Death's randomness

It has been about month since I started second year and all of my shifts so far have been in my homeland of Emergency Medicine.  Most days, I am the resuscitation resident.  My job is to pick up the sickest of the sick as soon as they roll into the department and utilize my medical magic to make them all better.  In some instances, that magic works.  80+ year old with congestive heart failure, totally crapping out due to his lungs being flooded with fluid....slowly tiring out...turning blue (cyanotic in our world).  The magic of intubation and a ventilator as well as a stay in the medical ICU makes this gentleman all better.  Job well done resus resident!!

But there are many other instances that no matter what you do, no matter what you pull out of your magic bag of medicine tricks, people die.  Two weeks ago, I had a cardiac arrest.  The guy was 50+ years old.  He was home on a Sunday morning, with his wife and daughter.  Suddenly, he clutched his chest, turned white, and collapsed in front of his wife.  She quickly started CPR, which was continued by the medics for 45 minutes with the addition of two shocks from the AED, and multiple doses of epinephrine in an attempt to re-start the heart.  Of course, we continued the code when this patient hit the door...CPR...more epinephrine...sodium bicarb....calcium chloride.  Checks for pulses....rhythms on the monitor....and ultrasound of the heart all showed the same thing.....no cardiac activity.  Eventually, you realize that no matter  what you throw at this gentleman, he will never return.  I pronounced him dead, and with my attending, we informed the family (how this occurs is another talk for another day).

Contrast that patient with my overdose one week ago.  Woman in her 50's comes in unconscious.  Not even a deep sternal rub or poking her nail beds with my pen could arouse her.  Blood pressure was 58/40 manually...breathing was slow and erratic.  A quick look at her history in the computer showed multiple episodes of overdoses and suicide attempts.  I intubated her...threw 6 L of fluids at her...placed a central line...started pressors in an attempt to raise her blood pressure.  Managed to get the BP to just over 90/50 at the max of my pressor of choice, Levophed.  Lactate 9.8...patient making little to no urine...ABG shows pH of 7.0.  I admitted the patient to MICU and thought to myself, this patient won't make it and she finally succeeded at doing what she has attempted to do for the past year.  Two hours later, patient self extubates herself...sitting up in bed....and swearing at me!!!  Calling me a bitch for not letting her sign out AMA (against medical advice).  Your welcome for saving your life.  I am sure I will see her again sometime soon.

In both of the cases above, my patient's did not take care of themselves.  The 50 year old man had hypertension, diagnosed years earlier, but refused medications (plus he was grossly overweight) and hadn't seen and doctor "in years".  The 50 year old woman was a chronic alcoholic and drug abuser who continuously ravaged her body with poisons in an attempt to end her life.  As emergency physicians, we take care of all....we never turn people away....never discriminate based on medical history, race, religion, socioeconomic status, or sexual orientation.  We work hard to save everybody.  And sometimes we succeed.  And sometimes we don't.

Death is ironic with a sick twisted sense of humor:  why would the person that wanted to end his/her life make it and the one who never even had the thought of dying is gone, forever.  Of course, I will never have the answer.  But I do think about death often.  I have to.  It is part of my job.  I mentally re-live my actions, judgments and decisions regarding my patients to be sure I didn't miss anything....that there wasn't anything else I could have done to save my patients.

Death is just one of those variables I have no control over, no matter how hard I try, it will come...randomly...or, not come just as randomly.  Unfair advantage.  Not cool death.  :(