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Black Clouds

"Storm over Frankfurt" (CC BY 2.0) by CoreForce

“Dr. C. is a white cloud, so you won’t see much with him on call this weekend,” my attending mumbled. I immediately asked what he meant by a white cloud. He gave me a withering look like he always did when I asked too many questions. He went on to explain that a white cloud is a doctor who never has anything crazy happen while on call. He stopped walking, turned around, looked me in the eye and said, “We are black clouds.”

I had just started my third year, and I had already witnessed six patients die. I had never been called a black cloud before this, but it immediately stuck and seemed fitting. Wherever I went on rotation, troubled patients seemed to follow. It was a double-edged sword though. From the outside, being a black cloud seemed exciting, but as much as it was exciting, it caused me emotional toll. I saw the worst of the worst: I saw patients mangled, maimed and dying.

My classmates and I didn’t talk much during third year about the patients who we saw die. It was an unspoken truth that some of us had probably seen more than a fair share of morbidity. Sometimes, it seemed like other medical students wanted to be black clouds because they wanted to be involved in the excitement. Of course, it didn’t stop any of us from continuing, but those volatile patients sometimes weighed heavily on my mind.

The initial patient encounter etched permanently into my memory was my first code. During my internal medicine rotation, I received the title of “black cloud” in the second week of my first month of my third year. We ran into the intensive care unit (ICU) after receiving the page, and I saw blood everywhere. The nurse quickly informed us of the details. The patient had undergone esophageal surgery the day before and subsequently vomited bright red blood twice, which caused diminished peripheral pulses. Unfortunately, his family, who had stayed with the patient for a few days in the ICU, had left thirty minutes prior to his episodes of hematemesis. What struck me the most is that he died without the comfort of his family’s presence. Rather, he was  surrounded by doctors, residents and medical students who did not know him. We were just there for the code blue.

There are parts of that code that I try to forget. A code is always a hodgepodge of people milling about and working hard to keep a patient alive. During this particular code, the various medical and trauma teams discussed what should happen since the patient was going to be pronounced dead. After some discussion, it was decided that the surgery team would call the family. The surgery team members who had been called to the bedside were not the team members who had operated on the patient. Therefore, no one was familiar with the patient or his case other than the health records they had glanced over during the code.  

I passed the intern a sheet of paper bearing the family’s phone number. Obviously exhausted from tedious shifts, he dialed the number. I don’t blame him for forgetting the patient’s name, and I am sure it wasn’t intentional. He had never met the patient before, and this phone call to the family was his only part in the patient’s care. Crestfallen, he crumpled into himself when he realized that he had identified the patient incorrectly during this significant phone call.

I will always remember my attending physician’s words and actions in that situation. As soon as he responded to the code blue, he pulled me out into the hall and whispered, “Close the other patients’ doors.” I didn’t ask why: I just made my way around the horseshoe-shaped ICU and slid the doors closed. It was a simple thing that I thought purposeless, but I also knew I was no help as a third-year medical student with limited experience. Later, I asked him why he had me do this. He explained that it was to protect the other patients from hearing the code and possibly reliving what they had experienced with their own family members.

At the end of the call shift, the attending asked if I had any questions. Ashamedly, I asked, “How can you watch someone die and move on with your day?”  

To my surprise, he brushed it off he said, “Just try not to take it personally or get yourself emotionally involved. It will ruin you if you invest part of your heart in every patient.”

I was floored. This was an attending who brought patients their favorite snacks or games, and he was always smiling and laughing wherever he went. I trudged out of the hospital that day feeling defeated. At that point, I hoped that I would never lose that tightness in my chest, that swelling of emotion and that lump that arose in my throat when I realized the patient was going to die alone. However, I felt a wave of embarrassment when I remembered how excited I was to respond to that code.

I try to remind myself of this when I hear the code pager ring, the call for a trauma room or the ringing of my phone in the middle of the night. I will admit that I am still excited to be involved in these emergency situations. I’ve seen what I can only describe as miracles and people brought back from the edge of death. However, I have also witnessed people die when I felt like they would survive. Most of the time, there is a fifty percent chance of devastation and a fifty percent chance of a miraculous recovery. Now, my excitement in responding to a code is that I may be able to positively affect the outcome instead of merely being ready for a rush of epinephrine.

I carried these moments with me: the good, the bad and the in-between. In the darkest moments though, even when there seemed like no light could be found, eventually something would pierce the darkness.

Similar to a code blue, my third year of medical school was also a hodgepodge, but it included beautiful, funny and poignant moments. I can say now that I was not prepared for it, but I don’t think any of us could have been. Maybe being a “black cloud” isn’t a bad thing: Maybe some of us are just magnets for long, volatile call nights and days. My mentor claims to be a “black cloud” and jokes that someone must publish her call schedule because she believes that more patients show up to the emergency department while she is there. She never really complained about her crazy nights other than saying that she was getting too old for the excitement and inherent stress. After thirty years in practice, she has seen countless patients die, but she hasn’t lost her hope or her spark.  

From my few weeks spent with her, witnessing death was never monotonous. It never lost its sting. While I know that we, as future health care providers, must be empathetic and compassionate, we cannot personally invest all of our emotions in each patient, or we would live in constant disappointment. Losing a patient is difficult, and throughout the year, it never got easier. I found solace in my mentor. As “black clouds,” both she and I experienced what we would subjectively deem the worst cases, together. She never grew numb to the tragedy of death. As I continue on this journey to become a physician, I hope to never grow ambivalent towards trauma or death because while I may be labeled as a “black cloud”, I never desire to be a walking cloud of pessimism. As the story goes, every black cloud should have a silver lining.  

Image credit: “Storm over Frankfurt” (CC BY 2.0) by CoreForce

Alyssa Brown (4 Posts)

Contributing Writer

University of Louisville School of Medicine

Alyssa Brown grew up in Chattanooga, TN. She went to Centre College for a B.S. in Biology and minor in History. She fell in love with surgery after seeing her mentor perform an anoplasty during the first year of medical school. In July, she finished her third year of medical school and wandered off the beaten path to get a PhD, before finishing her MD. She is receiving her MD degree from University of Louisville School of Medicine, and her PhD in Biomedical Engineering and Physiology at Mayo Clinic School of Biomedical Sciences. She is currently working on research projects involving pediatric ulcer disease, diaphragm sarcopenia, and benign breast disease. She currently works as part of the AWS Blog Subcommittee and AWS Instagram Subcommittee. When she is not being a black cloud, you will probably find her in the pediatric surgery OR, baking sweets and pastries that she saw on “Great British Bake-Off”, or off on an adventure. You can find her on Instagram @alyssabrown1013 and Twitter @Alyssa_B_MDPhD