TILIF#8-9: On the subject of clouds

Doctors are incredibly analytical; intensivists even more so. I want ALL of the data available so I can hyper-analyse the situation and pick an appropriate plan. But in certain areas, we are consistently superstitious. Some examples:

• Never say the "q-word,"
• Don't definitively tell a family that they are going home on a particular day/at a particular time
• Some people have clouds

This last one is shockingly widely believed with a degree of tongue-in-cheek seriousness that makes you wonder if it is really tongue-in-cheek. The idea is that some people have dark storm clouds following over their heads portending a flood of admissions, high acuity, and irrationally bad outcomes - these folks to be or have black clouds. The opposite is people for whom everything seems to work out well, irrespective of talent or deservedness - these are the white clouds.

If you ask any medical provider they can instantly tell you which kind of cloud they are associated with and even how it has changed throughout their career. These designations are generally arrived at by group consensus and altered with feedback (e.g. "What?! You're not a white cloud; remember last Sunday? It was a nightmare!").

In residency I had a reputation as a white cloud, which was lovely in some ways - smooth shifts are always pleasant. But for my PICU blocks, and now as I start fellowship, I really kind of want experience. I want things to go wrong now, while I'm still learning and have supervision, so I can build up my knowledge and problem-solving skills.

We jokingly never wanted to work with our co-residents who were black clouds, because it often meant more work. But by the end of residency, it was those residents who we wanted on with us because they had seen everything and had a better idea what to do thanks to having seen most situations before.

TILIF: My co-fellow appears to be a black cloud.

From Wikimedia Commons/CDC

If a baby is blue/"dusky" on day 0 or 1, then they have transposition of the great arteries (TGA). There are many cyanotic heart lesions but only one that can cause cyanosis that early in life. TGA is when the blood circulation to/from the lungs, and to/from the rest of the body are pumped by the heart in parallel rather than in series. In other words, the two sides never mix. Oxygenated blood from the lungs goes right back to the lungs and deoxygenated blood from the body gets sent right back out to the body. Once the heart's prenatal holes that allow for mixing convert to the normal post-birth configuration, things take a turn for the bad quickly.

Another cyanotic heart lesion, truncus arteriosus, is when the two outflow tubes from the heart are joined together into a big... trunk (hence the name!). The aortic and pulmonic valves that normally block reversal of flow back into the heart are smushed together as well. Each normally has 3 leaflets that close up each tube, but what about when they are combined? Actually the super valve usually still has only three leaflets (~50%), next most common in 4 leaflets (~35%), with the rest being a mix of 1/2/5 and very rarely 6.