...COLD

I wrote this essay that was published in the Annals of Emergency Medicine last December. Enjoy :)

"Icicle"

As the dawn sign-out trailed off, the loud bell of an EMS ring-down disrupted the relative calm. Moments later the charge nurse emerged from the radio room, waving a white
sheet of paper on which he had scrawled some notes: “Unresponsive. Homeless. Very cold. HR 30. ETA 5.” The senior resident finishing her night shift quietly said, “Don’t
move him around too much or he’ll code,” and then slipped out the double doors to the parking lot while we prepared.

The bear-hugger was inflated and warmed, heated fluids at the ready, blankets in several hands. We pounced on him as the stretcher rolled in. Nurses, techs, and physicians on all
sides. His skin was as cold as ice, barely moving. If not for the quiver of heart motion on the snowy ultrasound screen, I would swear he was dead. He was homeless, huddled outside
on the stairs of a church throughout a cold December San Francisco night, during which rain intermittently turned to hail. We never learned how he was discovered that morning,
or who brought him to the attention of the police. They only knew he was frigid and barely breathing. His hair was matted against his head, stiff with cold. Harsh weather had aged his
face beyond his years and a fine layer of dirt settled among the wrinkles in his face. Unable to say his name, he was dubbed Medical Patient “Deer.” The medic’s thermometer showed an “-E-” on the screen. Given the frost of his feet, we knew it was not broken, only too cold to read. A Foley was deftly inserted. The bladder temperature winked alongside
the other vitals on the green and black monitor: 23.4. The number gave us all a brief pause. How could a person still live at 74 degrees Fahrenheit?


For a patient this cold, there are several mantras. Move them as little as possible; the heart is so sensitive to the cold it may twitch into a deadly ventricular arrhythmia at any
moment. Passive rewarming is ineffective; warm water and air must be pushed into the body. A Foley catheter was inserted into his bladder and warm fluids flowed in and out.
We deferred placing a central line into his neck as the catheter would sit too closely to the irritable heart. Instead, a large cordis threaded into his femoral vein provided a route
for a great volume of warmed saline to squirt through the level 1 blood transfuser. Earlier that day the same machine kept alive an exsanguinating trauma patient. A blanket
wrapped as a turban kept in the precious body heat lost through the head, replacing his worn SF Giants ski cap that was riddled with holes.

The core temperature reading slowly began to creep upwards: 24, 24.5, 25. But his heart remained slow, breaths intermittent. A breathing tube slipped between the vocal
cords supported his efforts and pulling air into his lungs. Still cold. Too cold. The chest tube tray was opened, and following a cut with the scalpel, a large tube was slipped
between his ribs. A second infuser pumped a liter of warm fluid into his chest to bathe his heart and lungs, and then sucked it out. In and out: 26. In and out: 27.


Throughout this time his blood pressure remained low as his heart was still so slow. Supportive drugs helped bring it upwards. I waited with bated breath for him to slip into
cardiac arrest. A bleary-eyed ICU resident appeared with admission orders in hand. We “packed up” the patient and all the various tubes hanging off him and headed towards the
elevators. That is where we parted, he to the ICU and I to my teenager with a broken ankle, and then a woman with chest pain.

Four days later, on the next ICU call schedule, I encountered that same critical care resident while resuscitating a GI bleeder. I learned that our frozen man lived through the night, and the next and the next. His temperature rose and eventually he emerged from his coma,
with minimal neurologic deficits. We cool patients postarrest; he cooled himself before we got to him. Is it neuroprotective in the same manner? Eventually he made it
out of the ICU and then passed out of the main doors of San Francisco General Hospital, past the Heart Statue and onto Potrero Ave. From there, who knows?

I suppose his case is a triumph for the emergency department team of physicians and nurses who literally brought him back from the dead. Later that day, I had boasted to a fellow resident that I placed 6 lines in the patient in under 30 minutes (endotracheal, nasogastric, left internal jugular, right femoral, left arterial, left chest tube).
But honestly, I could do that to a cadaver. Triumph for me, perhaps.


But while I was driving home, that patient was in the ICU. Would it not be cheaper to buy him a sandwich, give him a roof over his head, than pay the daily room rate of an ICU bed? I
hear those rates beat the Hotel Continental’s presidential suite almost 20 times over.

My day off this week, I went shopping in Union Square. Walking from a coffee shop towards Steve Madden, I passed a tiny church sandwiched between 2 commercial storefronts.
Crouched in the corner, under a pile of blankets and old wool hat was a similar-looking man getting some rest. The day was warm, yet a shiver ran up my spine. Would I see this
homeless wanderer in the resuscitation bay in the future? I dropped a dollar in his Styrofoam cup and hoped we would never meet again.