I went for pizza and beer with some friends tonight after work.  My wife and kids came too.  The pizza came wood-fired from a food truck and the beer cold and crisp from a micro-brew tap and labeled Honey Blonde Ale.  The kids ran around the brewery grounds in the rain inventing “zombie tag” games and throwing a football in the dark.

“How was work today?” my friends asked me.

“Fine. Another day at the office, you know. How about you?” They knew I was lying.  My day wasn’t fine.  My days rarely are.

A few hours before dinner I had gathered a family into the meeting room in our ER to tell them that their seventy-three-year-old husband/dad/grandfather had died.  He hadn’t suffered, we had done everything, we wish we could have done more, but his heart just gave out. The family cried, and I teared up a little. An hour before that case we had given epinephrine to a little girl whose allergic reaction was closing up her throat and airways. We flat out saved her life! Earlier that morning I had to tell a fifty-four-year-old woman that the CT scan unfortunately showed us what was causing her headaches—a tumor. As an ER doctor for the last thirteen years, I have rarely had a fine day. I have had adrenaline-packed days, miraculous days, sad days, terrifying days, bittersweet days, life-affirming days…but rarely fine days.

Many doctors and nurses will tell you the heaviness of the work sticks with you when you leave the hospital. It’s hard to wash it off. It clings like a residue, blunting your responsiveness to the stimuli around you at home, forcing your gaze inward while trying to smile and engage with those around you.

Some of the toughest work in the ER, in any medical setting in fact, comes when we have to break bad news. Delivering hard diagnoses requires candor and empathy, tact and trust, patience and time. When we do it well, relaying bad news becomes some of the best and most important work we can do in medicine. I often think it’s the most impactful thing I do in the ER. Recently recognized as a mission-critical skill, there are now articles and books and curricula and entire fields of study dedicated to discussing tough news well with our patients. I have worked hard over the years to hone these skills.

When breaking bad news in an ER setting, however, we sometimes simply don’t have the luxury of time.  Sometimes we don’t even have the luxury of knowing just exactly what the bad news is—just that it’s very bad. The hardest cases are when a serious diagnosis comes quickly and unexpectedly, when the exact diagnosis still seems somewhat uncertain but the illness requires immediate intervention to prevent death. I had this exact situation on Christmas Eve a few years back, when I had a little less white in my beard.

At 2 a.m. EMS radioed that they were bringing a woman in her forties with chest pain to our busy ER. My ears perked up from my workstation to hear the tail end of the EMS radio call in-code. “Patient has stable vital signs and a normal EKG…” Meh. She’s not dying. Back to work. Plenty of patients to keep working on—the holidays never fail to bring in lots of action to the ER.

When the stretcher rolled past a few minutes later, I casually followed the patient and the paramedics to Room 8, a small room for non-critical patients. They began their report, and I took a look at my new patient: Mrs. Hudson, a middle-aged athletic woman, dressed well in athletic clothing and running shoes. She looked awful! Pale, sweaty, short of breath, and in a lot of pain.  I was wrong, she might be dying.

“Let’s get her over to the bed, cycle some vitals and get an EKG,” I said. “And can someone call for a chest x-ray?”  In all honesty, these things would have happened automatically, but I felt it my doctorly duty to emphasize a sense of urgency here.

Something was very wrong. Sweating (or diaphoresis as we fancy doctors like to call it) is never good if not related to exercise or a fever. Coupled with chest pain it almost always means something life threatening very bad. No problem, I reassured myself. Probably a heart attack. We’ll get this EKG and call cardiology, get her over to the cath lab and get her fixed up. We’ll move quickly because she looks pretty bad. We do this all the time.

The blood pressure cuff cycled while our tech struggled with stickers on the patient’s sweaty chest to get a clear EKG. The paramedic told us the patient, a natural night owl, had been sitting at her desk when she felt a sudden severe chest pain going through to her back. Her husband, a middle-aged man with athletic build, who was now in the room looking very concerned, had called 911, and the transport had been uneventful. He told us his wife was healthy, had no prior health history and exercised regularly.

The tech handed me the 12-lead EKG as the paramedic wrapped up his story with one last detail.  “Yeah, doc, I couldn’t feel a pulse in her right foot, and it felt a little weak in her left foot, too.  Alright, y’all be good!  Have a great shift!”  Hmmm…no pulse in the foot…not a trivial detail.  Think fast, Jorgensen. This is what you trained for. In my mind I began to tick through the life-threatening causes of chest pain one by one.

I looked at the EKG. Normal. Could still be a heart attack, but if it’s a heart attack bad enough to make her look this bad, the EKG should show something.

Blood pressure? Normal, but a little on the low side. 105/74. Not a hypertensive emergency.

Lungs sounds?  Clear. Not likely to be flash pulmonary edema or a collapsed lung.

Oxygen level? Normal. No calf swelling. Unlikely to be a blood clot in the lungs.

I check the pulses one more time.  I could feel the radial pulses in the wrist, but no dorsalis pedis pulse in either foot. I have checked for pulses in the feet of every patient I have ever seen who’s complaining of chest pain. My training insisted on it. And I have felt the pulses almost every time. Not that night. She’s got an aortic dissection, almost certainly, I concluded. And a bad one at that.

As I waited for the X-ray tech to arrive, I pictured the dissected aorta in my mind. Right where the aorta leaves the heart something caused a rip between the tissue layers that make up the wall of the aorta. This causes a lot of pain. But the real problem is that with each heartbeat, the tear gets bigger and the layers of the aorta unzip. This creates an alternative passage for blood, a false lumen. The pumping blood continues to make the false lumen bigger until more blood enters the false lumen of the dissection than the true lumen of the aorta. Blood gets trapped in the false lumen and cannot get to the body’s tissues. If the dissection continues to spread, patients experience strokes, bowel ischemia, limb paralysis, organ death, and can die very quickly.

The x-ray tech showed me the image of Mrs. Hudson’s the patient’s chest on the portable machine at the bedside in real time. Just as I feared; the dissecting and swollen aortic root distorted the normal clean appearance of the heart and aorta in the center of the chest turning her anatomy into a smudgy, widened heart-ish blur, like someone exchanged a Da Vinci anatomic sketch for a finger painting left out in the rain. This supported my suspicions. She needs surgery and she needs it now.  Don’t let her die, Jorgensen. Not on Christmas Eve!

“I’m gonna go take a look at the x-ray on the big screen, Mrs. Hudson. You tell us if anything changes. We’re gonna get you better.”  I ordered her some pain medication and went to call the surgeon. I would tell her my presumed diagnosis and the plan for surgery once I reached the surgeon. I have found it helps to line up a plan of action  before dropping a bomb like this one.

The definitive test to diagnose an aortic dissection is a CT scan, but there are times in emergency medicine when we don’t have the luxury of definitive diagnosis. We have to act boldly with incomplete information and ask others to do the same. I would have to put myself out there and tell the surgeon what I was dealing with, what I thought was happening, and hope he trusted me.  When doing this at 2am on a holiday, I never really know how it might go. Just make the call, Jorgensen. Don’t stall. Pony up. The cardiothoracic surgeon answered right away. I’m not sure if my pressured speech betrayed my fraying nerves, but he heard me out and shared my concerns for this patient. He would be here in twenty minutes.

Awesome. Case closed. I celebrated with Dr. Singh, my colleague and friend manning the ER with me that night, that I had just diagnosed an aortic dissection without a CT scan.

“I sure hope I’m not wrong. I’m gonna look pretty stupid.”  She listened to me explain the case, and assured me I was doing the right thing. I am always so thankful for colleagues like Dr. Singh.  My anxiety lessened, knowing that the patient would soon be getting the life-saving intervention she needed. I went to tell the patient.

“Mrs. Hudson, your x-ray suggests what I feared. Your chest pain tonight is likely caused by an aortic dissection. Basically that means that the major artery that takes blood from your heart to the rest of your body is sick and needs surgery. I can’t say for sure that this is what’s happening because you are not stable enough to get to the CT scanner. But it sure looks like it. We can fix it, but you will need to go to the operating room. We’ll need to act fast. Our surgeon is on his way in right now.”

I looked up to gauge my patient’s response. She hadn’t said anything this whole time, and she looked significantly worse. The sweat poured off her brow now, her color changing from pale to grayish.

“You feeling ok?” I asked.

“No,” she said with new desperation and fear in her voice.

I cycled the blood pressure and hollered for the nurse to come back in the room. Blood pressure 85/44.

“Start a second IV and get me two liters of normal saline wide open,” I said as calmly as I could.  “Let’s get some levophed started. And let’s repeat an EKG, please.”

Then one nurse turned into three and two techs. Our team could always sense when a patient started crashing and would swarm to help. The lesser emergencies could then wait. Man, I loved this ER. It wasn’t pretty, but everyone sure knew how to save a crashing patient. A couple minutes later with the second IV started, the fluids rushing in, the levophed (a blood pressure booster) surging in her veins…and nothing. Repeat blood pressure 75/40. She looked even worse.

The second EKG looked normal—still no heart attack. This was bad. And curious. Aortic dissections normally have very high blood pressures associated with them. That is unless…unless the dissection involves the sac around the heart, the pericardium.

If the false lumen extends into the pericardium it fills with blood. When the pericardium fills with blood, the heart can no longer expand to receive blood from the lungs to pump to the rest of the body. We call this cardiac tamponade. Each squeeze of the heart gets weaker and weaker as the heart is smothered and has no blood to pump forward. The blood pressure drops, the brain gets foggy, the patient loses consciousness, and soon the heart and the body die. Cardiovascular collapse. That is unless you can quickly empty the blood from the sac around the heart.

Shit. That means I have to do an emergency pericardiocentesis. An emergency peri-cardio-centesis. Now. Or she’ll die. And I’ve never done one before.

I had done countless emergent procedures in the ER over the years— time-critical, get-this-right-now-or-the-patient-dies procedures. But never this one. I’d practiced the procedure in a simulation lab. I’d performed this procedure during codes when a patient’s heart was already dead. But I’d never done one in a lifesaving, time-critical situation. In fact, I didn’t know any ER doctors who had done this procedure in this situation. And now I had no choice. Why can’t she just get to surgery already? Why am I not home with my family right now?

No time to wish I was somewhere else. Only time to act. Fifteen minutes until the surgeon would arrive, and about five minutes to her complete cardiovascular collapse and death by my estimation. I still didn’t know with certainty the cause of her blood pressure drop, but I had to trust my gut.

“I need Chloraprep, a set of OR towels, a 60-cc syringe with a leur lok, and a 20 gauge spinal needle. I need them now. I’ll be back with the ultrasound machine in one minute and we’ll do an emergency pericardiocentesis.” The nurses and tech nodded and got to work.

As I stepped out to grab the ultrasound machine doubts swirled in my head. Is this really a dissection? Do you really think it’s tamponade? You really gonna do this procedure? If you screw up, that surgeon’s gonna crush you, and that patient’s gonna die. Another voice countered. You know this. You trained for this. If you do nothing, she dies.

Dr. Singh, always cool and steady, reassured me I was on the right track. She offered to join me in the room and hold the ultrasound steady for me so I could visualize the pericardium as I advanced needle. I quickly reviewed a procedure diagram in an online ER manual and reminded myself just where to insert the needle to angle it into the pericardium. I speed-walked back to the room. They tray with my supplies was set up perfectly on a Mayo stand at the bedside. Dr. Singh captured an image of the struggling heart and the smothering fluid on the ultrasound machine. I love it when a plan comes together. Thirteen minutes to surgery. Three minutes to cardiovascular collapse. Act calm.

“OK, Mrs. Hudson, the surgeon is on his way. But as we can see on this ultrasound, there is blood building up around your heart. The blood is making it hard for your heart to work. We need to use this needle to remove some fluid so your heart can beat strong enough to make it to surgery. OK?”

We could all feel the anticipation in the room. This was a rare and wild moment. No one in the ER that night had witnessed this scenario before. I cleansed the chest and abdomen and picked up the five inch needle. No one spoke. No one even breathed.

“Hold on, doctor.” Her husband’s voice broke the silence. How dare he?

 “Huh?”  I replied, startled.

“Can you step outside with me?” he pleaded, motioning toward the door with his eyebrows. Are you kidding me? I don’t have time for this. We stepped out into the hall.

“Look, is this really all that serious?” he asked me. “This seems really invasive. We always said we wouldn’t want to do anything big…you know, big medical procedures, being kept alive by machines.” You want me to just let her die?

“I totally understand that. And I appreciate that. I really do.” I paused.

He seemed to be telling me that they had discussed their own mortality in the past. Recent national news stories about neurologically-devastated patients being kept alive indefinitely by machines had led a lot of people to have these sorts of discussions. Mr. Hudson knew that he and his wife had no interest in artificially prolonging a life that left either one of them incapacitated. And I didn’t blame them. I wouldn’t want to be kept alive by machines with no quality of life either! But I sensed that they hadn’t really thought about their mortality very seriously. The Hudsons had never had to slow down due to illness or injury. They were still in their prime.  Tough decisions could be addressed later, but failing to treat a potentially reversible emergency like this could rob them of decades of quality life together.

Unfortunately, with critical illness, it’s not always all or nothing. Sometimes our bodies take hits that we can survive and would want to survive, even if it means we lose a step. Unless we die young by suicide or trauma, most of us die slowly and by degrees. Would we rather die than accept the consequences of the first hit? Some certainly would, but I could clearly tell that the Hudsons’ discussions about death and dying had not been so nuanced. I have always appreciated the stance of “when it’s our time, it’s our time.” I just didn’t think it was her time. And neither did she as it turns out.

The Hudsons now faced an extremely dangerous and rapidly-lethal diagnosis. (More like an event! Cancer is a diagnosis, a dissection like this is an atomic bomb!) She might actually survive with good recovery, but only if we acted fast, we acted deliberately, and we acted what might appear to be dangerously. Then again, she still might die, or worse, she might survive but with severe impairment. Mr. and Mrs. Hudson deserved more time to think about things but we didn’t have it. I hated to cheat this conversation.

“I wouldn’t want to be kept alive by machines either. But if we don’t act, your wife will certainly die in the next two minutes. Are you ready for that? Is she ready for that?”

Bewilderment. Overwhelm. Shock. And a wavering, “I don’t know.”

“Ok. I know this is coming at you fast. And we don’t have time, and I’m sorry. I’m gonna go ask her what she wants.”

I went back in the room and she was fading—shocky, as we say in the ER. Ashen with sweat pouring off the forehead, her life circling the drain. Lucidity threatening to vanish, barely hanging on. The monitor now displayed 63/37. We had moments left. The beads of sweat gathered on my forehead, too.

“Like I told you before, you have a tear in your aorta. It is causing fluid to squeeze your heart.  You need emergency surgery, but you won’t make it to the operating room if we don’t act NOW.  If I don’t put this needle in your chest you will die in the next couple of minutes. Do you want me to put this needle in your chest and suck out the fluid and save your life?”

No words in response, just a wide-eyed, wildly vigorous head nod signaling “Yes!”

This was my answer. It was time. Here goes nothing. Twelve minutes to surgery. Two minutes to collapse.

I inserted the needle attached to the 60cc syringe through her skin in the right upper abdomen to the right of the xyphoid process, just like I had practiced on high-fidelity patient simulators My training took over and everything else faded from my mind—the doubts, the fear, the monitors, the beeps, the nurses, the husband, the very patient herself. My vision narrowed to the only things in the world that mattered right now—her thoracic cavity and the tools in my hands. I advanced cautiously but steady, at a 45 degree angle to the skin, aiming toward her left shoulder. My needle tip poked through the skin, through the abdominal fascia, pierced the tip of the liver, slid under the ribs, and penetrated the diaphragm. One minute to collapse.

I continued to advance the needle, and manipulated the fingers of my right hand to apply a steady negative pressure on the plastic syringe plunger, my left hand steadying the needle at the level of the skin. It seemed the needle was deep enough, but no blood had entered the syringe yet. I looked up to the ultrasound machine.

Dr. Singh and I saw it at the same time. The white grainy image of the needle tip on the ultrasound display, entering the black of the bloated pericardial sac.

“I think that’s your needle tip, Tyler,” she whispered to me.

“Me too,” I whispered back. Man, I needed her with me that night.

And then it happened. The tension in the fingers on my right hand suddenly gave way, the plunger retracted, and the syringe filled with dark red blood. Everyone in the room finally exhaled. I could actually see the pericardial sac collapsing on the ultrasound machine. The heart visibly expanded as its chambers were finally able to fill with blood. Strong heartbeats resumed.  I could see them. We could all see them.

We cycled a blood pressure, but we all knew what it would say: That she was now doing much better, that she would make it to surgery. The color returning to Mrs. Hudson’s face told us that too. The blood pressure finished cycling and read 112/73. Cardiovascular collapse averted. Ten minutes to surgery. Merry Christmas to all, and to all a good night!

“Good job, Mrs. Hudson.  You did great!” Now don’t you go crashing on me again. She survived and made it to the OR. Our fantastic surgeon repaired her entire aorta, and she made it through the long surgery. She recovered enough to leave the ICU after just a few days. A bona fide Christmas miracle.

I visited her in her hospital room a few days later. When I walked in the room, she smiled at me.  Kind of a dumb, goofy smile, but a really big one. The only emotions I saw in her face were happiness and gratitude. She raised her hands, gave a weak thumbs up, and slurred a thank you.  Actually, there was wonder in her face, too. Mr. Hudson also smiled, but there was a sadness in his eyes. His wife had miraculously survived, but she was different now. The dissection had caused a stroke. She was recovering some, but she wouldn’t ever be quite the same. Their life together wouldn’t ever be the same. He couldn’t hide the pain of that realization behind his grateful smile.

Our diagnoses change us. What we do about our diagnoses changes us even more. I had never had a more rushed, higher stakes, more uncertain moment of shared decision-making in medicine than I did with the Hudsons. On Christmas Eve for Heaven’s sake! I think I did the right thing for Mrs. Hudson; she seemed to think so. I hope Mr. Hudson thinks so, too.

I hope that the new reality of their life together is full of joy, wonder, love, and adventure, even if those good things look different now than they did before. I hope that the next time they face a tough diagnosis they have more time to process it and make good decisions consistent with their values. I hope their doctors can approach these tough situations with candor and empathy, tact and trust, patience and time. So much more time than we had.

The Hudsons came with me tonight as I ate my pizza and watched my kids run around. They follow me everywhere. So too does the older man who died this afternoon, the little girl we saved from anaphylaxis, and the middle-aged woman we devastated with bad news. And so many others. When you’ve shared experiences like these with your patients, they never really leave you.

Tyler Jorgensen is a physician who practices both emergency medicine and hospice and palliative medicine. His patient care and outdoors stories and essays have appeared in the Annals of Emergency Medicine, the Journal of Pain and Symptom Management, Snapdragon: a Journal of Art and Healing, Emergency Physicians International, Wild Roof Journal, Hospital Drive, and the Examined Life Journal. He believes there’s a fascinating human inside of every patient that we meet, and something magical to be found every time we step outside. We just have to look for it.