Every once in a while, a moment becomes indelibly etched into our psyches.  No matter what happens for the rest of our lives, these moments will forever be crisp and clear, in some cases disturbingly so.

The call came early.  4 am to be precise.  Low blood pressure.  Nothing new, nothing too concerning for the most part.  There are lots of reasons a person's blood pressure can drop, some serious, some not too serious.  He was a dialysis patient.  Kidneys are dead, so too much fluid and he couldn't pee it off.  "Give him a little extra fluid, I'll be right down."

A few minutes later I'm in his room.  He looks pretty good.  Says he feels a little light-headed, but that is all.  His belly is a little firm, but he had a pretty tight abdomen to begin with.  Nevertheless, in an effort to be complete, I sent some stat labs.  I didn't want to miss something. 

Off to the ER, to find the mid-level resident.  Again, trying not to miss something I wanted to run it by him, make sure there wasn't something I was missing.  He agreed with my plan, and by this time the labs were back.  Hemoglobin level looked rock stable from the day before: it didn't look like he was bleeding somewhere.  Electrolytes were normal as well: no weird cardiac or smooth muscle abnormalities.  He was probably just a little dry.

"He could probably stand some more fluid" the mid-level tells me.  I agree.  Back upstairs, to check on my patient, see if he responded to the fluid, and give him some more.  "How is his pressure?" I ask the nurse.  She was just on her way in to check.  We walk into the room together.

Asleep.

I don't blame him.  I have been bugging him, as well as the nurse, in the early hours of the morning.  Add to that the serious surgery he just went through a couple of days ago and he has every reason to be tired.  But, bugging people is part of my job.  So I call his name.

No response.

Wrong answer.  Wrong frigging ANSWER.  When I call your name, you wake up and say "Hey Dr. Jones."  That is the rule.  You wake up and answer.  I AM SERIOUS.  I call his name again.  Nothing.  In these few seconds my heart has gone from a calm and casual 70 beats per minute to at least 150.  Easy.

I grab his hand.  No response.  "Dr. Jones, his arm is cold and clammy," the nurse informs me.  Sure enough, it is.  Sternal rub.  No response.  I check his pulse with one hand (weak and thready) and his pupils with another (dilated and fixed).  The pupils are the key.  I was hoping they would be pinpoint.  That is one of the classic signs of someone who has had too much narcotic.  Hit them with some Narcan and the game is over.  They wake right up.  But he wasn't pinpoint. 

"Try to get a pulse ox reading."  Nothing on his finger, nothing on his ear, nothing on his toe.  But we get a blood pressure (and a pretty decent one) on his leg.  Still no response though.  By now my heart rate is easily 300, I am feeling cold and clammy, and it is getting a bit hard to breathe.

I run and page the mid-level.  Back to the room, I can hear the phone from here.  He doesn't return my page.  I page the upper level.  Someone with more experience NEEDS to get here, and they need to get here now.  Some other nurse bring in the defibrillator.  We start bag-masking him.  The defibrillator shows normal sinus, no shock advised.  He is still breathing, but it is coming slower and slower.  His pulse is getting weaker.

I send a text page to the mid-level.  Get your butt here STAT.

Run back to the room.  He is fading.  I turn to the nurses, "Call the code."

BAM.  Everything is in slow motion.  I am wading through air as thick as stone.  We put a CPR board under his back, a nurse starts chest compressions, another is ventilating.  I am trying to muddle through running this.  Like shinning knights the code team arrives, along with the upper level surgical resident.

I back away, ready to answer questions tell them what happened, tell them about this man, this patient of mine, this human being who is trying to die right in front of my eyes.  Not on my watch sucker.  We are not about to let you go yet.

Time stands still.  Lines are placed, defibrillator pads are applied, but no shock is advised.  Anesthesia intubates him.  He has vomited.  They suction him.  Epinephrine is given.  Still no pulse.  Compressions continue.  Labs are sent.  I tell them the value of the labs I sent just a few minutes ago.  None of us are sure why this man is dying on us.  But we are not about to let him.

Atropine is given.  One minute passes, that feels like a thousand.  Suddenly he has a pulse.  Carotid, femoral, radial.  We cycle his pressure.  His heart is beating again, and it is actually beating pretty well.  But he needs to go to the unit.  We rush him over there, the code team disperses, and I am left in its wake, wondering just where I screwed up, and how I almost let my patient die on me.  In my mind's eye I see his family, and I get sick thinking about what we are going to have to tell them.

Hardly daring to do so, I ask the upper level what I should have done differently.  I fear the answer, terrified to hear that my negligence may have cost this man his life.

"Nothing.  You did just what you should have.  You responded, you saw your patient, you checked with someone up the line, and then went back to see your patient again.  You didn't try to sleep some more, you didn't assume he would be fine without you.  You came back, you were there, and you stood by his side the entire time.  No one could have asked for more."

I feel the tears starting to well up in my eyes.  His response doesn't make me feel any better.

I can tell the nurse feels the same.  She is a young nurse, not too long out of school.  This was her first code as well.  We are both visibly shaken.  Doubtful we will ever forget what just happened.  But there are still other patients to see, and some of mine are still pretty sick.  So I try to focus on them.  I try to fix their problems. 

Rounds.  To the unit with the rest of the my team, finally here as the day is starting.  In the unit, they all stand, wondering what happened to our patient and why he is intubated in the unit.  The onus is mine.  I tell them what happened, choking on some of the words, struggling to keep it together.  We see the patient.  He is posturing.  Not a good sign.  Cerebral damage seems likely, it is possible he will never be himself again. 

Post-call, I go home.  Sleep a couple of hours.  Tell my wife what happened, sobbing the entire time.  I need to release.  I need to get this off my chest.  It is suffocating me.  I can hardly bear to see him on Monday.  He probably will never speak again, much less practice law.

A troubled night of sleep passes, all too quickly.  Monday morning comes, grim, bleak, and forbidding.  To the unit, time to round.  I walk in his room, and almost fall to my knees, weeping, as the patient looks me in the eyes, raises his hand and says "Good morning, Dr. Jones!"