The Specialty of the First Hour - Where Other Doors Close, Emergency Medicine Begins.
#3 Pulse checks and Reflections
By-
Dr Arihant Jain, MD | lifeonthefrontline.com
Instagram: @humans.of.em
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On this Emergency Medicine Day, let me tell you a recent story from a peripheral center where I am currently working — a story that reminded me why I chose this specialty, and why, despite the chaos, exhaustion, uncertainty, and emotional burden, I remain deeply proud of what we do as Emergency Physicians. Because Emergency Medicine is not merely about treating disease.
It is about standing beside human beings during the worst hour of their lives, making critical decisions before certainty arrives, and fighting for patients who still have a chance to come back from the edge. This is a story from a peripheral center where I am currently posted. Not a large tertiary-care resuscitation bay. Not a perfectly staffed academic unit. Just one of the many frontline centers in our healthcare system where critically ill patients arrive first — often before systems are ready for them.
“She had finally won.”
For almost a decade, cancer had dictated the rhythm of her life.
Hospital corridors.
Chemotherapy cycles.
Surgical scars.
Follow-up scans.
The quiet anxiety before every report.
Cervical cancer had taken years from her life, but not her fight. And then, fifteen days before I met her, she heard the words every cancer patient waits for:
No metabolically active lesion.
Her PET-CT showed remission.
For her family, it was not merely a report. It was resurrection. But medicine has a cruel way of reminding us that survival is rarely linear. Seven days before arriving to our Emergency Department, she had noticed swelling in her left leg. She visited the outpatient department of our peripheral center, where a lower limb ultrasound was advised.
The scan date was given three days later.
Nobody was wrong.
Nobody was careless.
Just another ordinary delay inside an overburdened healthcare system.
Three days later, she returned. She walked into the ultrasound room alive. While lying down during the scan, she suddenly became breathless. The scan was somehow completed. But now she could barely complete sentences. She was visibly short of breath and rapidly deteriorating. She was rushed into our Emergency Department.
When she arrived, her blood pressure was not recordable.
Her oxygen saturation hovered in the 80s.
Her body had already entered shock.
The monitors were connected. IV lines secured. The first fluid bolus started.
The venous blood gas returned:
pH: 6.7
Lactate: 15
Hco3 = 6
Her body was failing faster than words could describe it. We performed Point-of-Care Ultrasound (POCUS). The right atrium was grossly enlarged, right ventricle ballooned against a struggling septum. McConnell’s sign stared back from the screen.
At that moment, the diagnosis became painfully clear. Massive pulmonary embolism.
A clot had likely traveled silently from the swollen leg she noticed days ago, into the pulmonary circulation, and now her right heart was collapsing under the pressure.
Most textbooks make the next step sound straightforward.
“Give thrombolysis.”
But medicine at the bedside is never written like textbooks. Because now came the real problem. We were functioning in a peripheral center. No unit was willing to admit a post-thrombolysis unstable patient in this centre, before even documenting they were told not to admit the patient. And she was too unstable to survive transfer elsewhere.
There are moments in Emergency Medicine where the physician stands alone between protocol and reality.
This was one of them. Giving thrombolysis carried enormous risk. Not giving it would almost certainly kill her. And then came the hardest part of Emergency Medicine — not the procedures, not the drugs, not the ultrasound.
The conversation.
I had to sit beside her daughter and explain that the mother who had just survived cancer was now standing at the edge of another catastrophe.
I explained the diagnosis.
The risks.
The bleeding possibility.
The uncertainty.
The fact that we did not have the ideal system support around us.
The fact that shifting her in this condition might itself become fatal.
I still remember the silence after that conversation. The daughter’s eyes filled with tears. Fifteen days ago, they celebrated remission. Now they were discussing whether her mother would survive the next few hours. Emergency physicians witness human beings at the exact moment life changes direction.
Not in conference halls.
Not in polished discharge summaries.
But in overcrowded resuscitation bays, where decisions must be made before certainty arrives.
We minimized fluids after identifying the failing right ventricle.
Noradrenaline was started.
Vasopressin followed.
Anticoagulation initiated.
Nebulized nitroglycerin was prepared.
And finally, after informed consent, the thrombolytic infusion began. At that point, another decision had to be made. Should we intubate?
Many critically ill patients eventually require airway support, but in massive pulmonary embolism, induction and positive pressure ventilation can precipitate cardiovascular collapse. She was compensating for her acidosis still — and we decided to maintain a very high threshold for intubation.
So we waited. Watched closely. Adjusted vasopressors. Repeated assessments. Managed physiology minute by minute.
Slowly, she began improving. The blood pressure returned. The oxygenation improved.
The storm inside her pulmonary circulation began to settle. And sitting there afterward, exhausted in that resuscitation room, I kept thinking:
This is why Emergency Medicine exists.
Emergency Medicine is not merely triage.
It is not just “initial management.”
It is not a transit lounge before “real specialties” take over.
Emergency Medicine is the specialty of the first hour, the resucitation, the time.
The hour where diagnosis is uncertain. Where systems are imperfect. Where protocols collide with reality. Where families collapse emotionally. Where physiology deteriorates by the minute. Where someone must integrate ultrasound, resuscitation, communication, pharmacology, risk-benefit analysis, airway judgment, hemodynamics, and ethics — simultaneously.
That someone is the Emergency Physician.
Emergency Medicine also exists for another uncomfortable reality in healthcare. It exists when diseases stop fitting neatly into one specialty. When the patient has shock, respiratory failure, metabolic acidosis, hemodynamic collapse, and an unclear disposition — all at the same time. It exists when multiple systems are failing together, and multiple departments hesitate because the patient belongs partially to everyone, and completely to no one. It exists when nobody wants to take responsibility first. It exists when a patient has nowhere else to go.
When transfer is impossible. When admission is uncertain.
When the patient is denied from everywhere else because they are “too unstable,” “too high-risk,” or “too complicated.”
That is when the Emergency Department becomes more than a physical space. It becomes the safety net of the healthcare system. And the people holding that net together are Emergency Physicians. Because at the core of Emergency Medicine lies one simple responsibility:
To resuscitate the patient who made it to the hospital in time. To pull them back from the edge of physiological collapse. To bring them out from the doom of illness before the body crosses a point where recovery is no longer possible.
That responsibility exists regardless of whether the diagnosis is clear. Regardless of whether a bed is available. Regardless of whether another department has accepted the patient. Regardless of how chaotic the environment becomes.
Our first instinct is always the same:
Stabilize.
Resuscitate.
Buy time for life.
And the strange thing about Emergency Medicine is that most patients never truly remember us afterward. They move to wards, ICUs. Then discharge summaries.
Then follow-up clinics. Then life slowly returns to normal.
The emergency department becomes just a blurred chapter in their memory. And honestly, that is okay. Because our work was never about recognition. But sometimes, families remember. Sometimes they see the physician running from one crashing patient to another, handling chaos while still trying to reassure a frightened daughter standing beside her critically ill mother. At the end of that shift, after hours of vasopressors, thrombolysis, difficult decisions, and uncertainty, her daughter came to me and simply said:
“Thank you, doctor.”
It was a small moment. But after one of the heaviest shifts, it made my entire day. Because in that moment, someone understood what Emergency Medicine truly is.
Not glamour.
Not heroism.
Not dramatic television scenes.
Just human beings trying to hold life together in its most fragile moments. This is why we exist. Qualified Emergency Physicians are not a luxury for tertiary hospitals.
They are a necessity for every medical college, every emergency room, every frontline center where critically ill patients first arrive.
Because salvageable patients do not always reach ideal systems.
Sometimes they reach peripheral centers.
Sometimes they arrive before specialists.
Sometimes they deteriorate in front of junior doctors with minimal support.
Sometimes the difference between life and death is whether someone in that room understands shock physiology well enough to act before certainty appears.
Emergency Medicine exists for those moments. Not every patient can be saved. But many can be salvaged if the right decisions are made early enough. And that is what Emergency Physicians are trained to do:
make critical decisions inside physically chaotic, emotionally overwhelming, resource-limited environments — while time itself is collapsing around the patient.
This is where Emergency Medicine comes in.
At the frontline.
Before clarity.
Before admission.
Before certainty.
Sometimes, before death.