ROSC - Return Of Spontaneous Circulation
Stories from the Frontlines of Emergency Medicine
The Night I Started Writing
Friday night in the resuscitation bay is never quiet. As the only trauma, stroke, and cardiac center in the region, our emergency department is the final stop for the most critically ill. As the ED physician, I hold the responsibility of managing patients in their most vulnerable, life-threatening moments.
When I arrived, the situation was already dire. The department was bursting. Critically ill patients waited with no beds available. Many who’d already been admitted had spent days in limbo. Weekends are especially brutal—hospital flow slows to a crawl. No one was going anywhere.
And yet, the front doors never close. Patients keep coming. More stretchers. More desperation.
The frustration of being unable to reach the sickest patients—because of space, staffing, or system failure— feels like a betrayal of my oath. As the physician in charge, I’m accountable for everything. If someone deteriorates because we couldn’t get to them in time, the burden lands squarely on me.
To make matters worse, I was still recovering from a lingering respiratory illness. I felt fragile—fatigued, irritable, foggy. But in this line of work, calling in sick isn’t a real option unless you’re incapacitated. Tonight wasn’t the night to push limits. I half-joked to a colleague: Let’s just hope a busload of hemophiliac children don’t get into a gun-battle.
The Floodgates Open
I reviewed the early cases with the resident: unstable angina, pneumonia, a transient ischemic attack.
Then came the wave.
Over the next two hours, a flood of critically ill patients arrived. I bounced between stretchers, trying to keep everyone alive.
A code came in: a man had collapsed at the gym. He was pulseless. Thanks to bystander CPR, he arrived in our trauma bay with return of spontaneous circulation (ROSC). We intubated him and confirmed a massive heart attack on ECG. I called cardiology and sent him straight to the cath lab.
While managing him, two more stroke patients arrived. Then a young man in diabetic ketoacidosis. And another with a fentanyl overdose, revived with multiple doses of intranasal naloxone.
He was is florid withdrawal—agitated, sweating, delirious—chasing a nurse around the exam room before security could restrain him. Minutes later, he was back to being somnolent, his body overwhelmed by the drug’s return as the naloxone wore off.
Triage on the Brink
Then a trauma arrived with no pre-notification: a 95-year-old man who’d fallen down 12 stairs. He had a brain bleed, cervical fracture, rib fractures, a fractured scapula, and a large scalp laceration that wouldn’t stop bleeding.
As I sutured his scalp to control the hemorrhage, a nurse leaned in urgently:
"Doc, the patient next door doesn’t look so good."
I stepped over.
He had been waiting for hours in a hallway. Pale, confused, and hypotensive. Chronic hip pain. A vague sense of malaise. His chart mentioned schizophrenia. His words didn’t make sense.
I started aggressive fluid resuscitation. Then vasopressors. Labs came back: profound anemia and metabolic acidosis. But no clear source of bleeding.
That’s when I felt it.
My cognitive bandwidth snapped.
I’ve been here before—on shifts like this, making impossible choices in real time. But something was different. I was drained. Lost. A wave of panic hit me.
An emergency physician cannot afford to panic. But this wasn’t something I could push aside.
A colleague passed by. I asked, as casually as I could:
"Hey—are you busy? I’m feeling a little overwhelmed."
He glanced at the clock. “I’m outta here in 15,” he said, and kept walking.
I stood there, drowning.
Resuscitating the System and Myself
I pulled myself back. First things first: the sickest patient. I activated the massive transfusion protocol. We kept pumping in blood and fluids, searching for the source.
Eventually, we found it: a ruptured spleen.
I stabilized him—just long enough to get him to the OR.
By the time sign-out came, the department had quieted slightly. I handed off to a hypercritical colleague. They nitpicked everything. They didn’t ask how I was. They didn’t know the turmoil I was experiencing inside.
I left the hospital defeated. Exhausted. Almost in tears.
And I wondered:
How do I keep doing this?
This Is the Cost
Emergency medicine is one of the most demanding roles in healthcare. It requires not only technical skill—but stamina, resilience, and the capacity to make life-and-death decisions with a calm face while drowning inside.
You must want this work. Passion is not optional. Without it, the emotional toll will consume you.
After nearly a decade as an attending, I’ve transitioned from the thrill of early practice to the weight of accumulated trauma. This story isn’t just about one shift—it’s about the quiet reckoning many of us face in emergency medicine.
They call us “gatekeepers” of the hospital. But we’re really gate-openers. We’re the ones who say yes to the bleeding, the broken, the dying—when no one else will.
The Long Road to the Frontlines
The journey to becoming a doctor is brutal. You don’t just earn a degree—you pass an endurance test.
Getting into medical school demands perfection. Training demands sacrifice. Early on, students arrive with hope and idealism. But medical culture is a pressure cooker. Brilliant people feel like imposters. Everyone doubts themselves.
Empathy peaks early—then erodes.
The first two years of medical school are mostly books and theory. But by year three, when patients enter the picture, empathy begins to decline. Not because we care less—but because we must protect ourselves to survive.
Residency turns that erosion into a landslide. The hours. The pressure. The trauma. The moral injury. By the time we emerge as attendings, many of us are burned out—or numb.
Some physicians never recover that initial spark.
Why I'm Writing This
I’m writing this because I still care. Because I still want to believe that this work matters. That we can do it better. That we can survive it—and maybe even heal.
ROSC—Return of Spontaneous Circulation—is the term we use when a heart restarts after it has stopped.
This newsletter is about our ROSC—about bringing ourselves back to life after everything we’ve given to others.
It’s about what it costs to stay in emergency medicine—and what it takes to stay human while doing it.
Welcome.
Excellent writing. I understand so much of what you've said. I was an ICU and ER nurse for many years. The best way forward is to revamp our entire health care model from crisis care to preventive care. I spent years in the ICU, surrounded by ventilators and grief, fighting for lives already slipping away. It broke my heart, but it woke me up. Health shouldn’t begin in crisis. It begins in the quiet: in the tea you sip, the herbs you grow, the daily walks you take.
We need to live and practice this with everyone. I am in my retirement years now and write about preventative health to teach others. It's my small part. But I am aware we are up against some powerful money-making machines. Health is not complicated, but healthcare is because it's a huge moneymaker. Preventive care and natural remedies are only profitable for the patient.
Thanks Mike for articulating what most of us in Emergency Medicine feel on a daily basis. This profession takes an incredible toll on our bodies, mind and soul. The thrill of the profession is intoxicating but like all intoxicants eventually the toxicity comes through. About 10 years ago (when I had been in practice for 20 years) I made a list of EM doctors, Nurses, PAs, and EMS personnel who had major life altering events. Off the top of my head I realized that I could count 16 people who I had worked with who had either ended up in rehab, attempted or committed suicide, were facing criminal/legal charges, and/or upended their family life (divorce,affairs,etc).
Yet we continue to come in to the department to bang out another shift.
Continue to tell our story. Continue to do the good work.