Work has been good recently. But in a quiet, very un-"e.r." way. I have been pretty confident in my dispos. I've gotten my dictations taken care of pretty close to on time. Easy relations with the nurses. Some interesting cases. Just recently I switched to overnights and had some grueling hours, but it's nothing particularly exciting; no drama or excitement, just hard work. Today I got off work at 8am, 2 hours late, but a deliberate 2 hours late--the over night PA called in sick (Diabolical!) and I spent an extra 2 hours in the zoo to cover her. Went home and wrestled the shit out of the dog. Then checked email, walked the dog down to get a replacement collar, and rode my bike down to meet the Biscuit for lunch. About an hour ride--I pushed the pace and it was a decent work out. The plan ahead is lunch at 1pm, in bed and asleep at 2:30 pm, up at 9 for work. I can hardly wait to hit the sack--my body is tingling in anticipation of joyous slumbering. After the cruise a couple of weeks ago I decided to lose the weight I have put on. I have become fat and happy. The decision has forced me back on the bike and added a shitload of lettuce to my diet. Still, I feel pretty good. Hungry all the time, but a little more fit and a little less doughy. Will be married in 8 weeks. Wow. U-561

At 0610 I was called to the ICU for a code blue. I ran up. It was a sixteen year old girl, which is bizarre and horrifying, and even worse it was a 16 year old girl I knew well. Three nights ago I had baby sat her in the ED as she had apneic spells trying to shake off the Ativan soem admitting doc had snowed her with. I chatted with her parents and, between sternal rubs, chatted a little with her. Sweet girl, high school age. Spent an hour with her and her family--more time than I've probably ever spent with an ED patient in my life. But now she's stuck in the ICU and not breathing. I tube her without meds. Her pupils are dime sized and fixed. Grim, grim, grim. I tell them to hyperventilate her and tell the team to get her ready for a STAT head CT. My thoughts are jumbled. Mannitol and steroids, but I'm afraid I'm missing something. I rack my brain, but I can't come up with anything else clever. The ICU nurses get her ready to go in good time. CT is waiting. We rush down, trundling the hospital bed before us. I stop en route to talk with the mother. Horrified, terrified, uncomprehending. I had noticed her as I ran into the ICU, but only now do I recognize her as the woman I chatted with as we watched her daughter's uncertain breathing. I tell her I have intubated her daughter and that I am afraid she has swelling of the brain. She wants to know if I have ever seen this before, and if I have ever seen anyone survive it. I tell her yes and yes and I run off to the CT. The team is working well. We spin the head. Even for me, who fumbles on CT reads, it's obvious--bad edema and pending herniation. Death sentence. I want to get more agressive, but have no idea what else to do. We elevate the head of the bed a little more and rush her back to the ICU. In the ICU we watch her BP. Falling. I decide to put in a central line because I want to do something useful. She has a thready little pulse and I'm trembling. There was moment when I got back to her room that I wanted to cry and as I watch my trembling hands and search desperately with my fingers for the whisper of a pulse I feel the cold fingers of despair and fear and sorrow closing around my throat. I'm going to flail. I make myself think "No, no, you can't do that. Just put the line in." And I do. And I realize just how worthless everything I have done has been. The intensivist is there. I am glad that he doesn't have anything to add to my management--I would have been devastated if I had failed this girl when she needed me. Dad has come in. And the younger sister. I talk to them. I feel stupid and insensitive and idiotic. They ask me and I say I am worried that things may end badly--and I immediately feel like a shit for saying something so terrible to them. I feel so stupid. Dad says "That's not an option for us." And I don't know what to say. I leave before I say something even more stupid and painful. I leave the ICU. Little girl dead. How did it happen? Encephalitis. So much for glittering Western Medicine. We had this little girl early, we treated her, and she died on us--right in front of us. She's not dead yet, but her brain is badly damaged and she will surely die soon. What a collosal failure. Sickening. I go back to the ED. I've been away for most of an hour, but it's early weekday morning and there are no patients to see. Talk with the nurses. Some of them remember her. We are all depressed. Three hours later I call the ICU. EEG showed artifact, and nothing else. Brain dead. My first thought, to my disgust and wonder, is that she will be a invaluable source of organs. U-561

There are times in the ED when something occurs that can't be translated into the realm of normalaity. Just as with language, some cultural experiences are untranslateable. Something comedic and surreal happened the other night. Ot perhaps it was perverse and terrible. A full code came in. A 41 year old female. Details on the radio painted a fragmented picture--41, female, Downs Syndrome, maybe 5 minutes down before CPR, asystole on the monitor. With each incoming fragment of information I ratchet the needle on my survivability scale up and down accordingly. When she arrives, splayed out across a paramedic backboard, one handed compressions pumping her chest up and down. Medics report she has been down....45 minutes total. The survivability meter plummets downward. I check her airway and, sickeningly, her airway consists of an EOA tube (yuck!) filled with granular yellow white vomiitus. They've been trying to intubate her through a ten inch column of vomitus. The survivability meter bottoms out--there is nothing to redeem here. I give it the old college try. If she is ever going to live she needs oygen and not vomit in her lungs and that requires a real endotracheal tube. I get the equipment, pull the shitty EOA, and dive in. The Yankauer suction (invented by Anesthesiologists) is worthless. I rip it off and using my hand as a scoop try to evacuate the womans oropharynx. It's a Sissphysian task--as I scoop the puke out more bubbles up from deep in her bloated stomach. I look in and deep, deep, deep in this tight oropharynx is a tiny chord flanked passageway. I try to muscle a tube down there, but the geometery is against me. I bail and run a GUM elastic buogie in there. It passes (!) and I push a 6.0 tube in after it. Yes--a real fucking airway! Immediately puke begins bubbling out of it. We suction down the tube and start ventilating. Poor, poor breath sounds. She's gone. We run in a few more meds and we call it. What makes a 41 year old basically healthy woman arrest? Cocaine. And if not cocaine, as in this case, marshmellows. What? Well--at the group home she lied at, she had been put on a diet for the new year. She had a weight problem and had been suffering on a restricted diet for the last two weeks. Then, as she was doing her turn washing the dishes in the kitchen, she saw a bag of marshmellows lying unprotected. Bam!--she leapt on it and started stuffing marshmellows in her face! And--in this happy orgy of forbidden sugar, she sucked in a little puff of marshmellow and plugged her tiny little airway. Death by marshmellow. Tragic. Comedic. Surreal. Unbelievable. I told the Biscuit about it, but I just couldn't communicate the fullness of the experience. The more I tried to express the sick black humor of it the more I saw her glancing worriedly at her engagement ring and glancing out the car window as if calculating her chances of surviving the jump. In other news. Went on a nice discount cruise down to Mexico--4 days for $324 per person. Nice. The puppy is doing....okay. Sleeping in the crate, and doing a pretty good job of evacuating outside. She does, on occasion, piss on the carpet and leave large steaming wet feces in the corners of the room, but...baby steps, baby steps. U-561

Amazing shift in the ED. Unbelievable. We had been having a medium paced day. The med student was doing the heavy lifting and I was keeping up with charts and chatting up the patients. 9:30 pm passed and a little bell rang in my head--shift's over, everyone coming in now belongs to the 10pm guy. Great--wrap up three or four outstanding dispos and be home to potty break the dog and see the Beautiful Biscuit twenty minutes early. Ten minutes later the medics call in--gun shot wound to chest, coming to us. I half listen to the radio until I hear the guy is in agonal respirations. Then I stop the med student's presentation and go to the radio room. Young guy, found down in a pool of blood, apparently one through and through gunshot, and--here's the vital part--agonal respirations and (they think) pulses. Question: 1) Does he go to a trauma center? 2) If he comes here, do I crack his chest? The guy deserves a trauma center. Surgeons in house, plety of docs to manage the initial resusc, OR ready and prepped, etc. But he'll never make it to one. We're twenty to thirty minutes from County USC, and twenty to thirty minutes to UCI, and about the same distance to Arrowhead. Ah, California, your miserable Trauma/Emergency infrastructure--what madness is this? So, the medics want to bring him here and I feel that we're honor bound to take him. And if we're going to take him we have to do it right. Vitals in the field, penetrating chest wound, and loss of vitals....the textbook says crack the chest. My ex-residency director made it clear all those long years ago--never crack a chest in the community: the guy will die, you'll be holding the bag, and you don't want to be the last hands on a corpse. But in the absence of a state wide legitimate trauma system we need ER docs who are willing to do it all. So I ready myself to crack the guys chest and wait. Wait and prepare. We get all the equipment together--chest tray, chest tube tray, central line, intubationn equipment, O- blood, rapid infusers, four IV's stripped and ready, goggles on, gowned up, double-gloved. I run through the various options and plays ahead of me. Sirens in the distance, and I feel myself tightening up and getting ready. It's a great, great feeling. They roll the guy in, doing compressions and wiith blood burbling out of the EOA tube jammed in his mouth. Okay. Do compressions and give me the rib spreader. I take a flimsy little scalpel and make a sternum to gurney incision in his chest wall. Big guy and only on my second sweeping cut do I hit the ribs and trace my blade through the intercostal muscles. Rib spreader ready (I've never used it) and I wedge it in place. Crank, crank, crank and with a pop and snap I'm looking through a bloody, meaty, ragged edged hole into this guy's chest. Big pink wet floppy lung rises and falls. I shove it out of the way with the back of my right hand and dig in with my left to find the heart. There it is, the motionless avocado sized piece of muscle just above the spine. I pull it towards me--pericardium tight on the heart itself--no blood to evacuate. I make my incision, paralell to the axis of the body to lessen the chance of hitting the phrenic nerve (an odd nicety considering the gravity of the situation.) I nick the myocardium on my way in. I examine the heart and run my fingers over it--no holes. I cup my hands around it and compress while I think about the next move. Have to clamp the aorta. Shit--never done that before either. The great nurses have started lines and pushed epinephrine and atropine. I take these odd long curved hemostats and push them in to the cavern of this guy's chest. No, this won't work. I picture the anatomy and put my right hand in until I'm feeling the spine. There's something meaty above the spine. I slide the hemostats in my left hand in, along my right hand and clamp the shit out of the meaty thing above the spine. What next? Central line. It's busy at the head, and he's got a GSW right by his right subclavian. I go for a cordis in the left fem--hit it blind on the first shot. Feed the line in and call for the saline that we have prepped--we're filling this guy with fluid. We have blood on the rapid infuser and saline going in on pressure bags. The nurse is doing internal compressions. We stop, reassess, and I see the heart twitching and shivering. It's hanging out of the hemithorax, a grey-pink yellow veined egg shaped organ, nude, exposed, glistening and twitching under the lights. We'll haveto defibrilate this. Internal paddles (I've never done this) and guess that we should go for 10 joules. I cup the heart in the paddles and call "Clear". Thud--the heart starts beating. We give more epi and now the guy has a carotid pulse. And now what? It never occured to me that we might get to this point. Return of pulses?! I ask them to call the trauma surgeons. Cardio-thoracic responds. She has all sorts of good reasons for not getting out of bed and coming in. The guy probably won't live. I agree-but my job is to get pulses back and call the surgeons. This is a job for trauma surgeons--I agree, and we're calling them also. Angrily she agrees to come in to "help the trauma surgeons". We call trauma--they don't even bother to speak to me, they just tell the nurse its a job for thoracic and they refuse to come in. We call general who is in house, but, unfortunately, working on the bowel perf I gave them an hour earlier. What a surprise--I crack the chest on this unsalvageable victim, get his pulses back, and there's not a god damned surgeon who will have anything to do with him. Why take on the liability? The guy will probably die anyways, right? I put a chest tube on the right side and in thirty seconds a liter of blood pours out of the chest tube. I call for the re-infuser. I intubate the guy. A hard, hard tube to make--swollen oropharygeal tissues from previous attempts and chords constantly obscured by the blood pouring up out of this guy's airway. We push it a little further, but without surgeons willing to help this guy is already dead. When the heart slows on us and when it stops I push epi once and then canvass the room and call it. We almost did it. I'm glad we tried. I feel better about myself for going big and doing everyhting possible. My ex-residency director was right, of course, it was pointless and I did nothing but expose myself and my team to blood borne diseases and lawsuits. Still, if you call yourself a doctor you gotta try. This guy had one hope in the world, and what if I had given up on him? I don't mind failing, but I would have been ashamed to not be willing to try. It looked like a warzone. Knee deep in bloody sheets and discarded papers and plastics--the detritus of a full bore code. All of us covered in blood--I'm bloodied up to the elbows and have blood spattered on my goggles and face mask. The left lung and heart lay hanging there motionelss under the lights. The med student is just on cloud nine. She was part of something unbelievable. She held a human heart in her hands and helped keep it pumping. She says flattering things to me and I think I can say that she will never forget what we did tonight and what she saw me do. I wish my mom had seen this. She would never have been able to believe her son was doing this. It would amaze her and, I hope, make her proud. U-561

Tragedy and death in the ED last night. New Year's Eve. My shift started with me wandering next door to the lower acuity side and bumping into my boss. After holiday pleasantries the topic of another one of my screw ups came up. Damn it--not again. Just chicken shit little stuff, but it builds up over time. This last issue was not chicken shit, more procedural, but it made me feel like I had let the nurses down, and that they resented me for it and that maybe I wasn't a very good doctor. I knew that it was just one case among hundreds, but that's what each patient is--one case among hundreds. And they each have to managed, if not perfectly, then efficiently and compentently. I left the little session feeling demoralized and a little alone--maybe I'm the crummy doc all the nurses hate and who the other partners are preparing to fire. Maybe I'm really just a sloppy, lousy doc and maybe I've hurt a lot of patients in the last few months. It was a lousy feeling. Got back to the high acuity side in time to hear we had a full arrest coming in. Male. 53 year old. Oh, shit. When the 88 year olds die you can be philosophical, but when a 53 year old dies you know there are a wife, kids, friends who are going to be devastated. And I'm the person who stands between life and death for this guy. My confidence in myself was shaken, I wasn't sure the nurses liked or trusted or respected me, and now I have a 53 year old guy coming in whose heart stopped on the last day of the year. I felt scared and alone. I prepared myself and the guy came in. A big man, tall, muscled, obese--it was going to be hard to do adequate compressions on this guy's chest. Thre medics had tried, tried, tried to intubate him, but failed because of size, geometry, and vomitus (intubation is not complicated, but can be mechanically difficult). In the field they thought he might have been in Ventricular Fibrillation so they shocked him (correct intervention) and he went into idioventricular agonal rythm (unfortunate consequence). No heart beats, no oxygen to his lungs for at least thirty minutes and possibly for over two hours (when he was last seen conscious). I'm scared and I know I have to intubate this guy. I'm afraid I'll fail and he'll be dying in front of me and the nurses will see this crappy young undereducated doctor flailing hopelessly at the intubation. The guy has no chance of survival if I don't get a tube in his throat and oxygen to his lungs. I scoop vomit from his mouth and look in. Fat tongue, small oropharynx (due to a fat neck keeping the jaw tight), muscle tone that limits my ability to force the jaw open. I look in and see the epiglottis for just a flash and then it's gone and I see nothing but puke and edematous tissue. The medics banged away at this guy's oropharynx trying to get a tube in him (as they should have--it was vital for his possible survival), but now the swelling caused by that trauma is obscuring landmarks for me. And the vomit seems to absorb the light and masks the structures I'm looking for and the fucking Yankeur (invented by Anesthesiologists for suctioning "spittle") is totally fucking inadequate for clearing this guy's mouth. I search for the epiglottis, think I find it, try to pull the chords into view, lose my landmarks, have to search again. I find the epiglottis again and try to lever it up to expose my target of the paired vocal chords guarding the entrance to the trachea. No, I can't. But I hold the epiglottis in my sights and grab for the Guim Elastic Bougie I had brought with me "just in case". I grab the bougie with my vomit soiled gloves and have to rip the plastic open with my teeth. I taste the man's vomit in my mouth. I get the bougie and I slip it under the epiglottis. It doesn't pass. But in my efforts to get the bougie I displaced the blade held in my left hand and I have to reposition it. I slip the blade down into this dark mess of vomit and swollen tissue and there it is--thank God!--the epiglottis. I lever it up, and slip the gum elastic bougie down under it. I feel the rattle of the bougie slipping across tracheal rings. I'm in! I'm so happpy. Emotions rush through me in explosice succession--joy at my success, fear that the big tongue and oropharygeal tissue will inhibit passage of the endotracheal tube, intimidation at having to go to step 2 now (placing a central line in this guy's fat, pulseless thigh), relief, glorious relief, fear at the ever present potential for complications at any time. The tubes in. It's in! Thank God. I verify placement (very quiet breath sounds--body habitus or terrible lung injury due to aspiration of all that vomitus?) and announce "Tube's in! The nurses (Anne--very strong!) have gotten an IV. We push meds. Asystole. Still. I don't have much to offer him. We push high dose Epi. I'm working on the central line. I look at the thigh, look at the curve of his inguinal crease, and jab the needle in. Blood. First stick and I'm in. I calm myself and s...l...o...w...l...y advance the wire. No resistance. I'm in! More compressions. Central line in! Give more meds. Give fluid. I check the monitor. The high dose epi did nothing. I finish the protocol and try things that are off protocol. Nothing. I ultrasound the heart, Motionless. We push a little longer. I canvass the team for any additional ideas or recommendations--there are none--and I call the code. Alone and questioning my competence I have just overseen the death of a 53 year old husband and father. A man who chatted with his wife before she left for work three hours ago and a man who had breakfast with his son this morning. It is a painful, lonely, hopeless, melancholy feeling. I wish I had someone there to say "You did everything right. You did everything you could.", but that's not the job I have. I go to tell the wife. She collapses. I tell the son--he is distraught, angry, distrustful, devastated. Poor, poor man. I have no words to offer him comfort. I leave to see other patients. Five minutes after calling the code and making official this man's death I am seeing runny noses and sore ankles. There is no time for grief or reflection or commiseration or pep talks. That's the criteria to do this job. Can you have a man die in your hands? Can you do it all alone, without consultants or assistants to share the burden? Can you wonder if you're a lousy doctor and if maybe a competent, better doctor could have saved this husband and father of three, and still go on with the job? You don't have to like it. You don't have to feel good about yourself. You don't have to sleep well at night and you don't have to be proud every time you look in the mirror, you just have to be able to do it whenever it has to be done. Shift after shift. Patient after patient. Dead husband after dead father after dead child after dead wife aud infinitum. I called the Biscuit afterwards. And she was as she always is--wonderful and supportive and loving. But who do you talk to about this? I don't know. U-561