My next patient asked me to look at a mole on her shoulder that had recently enlarged. It was multi-coloured, elevated and irregular. She didn’t have a family doctor, so I removed it for her. More molecules of blood escaped into the air.

After the mole excision I went to the dirty utility room to deposit my used scalpel blade and needles. One of my colleagues had just finished a busy lumps-and-bumps clinic, so the sharps disposal container was nearly full. When I opened it I was assaulted by the odour of fresh blood once again.

Our bedroom is bathed in moonlight.

The clock on the wall reads a quarter past midnight.

I’m lying in bed, waiting for the Sandman.

I can still smell blood.

Paralyzed

Tharn - a fictional word used in the Richard Adams novel Watership Down to describe rabbits frozen in terror at the sight of the headlights of an oncoming car.

One night I was working in the emergency department when the nursing supervisor advised me an ambulance had just been dispatched to pick up a teenager who had collapsed. A few minutes later EMS radioed to notify us they were coming in hot with an unstable cardiac patient.

They rolled in with a drowsy 15-year-old boy named Johnny. He had a pulse of 230 and a dangerously low blood pressure. We got him into a gown, administered oxygen and put him on the cardiac monitor.

He wasn’t my patient, but I vaguely remembered seeing him in the ER a few years prior for issues related to an irregular heartbeat. At the time a pediatric cardiologist had strongly recommended Johnny undergo a relatively minor procedure on the electrical pathways of the heart to eradicate the disorder.

“Did you ever get that heart procedure done?” I asked.

“No.”

“Why not?”

“I didn’t want it.”

“Does your heart beat too fast sometimes?”

“Yes.”

“What do you do when that happens?”

“I take these.” He pulled a bottle of heart pills out of his pocket. “I’m supposed to take one three times a day, but sometimes I forget. If my heart’s going too fast I take a few extra. I’ve been doing that a lot lately.”

“Where are your parents right now?”

“I just live with my mother. Why?”

“I’m going to need to speak to her.”

“About what?”

The pills he was on can sometimes trigger abnormal heart rhythms if not taken as prescribed. Using layman’s terms, I advised him that with the current combination of heart disease, unknown levels of cardiac medication in his bloodstream and unstable vital signs, the quickest and safest solution would be for us to provide intravenous sedation and then use special paddles to electrically convert his heart rhythm back to normal.

“You’re not doing that to me,” he declared.

I telephoned his mother and asked her to come to the ER right away. When she arrived I reviewed the situation with her and explained why it would be better for us to cardiovert her son now, before things got any worse.

“What does Johnny say?” she asked.

He doesn’t want to do it, but he’s too young and scared to make a rational decision.”

“If he doesn’t want it, he doesn’t have to have it.”

The best alternative to electrical cardioversion was a medication named procainamide, so I started him on an intravenous infusion of it.

Half an hour later his pulse had decreased to 180, but his blood pressure was still too low and he remained in an abnormal heart rhythm. I telephoned a cardiologist for advice. He agreed the optimal treatment was electrical cardioversion, but felt that given the circumstances we could give a second cardiac medication a try. Two doses of the alternate drug had no discernable effect on Johnny’s rapid heart rate, so I restarted the procainamide.

By midnight his pulse had declined to 150, but his blood pressure was fading and he was nearly comatose.

I told his mother if we waited any longer to perform the procedure, he would probably die. She consented resignedly. My colleague Serge sedated him and I performed a synchronized cardioversion at 50 joules. His rhythm remained unchanged. I increased the power to 100 joules and shocked him again.

Johnny’s heart stopped beating. Stone-cold asystole.

“No pulse!” the emerg nurse shouted.

Time stood perfectly still. The silence was deafening. My body locked up. My brain turned to mush. I couldn’t think. I could barely breathe. Serge and I stared at each other blankly. We hadn’t anticipated this outcome, and as a result we weren’t mentally prepared for it.

Serge’s lips twitched spasmodically as he tried to decide what to do next. Finally he said: “Electricity got him into this and it’ll get him out of it. Shock him again.”

I looked stupidly at the paddles in my hands. The urge to do something was overwhelming. From the deepest recesses of my frozen mind a thought struggled to rise. I waited for it. Finally it burst to the surface: You don’t shock asystole!

“No,” I said numbly.

“Okay,” he said. “Put the paddles down, then.”

I think I was making him nervous. I woodenly returned the paddles to their slots in the defibrillator and watched in a haze as Serge strained to think us through this mess. He was as rattled as I was, but at least he was fighting it.

Suddenly his eyes widened.

“Start CPR!” he yelled. The ambulance attendants sprang into action. “One milligram of epinephrine IV!” He had broken free of his mental gridlock. He grabbed an endotracheal tube and intubated Johnny. Now everyone was moving but me.

The events unfolding around me seemed to be occurring in a surreal, molasses-like slow motion. Although I was fully aware of the fact that I had skillfully dealt with cases worse than this in the past, for some reason I was completely paralyzed. I remained in a near-catatonic state; a fly in amber. I tried to focus on the asystole algorithm, but I simply could not stop thinking, “What did I just do? I’ve killed this boy.” It was awful.

Although my sang-froid completely deserted me, fortunately for Johnny my teammates kept their wits about them. They performed excellent chest compressions and lung ventilation. They administered the correct drugs at appropriate intervals. Six inconceivably long minutes later Johnny developed a recognizable rhythm on the cardiac monitor. Seconds later his femoral pulses returned and a blood pressure of 70 systolic was recorded.

By that time my miasma was clearing and I was semi-functional. I ordered a dopamine infusion and got on the phone to the closest ICU with an available bed. Within an hour he was airborne.

Johnny went on to a full recovery and had his cardiac electrical problem fixed a few months later. He has not had any further heart rhythm issues.

As for myself, that night taught me the danger of getting caught flat-footed. I now try to be a good Boy Scout and prepare myself for every eventuality, even though in my heart of hearts I know that there’s no way that you can be ready for everything all the time. ER workers are, after all, only human.

Rick’s Tears

When they told me Rick was coming in by ambulance, I knew right away something was very wrong. Rick never called EMS, no matter how sick he was. To him, coming in by ambulance was tantamount to admitting defeat. I went to the resuscitation room and started preparing my gear.

Rick was a 35-year-old man who had been waging an intense chess-like battle against cancer for the past five years. Although he wasn’t my patient, I knew him fairly well because I had treated him in the ER on several occasions. One thing that always impressed me about him was his relentlessly positive attitude. Rather than walk around in a blue funk bemoaning his fate, he focused his energy on getting better. He had more important things to do than die of cancer. He wanted to spend more time with his wife, Tammy. He planned to help his kids make the awkward transition from childhood to adolescence. He had a business to run and projects to complete. Most cancer victims hope they’ll survive. Rick intended to. Death simply wasn’t an option.