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