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