The First Lightning

62/M

He came in just after dawn.

Buttoned shirt. Calm breath. Measured voice.

But beneath it all -

the quiet hum of a body that had been struck from within.

He had been asleep when the first one hit.

Then another.

And another.

Nine shocks in total.

Fired from the small black box buried beneath his skin.

His ICD, his personal shock machine.

Each one a bolt of calculated, necessary violence.

Each one a moment to interrupt, not to kill.

Each one a command to return.

His heart had slipped into a rhythm older than reason -

ventricular tachycardia.

Fast. Monstrous. Electrical wildfire.

A storm without rain.

A rhythm witout mercy.

The machine fired because it was built to.

Because it was programmed to choose survival over silence.

Pain over stillness.

Life over letting go.

And yet, he sat there.

Not confused.

Not crying.

Just… quiet.

The kind of quiet that settles when your own heart wants you gone.

And something deeper says no.

What the Monitor Knew

He was stable, technically.

A good volume, but racing pulse.

Normal BP.

Fully conscious.

But the monitor told a different story.

Heart rate 156/min.

Wide complex. Regular.

Ongoing VT.

Alive.

It wasn’t chaos.

No sirens.

No shouting.

No code.

Just the silence that gathers when death is near,

but hasn’t made a decision yet.

The crash cart rolled in.

Pads placed.

Lines drawn.

But we didn’t shock him again.

Not yet.

We reached for Amiodarone.

150 milligrams of precision damage.

Poison, repurposed.

Medicine, sharpened.

Sometimes, you have to hurt the heart to teach it rhythm.

And slowly, the numbers obeyed.

130s.

110s.

Then… sinus.

No drama.

No collapse.

Just… correction.

As if the heart had grown tired of rebelling.

He exhaled.

And so did we.

The Space Between Beats

There’s a kind of Emergency Medicine that never makes it to textbooks.

Not the glamorous kind.

Not the chest-thumping, tube-pushing, shock-delivering

theater of it all.

This is the medicine of holding your nerve.

Of watching a man sit perfectly upright,

while a bomb ticks behind his breastbone.

He had not coded.

He had not collapsed.

But something had shattered.

Not the heart.

Not the mind.

Something more delicate.

The illusion of safety.

And yet, there he was.

A man who had been jolted nine times in the chest

by the very thing designed to save him.

And still managed to ask us, gently,

if we needed his old discharge summary.

We joked, later, that cats have nine lives.

That maybe he’d burned through all of his before breakfast.

But it wasn’t a joke.

Not really.

Because what do you say to someone

whose heart was shocked nine times

by a machine in his chest,

and who drove himself to the hospital?

Nothing.

You just stand there and bear witness.

The Heartbeat Between Deaths

You want to ask what it felt like.

To be awakened not by light,

but by fire.

Not by alarm,

but by electricity.

To be pulled back into your body again and again,

not by love or memory.

But by sheer mechanical refusal.

Each shock not a salvation,

but a summons:

To live, not because you chose to,

but because something inside you refused to give in.

That is not a rescue.

That is a reckoning.

We say the heart is stubborn.

But maybe life is more so.

Maybe it claws us back not for greatness,

but simply for persistence.

One more breath.

One more hour.

One more chance.

Later, as he was wheeled to the CCU, he thanked us.

Not with relief.

But with reverence.

As if he understood something that we did not.

We are taught to measure survival.

But how do you measure the will to remain?

How do you chart the gravity

that pulls a soul back into his chest,

when it was already halfway gone?

And all we can do is to stand there and witness it.

Not to explain it.

But to remember it.

So it won’t be lost to the silence it came from.

If this made you pause, forward it to someone who might need it.

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More soon.

Another moment.

Another reminder that we are still, somehow, human in all of this.

Yours,

Dr. Adarsh Nath,

Letters from the ER

Disclaimer:

Patient details have been changed to protect confidentiality. This is a personal reflection, not medical advice or substitute for professional care.