Ish

Vidushi Rathi Ish Submitted 2017-08-20 00:00:00 -0400

A patient is wheeled in with a fluttering sensation in chest. You attach the monitors and find those rapid spikes of a supraventricular tachycardia. You find a cephalic vein, place a large bore cannula, push in adenosine and flush saline. Then, you wait…

The monitor flatlines. The paddles are ready. Those next six seconds seem like an eternity. And then you hear that quintessential beep, there is a flick on the monitor tracing… few more follow, erratic at first. This is when you inhale deeply, and realize you had held your breath all along. The relief on appearance of a sinus rhythm is almost euphoric.

Split-second decisions, life-altering choices, and pressure-cooker situations are the essence of emergency medicine. The exhilaration of puncturing a tension pneumothorax, draining a cardiac tamponade, and reversing a benzodiazepine overdose provide that instant gratification which other specialties rarely get. There is adrenaline rushing everywhere- through the veins of the doctor as well as the intravenous lines of the patient… It’s a life not for the faint of the heart.

To survive in this environment, the key is to be prepared for anything. The emergency department is a warzone, and should be treated like one. It is of paramount importance to keep a cool head about- surprises will be thrown your way with every case. The patients often reach us in an agitated or unconscious state. There is little or no history available, and there is no time to dig out information. The situation is emotionally charged with tempers often running high. It is then upto the emergency physician to be the pillar of stability around which the chaos ebbs away and a semblance of sanity is restored. This is why I find emergency medicine absolutely fascinating.

As a trolley enters the emergency department, the excitement begins. A chest pain could be anything from a heart attack to a broken rib. A teenager gasping for air could have a coin stuck in the throat, asthma, or a psychotic episode. An unconscious patient could be a suicidal poisoning, drug overdose, or a stroke. The possibilities are diverse and no two patients are the same. You start with set protocols, while keeping a keen lookout for clues to lead you home. Yes, it is just like a page from a Sherlock Holmes novel.

The excitement and the glamour aside, emergency medicine can be emotionally draining. Most patients do not do so well. There are end stage organ failures- renal, lungs, heart, liver- who keep coming back with complications. You lose patients to the Reaper on a daily basis- sometimes they die even before you can figure out what went wrong. With children, it is the hardest to cope. It is not talked about much, but I have known emergency personnel break down into tears in the confines of their locker rooms after a particularly heart-wrenching case. Physician burnout is a real concern.

In my country, the situation is a bit more complicated. A majority of my patients do not have insurance, and pay out of pocket. Even though healthcare is heavily subsidized in the state funded hospitals, our patients are often too poor to be able to afford that either. These hospitals have emergencies teeming with patients, sometimes over 10 times their capacity. So the emergency physicians often have to take decisions well beyond their moral limits- decisions like allotting a single available bed to a 60 year old with congestive heart failure, or a 22 year old with acute liver failure. The implications of such decisions are intense. No, they are not trained, nor fit to play God, yet they sometimes have to. More importantly, they have to go back home, always wondering if they made the right choice.

Emergency medicine is an exciting field, and the results of your efforts are evident almost immediately. A lot of the other branches of medicine do not have this privilege. However, the physical strain, the emotional stress and the shift-work schedule does take its toll in the long run. It is a specialty best suited for those with the ability to keep a calm head in crisis, withstand stress without it affecting performance, and a strong moral compass to deal with the repercussions of decisions taken. There will be patients who would not improve despite your best efforts, and you need to be okay with that as long as you have done your best. Sometimes, things go right and your patient gets to live another day. You live and breathe for those times.

Posted