Is doing “everything” enough?☆☆☆

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It's the middle of a sunny afternoon when we get the call on the paramedic line. “We're bringing you a 25-year-old male in full arrest, ETA 5 minutes.”

Where I work now (where emergency medicine is in its earliest stages of development) a call like that brings everyone running. Residents and fellows from intensive care, anesthesiology, cardiology, internal medicine, and even surgery all quickly assemble in the emergency department (ED) to await our patient's arrival. Emergency medicine residents are there too. All are bright, young and eager, full of life, and dedicated to saving the lives of others.

Moments later, the paramedic rig screams into the ambulance bay, and the medics roll their patient into the resuscitation room, double quick, cardiopulmonary resuscitation (CPR) in progress. Multiple willing, vital hands reach out to lift the young man from their gurney (their patient) to the ED gurney (our patient). He is slender and blond, with early male-pattern baldness (I still don't know why I noticed this, but I did), casually dressed, and would ordinarily be described as fit, but he's now ashen under his tan and his flesh hangs limply, undulating with every chest thrust.

Resuscitative efforts continue as the field report unfolds in breathless medical shorthand. “Healthy man, witnessed collapse at work, bystander CPR, ambulance arrival within 5 minutes, ventricular fibrillation, shocked once, asystole since, intubated, IVs started, norepi given per protocol, no response, no other history available.” I later learned from the paramedics that our patient had been sipping a cup of coffee at his desk when he fell. “Drinking coffee,” I think. “How ordinary in the life of a twenty-something person at work. How extraordinary, the tragedy that transpired just seconds later.”

For the next 90 minutes, our huge resuscitation team tries everything, protocol and nonprotocol, to revive our patient. Noradrenaline, pacing, other vasopressors, calcium, bicarb, fluid challenges, hyperventilation and more—much, much more. A stat blood sugar—normal. Narcan—no effect. Knowing most 25 year olds don't have coronary artery disease, we consider trauma and tox. Focused abdominal sonography for trauma—negative. Stat arterial blood gas with potassium level—not helpful. Near the end we consider, but reject, the idea of giving thrombolytics. Finally, a cardiac echo reveals myocardial standstill, and, after over an hour of asystole and much soul searching, we pronounce a man dead, who a short while before had been a healthy 25 year old.

Strangely, during the code, no family members have come to the ED, so residents stay in the resuscitation room, some misty-eyed, discussing the case in low voices, heads bowed. I circulate, overhearing themes of futility, senselessness, and injustice float out of the knots of murmuring junior physicians. I am near them but not really with them. I sense that in their minds I'm too old, too experienced, too distant from their reality to feel what they feel. I'm there if they need me; I hope they know that, but no one seems to. A sour pall of failure hangs in the air. Hints of doubt and self-blame issue from the conversing groups as well. “What did we miss?” “Nothing,” is my unspoken guess, but I stay silent, afraid to be wrong and ultimately cause more pain to these distraught young doctors whose contemporary has just died.

A day later we know for sure. The postmortem shows no life-ending intracranial or intra-abdominal pathology. Toxicology testing is negative too. Only his heart is abnormal, bloated to twice its natural size. Ventricular fibrillation secondary to a dilated cardiomyopathy is assigned as the presumed cause of death.

In the end, we really did do everything. We did it well, and we did it right. Our efforts were organized and by the book. We went far beyond the bounds of what is usually done in similar circumstances. But, as it turned out, even everything wasn't enough for our patient or for us.