviewed his chest xray which had already been performed and noticed that his heart size was questionable on the larger size. Erring on the side of caution, I requested that the nurse connect him to the cardiac monitor and obtain an EKG as I walked over to see him.

He was a larger man in his 30’s and otherwise appeared well and comfortable. He described having a nonproductive cough and difficulty breathing which was especially worse at night but that he occasionally felt random periods of shortness of breath during the day. His exam was what we call unremarkable, meaning no obvious abnormalities relevant to his complaint. After my evaluation, I decided he didn’t clearly fit any diagnosis but was reassured by his vital signs and how well he looked. I continued with my plan to obtain an ekg and some bloodwork to evaluate his heart all while trying not to badger myself for ordering potentially unnecessary tests for an otherwise healthy young man with no cardiac risk factors who looked good.

While reviewing his normal EKG at my computer, I heard another physician yell, “Room 12 is in V tach!!” Oh wow, I thought, I’d offer my help but I probably wouldn’t be very helpful since it’ s my first day and I don’t know where anything is, or who anyone is (other than my one patient’s nurse), or how to do much. That’s why I’m only seeing one simple patient with a cough.

“Dr. Jackson, isn’t room 12 yours?” a colleague nearby asked. Oh Shit! It was my patient. The ventricles of my patient’s heart were pumping away abnormally at 170 beats a minute, splaying wide, flat topped, waves, rapidly across his cardiac monitor. I jumped and ran to his room. Thankfully, he was conscious and with a pulse. Even better he was stable enough to tell me, “Hey doc, I’m having that breathing problem right now.” Time for action (Kavita, you got this):

2nd IV in process, code cart on the way and amiodarone being drawn up

I held his left hand briefly, “Sir, your heart appears to be beating abnormally and dangerously fast. This is likely the cause of the symptoms that brought you to the ER today. I don’t know why it’s doing that but right now I need to focus on stabilizing your heart rate and then we’ll get you seen by a cardiologist. Plan to stay at least the night”

Defibrillator pads on, amiodarone going in

.

No change. Okay, “lidocaine” “Lido’s up, doc.” Lido going in…

.

.

No change. I see… “procainamide” “Procaine’s up, doc” Procainamide going in…

.

.

.

No change! (What am I missing??? At least blood pressure’s ok.)

Oh no… blood pressures dropping… (Shit, shit shit!)

Alright, here we go! Fentanyl, versed, and get cards on the line. “I’m sorry sir, I’m going to have to give you heart a little spark to get it to behave”

“Meds in”, charging to 100 Joules 

CLEAR, shock delivered…no change (Dang, c’mon!!!) 

“Again!” Charging to 200 Joules

CLEAR, shock delivered……….HR 160bpm…140bpm (Phew)

“Run the blood pressure cuff, please.”

Okay the heart rate is starting to slow down, blood pressure is improving, and cardiology is here on the phone calling for the cath lab to be prepped. And off my patient went.

A person in my life that I will never forget- my first patient as an attending ER physician. I’ve been thinking about him and our experience together about 1 year ago. Preparing myself to return to my chaotic, unpredictably, but exciting and rewarding professional home. Battling my anxieties of having forgotten how to do what I do and concerns about being able to withstand the frontlines with the same rigor and bravery as my colleagues.

Thinking about the patients that have impacted me more than they know as a doctor and a human reignited my desire to be back in the ER doing what I do. The professional mission of the last 15 years of my life coming back to fruition. I am more prepared than ever to connect with my patients to be the best doctor I can be. 

But there has been a change in plans. I met with my oncologist this week, to get my return to work release only to find out that I am no longer cleared to return to the emergency department. With my immune system in its current state and with the pandemic in its current state…Doctor’s orders.

Instantly, I was flooded by so many emotions and also somehow devoid of feeling. My body burned up like it had been lit on fire, yet I was shivering. Or maybe I was shaking? So many questions yet I couldn’t seem to form a coherent thought.

“I trust you and if that’s your recommendation, doctor (aka amazing woman who cared for me with excellence and always considered my best interest), I will follow it.” 

“It is my firmest recommendation.”

With the play button on my livelihood stuck jammed, the taste of my pre breast cancer life that had greeted me, enticingly, now replaced by bitterness. This news in no way compares to receiving the news that you have cancer, however it is reminiscent of how it felt when my life was flipped upside down by the unwelcome war that breast cancer started in March. Just as unexpected, just as confusing, and dredging in the same amount of uncertainty into my life.

I didn’t expect this and now I am lost. Without direction or clear purpose, things I’ve always had. No matter what the situation is, I’ve only ever operated with a goal in mind. Go to medical school – check. Have children – check. Win against breast cancer – check. Well now what?

Many of you may be thinking, “What is she so upset about? I’d be thrilled if I didn’t have to go to work.” Like studying your ass off for a test that ends up being cancelled. Sounds like a win, right? And maybe you’re right, maybe I should be relieved and rejoicing. Part of me also thought I might feel that way, but I don’t. Not after what I have given of myself to be an emergency medicine physician. I’m not ready to stand down, I just got fired up to fight the COVID fight. I feel especially ashamed that I cannot show up for my patients and colleagues in a time when we are most needed. 

I should be there but I’m stuck on the sidelines, for now.

Kavita Jackson, MD

Advertisement