Black Clouds and Thankful Patients

I have always thought the idea of being a “black cloud” was crazy.  I always had two main reasons for feeling like someone being unlucky or somehow seeing worse things was either nonsense or, in fact, a good thing.  First, I was sent an interesting article a long, long time ago about it – a group studied workload of residents and polled them on whether they were indeed the Black Clouds.  They compared their reputation as Black Clouds to their workload and found, in fact, that they worked “more” (were awake more hours on call; slept less)!  …but they were all of them deceived (kudos to those who catch the reference).  For when they compared their number of admissions, patient volume and even patient deaths to this sense of Black Cloud-ness, it was in fact no different.  So being a Black Cloud essentially meant you were inefficient for one reason or other.  You could be a slow worker, an anxious doctor, indecisive or you could just agonize over decisions too much.  The second reason being a Black Cloud, with its negative conations, was dubious to me was that “real” black clouds get awesome experience. 

A good friend of mine in residency and now another anesthesia-intensivist, was really a Black Cloud.  Funny enough, he never thought so and I never heard him mention anything about it.  But when I heard about his month in the cardiac ICU, he did a ton of ECMO, had several emergent bring-backs for post-operative bleeding, and had some esoteric diagnoses pop up, like an oversewn coronary artery during a valve procedure!  He had provided anesthesia for five liver transplants before I even had one!  What a black cloud.  But, instead of viewing it as this horrible thing, he actually just viewed it as fun work and good training.  He was way beyond his level through all of training, and I’m sure that carried on with him through fellowship and now as a staff.  After all, Navy SEALs always say they have Hell Week to fall back on when they go through horrible times when deployed.  If they made it through Hell Week, they can keep going now.  Well, not only did my friend and colleague learn a huge amount and experience some unique things, but he had this intense experience to fall back on whenever he was exhausted and had yet another admission, and another patient need at three or four in the morning.

While I’m sure I’ve whined about workload like most residents, probably more than quite a few, I have really tried to never call myself, or think of myself as a black cloud.  But my health care experiences all seem to come in waves – during fellowship I repeatedly broke the number of admissions in a night, number of patient deaths in a day, and the like.  But I also had the most goose eggs (zero admit nights) amongst my co-fellows.  And right now I’m in a wave…

I was supervising the anesthesia for a routine, straightforward procedure a long time ago in a HIPAA-compliant hospital far away (as always, names/sex/surgery/dates/specific clinical situation changed so the meaning is the same, but the situation is not identifiable) when the patient was injected with a (routine) medication by the proceduralist, and she immediately went into cardiac arrest.  There was a heartbeat….and then there wasn’t.  A routine vagal “sinus pause” seemed most likely – except it didn’t come back.  Thirty seconds in I was called to the room and we had compressions going by 35-40 seconds.  Thankfully, we were able to get her back, after a cardioversion, a stat central line (an IV placed in the neck and allowing medications to be given right near the heart) and about an hour of very high dose vasoactive drugs.  But I was very shaken.  I kept thinking through the code – “What if I lose her?  What in the world could I tell the family?  This was routine!  She was healthy!” 

I thought about her case endlessly for the next several days and followed her chart as the workup was ongoing.  When I came in Monday to see her, her partner grabbed my arm and thanked me for saving her.  “God put you in the room that day. Thank you for being there.” And my patient told me how glad she was that she was going to be able to go home, how thankful she was to be able to go see her kids and friends again. 

I left the room and walked away, and I started crying.  It sounds a dumb thing to cry about.  I know it’s a dumb thing to cry about.  I can’t even explain why I cried.  Some of it was straightforward – I was scared the family would blame me, question everything that I did trying to find a way to blame me, or sue me (I didn’t do anything wrong, but such is the state of health care), or whatever. Some of it was the power of interacting with someone on the far side of a near-death experience. And some of it was selfish: it felt good to be appreciated. 

Such is the oddity of healthcare – we all (nurses, doctors, PAs, NPs, MAs – everyone) give immensely of ourselves for varied reasons that largely revolve around being there for people when things aren’t going well.  We run towards explosions.  Sadly, I don’t actually expect thanks when I do anesthesia or critical care – ever. Other than this situation, I don’t recall any other experience of a patient / family thanking me while wearing my anesthesia hat.  It’s simply too rare that a patient understands that I mean it when I say “I’ll keep you safe,” and sometimes keeping someone safe is intense, stressful and impeccably challenging.  I do think I had a little more expectation to be thanked in our ICUs – most of us do, if we’re honest. When we think about “being a doctor” and write our personal statement, there is an edge to the job that we expect to be valued and appreciated. It isn’t totally selfless (of course).

And I know inside myself that this is a horrible reason to do anything, and it’s not why I do it.  But it means an immense amount to get one, and it’s fairly rare.  Rare to get a real Thanks, anyway, from the heart, not a quick thanks but one that means – “You helped me; I appreciate you.”  One that reinforces that I have a job that in fact, does all the things I thought it would when I was a green and idealistic, naïve student writing personal statements. 

So, try to be thankful to everyone around you.  And yes, of course, selfishly please be thankful to your doctors : ). It means the absolute world to us.  It keeps us going and it gives us purpose.  And to the family that thanked me:  Thank You back.  Your appreciation will keep me going the next whole load of tiring call nights and through anything else I see.  I will remember it when I am at my wits end, and there’s another admission.  I am thankful that I felt appreciated.  Thank You.