Wow. High mortality day in the ED. Was working at about two-thirds speed through the beginning of the day, and then a patient bomb exploded. We had two full arrests come in at the same time. I was rushing to room 13 (bad sign) for the first when I saw goggle-eyed medics wheeling in the second. Nothing for it---stabilize the first and see the second when I can. Ah, California, you're carefully designed public safety net in action. Look ye upon it and rejoice! This first guy was young, fifty, and a complete cipher. No pulse, no breathing, and idio-ventricular (Latin for WTF) rhythm. We coded him up. The medics thought they might have seen a peaked T-wave or two before the guy dropped out, and he had a dialysis shunt, so hyperkalemia seemed like a reasonable bet so we treated for that. As I was tubing the guy--almost a cluster, but salvaged it at the last minute--I was calling out orders. Epi, Atropine, 2 of Bicarb, 2 of Mag, 2 of Calcium Chloride, Insulin 10 units IV, D50.....and when I lifted me head up to check on the nurses they hadn't missed a beat. What a team! So, so, strong! We had a trainee EMT with us and he got to see an eyeful--from the convenient perspective of doing chest compressions. I put in a central line--bloody, bloody mess that i had to apologize for afterwards--and we reassessed the guy. I'll be damned if he didn't have a rhythm and a pulse. Bolused Lidocaine, hung a drip, and moved to phase 2--Consolidation. Ahhhhh....not so fast young Dr.U! I checked on the second Code--thank God! Paleo had been called from ED2 to run it (F'ing STUD this Pableo guy). Then my guy dropped again and we had to code him back up. He just slipped from a booming sinus tach with robust 130/74 pulse to an indetectable dribble of QRS complexes at about 20 per minute. The only thing keeping this guy alive was IV epi. And over the course of fifty minutes we gave a lot of it. Pressors were hung, labs were sent...and I went to see the family. Young daughter who speaks English and wife who doesn't. I was direct, not quite as gentle as I would have liked, and left no room for misunderstanding the fatal severity of the issue at hand. We called them in to see the patient....just as he dropped out again. We were an hour and fifteen minutes in, and I'll go pretty deep into reserves to pull out a 51 year old, but I was increasingly confident that we were no longer working towards a medical or moral good outcome. I called it. Poor guy. The next guy was almost called in the filed, but freakishly we got a (questionable) return of pulses and the guy lived just long enough to be subjected to a mediocre five minute code before I called that as well. Another guy would have been coded, but was a DNR and another guy (Pableo's) lived through the first resuscitation effort and hung on for three hours before dying on the hands of my evening shift replacement. A whole lot of dying going on. In happier news...I may have made a briliant diagnosis! Listen to this! A very sweet Muslim girl comes in with an odd rash on face, palms, soles. I won't be coy and tease you through the medical investigation but suffice it to say: INH, fasting because of Ramadan, and unusual rash on her palms and soles--am I seeing a case of Pelagra? I treated her per the standard Pelagra regimen (for those of you not in the medical field, this "standard Pelagra regimen" is a bit of a joke) and arranged follow up with Family Medicine. You could almost here the stupified disbelief in the FM attedning's voice. Not that Pelagra had been found in 21st century America, but that a grunting Er doc had 1)been able to consider such a non-obvious diagnosis and b)been able to pronounce the word. Home early. Two days down, six days to go.