The power of life and death

I was half way through discharge instructions with one of my patients when I heard the page overhead. "Available ER physician to room 2A stat!" I put down the papers. That was one of my rooms. I jogged quickly out of the room, mumbling something to the effect of "I should check on that" as an explanation.

As I exited the doorway I saw my coworkers swinging around the corner from the ambulance doors to the opening of my room with an ashen young man in his twenties lying sprawled on a gurney. They had pulled him, blue, mottled, and not breathing, from the backseat of a car where he'd been lying face down in bloody vomit. It seems for every sprained ankle that calls an ambulance we pull a half dead person out of a car.

One of the nurses was doing a jaw thrust to hold his airway open while another searched intensely for a pulse while simultaneously pulling him into the trauma room. One of our docs came jogging up at the same time. "Get me set up for an intubation" he said calmly and firmly.

"I'm not finding a pulse!" My coworker called, beginning chest compressions as the gurney came to a halt by our monitors and crash cart. As in all such cases, many things began to happen at once. I quickly combed through our IV start kit, grabbing a large bore needle and tubing as the doctor slid the metal tongue blade down the young man's throat to visualize his wind pipe. Other hands were slapping on cardiac monitor stickers, oxygen monitor, and blood pressure cuff while others continued pumping his sternum down to compress his heart then allow it to fill with blood again.

"Lets analyze his rhythm" the doc called as he placed the round plastic breathing tube and the respiratory therapist connected it to the ventilator. Stopping chest compressions we all stood back and watched the heart monitor to see what sort of picture would materialize.
"We have a rhythm, do we have a pulse?"
"No pulse"
"Resume CPR and given a milligram of epinephrine."
Two of us placed IVs and began hooking them up to fluid boluses to support his circulation and pushing medications designed to help the heart's pumping system re-initiate itself.
"Another round of epi"..."atropine"..."sodium bicarb"... "pulse?" "resume cpr"...

After three rounds of CPR we finally had a pulse. The monitor showed an ugly looking electrical pattern with a heart rate in the 140s, but that's all we needed. We had him back. His skin color was returning to a more natural pink. The doctor placed a central line, I placed a tube from his nose to his stomach to decompress it. Blood and urine were sent to the laboratory to begin unearthing the cause of a cardiac arrest in such a young man.

"Do we know the story?" The doctor asked.
"Only that he was at a friend's bar. A few guys were giving him a ride home when he stopped breathing, so they brought him here."

How does an otherwise healthy young man with no signs of trauma end up mostly dead in the back seat of a car? Common culprits to rule out for anyone brought unconscious to the hospital are drugs/alcohol, diabetic blood sugar problem, stroke, or bleeding in the head. He surprisingly didn't smell of alcohol, was not diabetic, and his urine toxicology screen would come back negative.

Maybe 40 minutes after he rolled through the doors of the room, I pushed my patient with his entourage of IV bag and pump laden pole, Respiratory therapist and ventilator, and er tech for extra muscle around the corner and down the hall to our cat scan. Working tentatively around IV tubing, monitor cables and oxygen tubing we moved him onto the stretcher that would carry him into the imaging machine.

I stood in the back room with the CT technician and the computers as the machine scanned an image of his brain. I didn't need to be a radiologist to interpret the picture that materialized on the screen. His brain was being crowded to the left side of his skull by a large density. He was bleeding into his brain.

"Ew, this guy's done" the technician quipped.

Slowly all the satisfaction of a successful resuscitation faded into the sad reality of the inevitable. A life saved only to be lost again at a later time. We would go through the motions of sending him to a trauma center to have the bleeding in his brain stopped and cleared out, but by this time the damage to his brain would be too extensive. I stared through the glass at the young man lying still on the stretcher. Yesterday he got up like it was any other day. How could he know that was his last one?

The story of how he ended up where he was from the people that brought him was inconsistent and suspicious at best. The type of bleeding in his brain could only be the result of some sort of blunt force trauma. Although he had no obvious signs of trauma, a well placed bat or other object to the back of the head can do plenty of internal damage without showing much on the outside.

The police came and took statements as our young patient journeyed by helicopter to the hospital where he would later die. We would never know the real story behind what happened to him.

I left that day with the reminder that the power of life and death will never rest in our hands, no matter how advanced our tools. Only God know the days of a man's life and He alone decides.