EM Mindset: Charlotte Wills – Black Clouds

Author: Charlotte Wills, MD (EM Program Director / Attending Physician, Highland Emergency) // Edited by: Manpreet Singh, MD (@MPrizzleER – Clinical Instructor & Ultrasound/Med-Ed Fellow / Harbor-UCLA Medical Center) and Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

Many years ago during a residency interview, I was asked by a program director what I would be if I couldn’t be a doctor. Without a moment’s hesitation, and maybe just a little too quickly, I answered “a meteorologist”.  So it’s probably fitting that very early in my training, I garnered the label of a “black cloud”.

As an intern, my days and nights were littered with patients crashing in spectacular fashion, taking unexpected clinical twists and turns on their way to asystole. My reputation grew. Soon, the flurries of admissions, megacodes, and exotic diagnoses abundant in any busy county teaching hospital were attributed to my particular presence.

Routine patients were anything but routine: the young man presenting with a distinctly unexciting seizure until we discovered he was a homeless poorly compliant hemophiliac now with a head bleed. Utterly stable patients were rendered unstable: the gentleman who for two months had been living a symptom-free life in respiratory isolation while being treated for multidrug resistant TB during my night on call perforated his duodenal ulcer. On hospital day #152. Even the most trustworthy of historians proved challenging: the nun with chest pain who during her workup for ACS complained of tinnitus and was discovered to be suffering from a salicylate overdose from continually popping baby aspirin. I was once even thwarted by a lunch tray: the lady with the chief complaint of ear pain whose aortic dissection was discovered after a plate of Highland meatloaf provoked her resultant mesenteric ischemia. One of my most beloved attendings pronounced this “classic WADS”: Wills Associated Dissection Syndrome.

My black cloud label persisted as I became an attending myself, and even to this day – perpetuated as much by my physician and nursing colleagues as the volume or esoteric diseases of my patients themselves. Battle-tested, I have come to embrace my cloud. My cloud means that it might be a good shift or a bad shift, but never a boring shift.

The mythos of the black and white clouds in medicine has long been debated, and even studied. The most referenced and possibly only scientific article on clouds profiled the clinical experiences of nineteen pediatrics interns in relation to their perceived clouds. The authors Tanz and Charrow concluded that, in reality, these interns all had similar clinical experiences, despite the perceived color of their cloud. The notion of a black cloud may actually be more a phenomenon of how people manage their workload and stress.

While I do disagree with the paper’s conclusion that all clinical experiences are created equally (any student of evidence-based medicine will be weary of a claim made with an N=19), the real take home point of that paper is that you are ultimately much more in control of your work than you may think or feel. This is good news, as it implies you can be the master of your cloud. So, here are some tips for dealing with your local weather:


  1. You can’t control the weather, but you can prepare ahead of time. Since early on in residency, I have been in the habit of coming ten to twenty minutes before my shifts to walk the department and run the board before sign-out. Since I’ve seen what the ED looks like, the anxiety of the unknown is gone. I have a sense which patients have the potential to go south, and I have a general impression of the weather for the beginning of the shift.
  2. Read the forecast. Or at least the nursing notes. It’s amazing how often clues to cases gone sideways were there in front of us in the triage or nursing notes. Always read the nursing notes and review ALL of the vital signs. We would never ignore a CBC or a chest x-ray. So don’t ignore this data. Nursing documentation is temperature and barometric pressure of your forecast. Use it.
  3. Forecasts change. So do patients. The weather right now might very well NOT be the weather four hours from now. Flexible thinking and frequent reassessmentswill stop you from getting soaked.
  4. Listen to your local weather spotters.The National Weather Service utilizes the observations of volunteers for minute-to-minute updates on local ground conditions. In the ED, we are surrounded by our own army of weather spotters. They include radiology techs, ED techs, volunteers, and family members, in addition to our nursing staff. LISTEN when they express a concern about a patient. That could be your clue that bad weather is about to go down.
  5. Sometimes you don’t need hi-def Doppler radar, you just need to go outside. Lovingly presented at our journal watch by one of our most testing-averse faculty, an article by Kroenke in Annals of Internal Medicine concluded that history and physical alone contribute between 73 and 94% of the diagnostic information needed to make a correct diagnosis. This is staggering, and makes the very valid point that we just need to get outside/talk to our patients more, and rely on testing less.
  6. Don’t wait to evacuate when you know a storm is coming. And don’t wait to intubate patients you think have a high likelihood of needing a definitive airway. Think of these patients as the stalwart locals your see on the news – refusing to leave their beloved house on the beach despite dire warnings from local officials. Maybe they will get lucky and dodge the storm, or maybe they will need many more personnel, equipment, and heroic maneuvers to save them when the storm hits.
  7. El Nino is fueled by ocean warming. And atrial fibrillation and DKA are fueled by some other disease process. To successfully treat and remedy those conditions, you MUST find and neutralize the provoking illness. Check anywhere infected fluid or tissue can hide – the lungs, the bladder, the CSF, the appendix, skin, and soft tissues. In women, look for pregnancy and pelvic infections. Because as that huge swath of ocean near the Equator continues to warm, El Nino continues to strengthen.
  8. Some areas are more prone to violent weather. Central Oklahoma experiences more tornadoes per square mile than anywhere else on Earth. Elderly ED patients have the highest rates of hospitalization for abdominal pain. Multiple studies have revealed that as many as 30-40% of those patients will ultimately need surgery for the cause of their pain. The elderly are the Central Oklahoma of abdominal pain. So start looking for that EF5 tornado in their gallbladder or their bowel wall. Because admission to the medicine service is not much of a tornado shelter.
  9. When a storm hits, quickly call the National Guard. Sometimes despite our best forecasting and preparedness, a storm hits and causes a huge amount of damage. Ultimately, it is our quick response and mobilization of appropriate resources that can make a difference in that patient’s outcome, as well as how that care is later viewed. Take any natural disaster, and you will see leaders judged largely on how quickly they recognized the scope of the event and effectively deployed needed aid. We are no different in the emergency department. Communicate to everyone involved the critical nature of the situation and mobilize all of your available resources rapidly and efficiently. Treat every crashing patient like a natural disaster.
  10. Learn from prior storms. The single best piece of advice I have ever received was early in my career from the chair of my department. When my cloud seemed most furious and forboding, he urged me to join our department’s QA committee. Adopting somewhat of a “if you can’t beat ‘em, join ‘em” mentality, I became a member. Fourteen years later, I still find looking at these cases uncomfortable as they inevitably evoke the icky and aching feeling of “that could have been me”. However, debating the patient care and studying the systems and medicine behind the outcomes has informed my practice more than any other educational endeavor I have been involved with. I am a better forecaster for it.

So do I really have a black cloud? Hells yes. However, those pediatricians in Chicago were likely onto something when they attributed clouds to how those newly minted physicians were responding to their patients and clinical environment. To my fellow black clouds out there, my comrades in arms, I would offer that the sky isn’t actually falling – even when it feels that way. Be resilient and adaptable, and you can indeed control at least a bit of the weather. And to all you white clouds, you should look up once in a while – you might be about to get rained on.

References / Further Reading

Tanz RR1Charrow J. Black clouds. Work load, sleep, and resident reputation. Am J Dis Child. 1993 May;147(5):579-84.

-Kroenke, K.  A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review. Ann Int Med.  Oct 2014 161 (8): 579-586.

-Lewis LM, Banet GA, Blanda M, et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. J Gerontol A Biol Sci Med Sci. 2005 Aug. 60(8):1071-6.

-Samaras N, Chevalley T, Samaras D, Gold G. Older patients in the emergency department: a review. Ann Emerg Med. 2010 Sep. 56(3):261-9.

-Tornadoes in the Oklahoma City, Oklahoma Area Since 1990 National Weather Service Forecast Office Norman, OK http://www.srh.noaa.gov/oun/?n=tornadodata-okc

Accessed 11/20/15

-Oklahoma Leads the World in Tornadoes June 8th 2013 USATODAY.comhttp://usat.ly/ZWI5gT




6 thoughts on “EM Mindset: Charlotte Wills – Black Clouds”

  1. Can’t think of a better metaphor than unpredictable (and sometimes deadly) weather as a metaphor for the emergency department. Excellent article!

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