Some things just don’t make any sense. It’s like in the “Red fish, blue fish” book be Dr Seuss: “did you ever fly a kite in bed?...did you ever walk with ten cats on your head?... Think about it. Does it make any sense? No, it doesn’t. What about doing CPR on your patient for two hours straight? Does that make any sense? At that time it seemed like it did. Even though, critical care medicine is inherently chaotic, we don’t like any surprises.
You often know who is “supposed” to die and who is not. A thirty one year old previously healthy man just was not supposed to die. You can’t let it happen.

Just a few days ago he was fine. Later he developed some flu-like symptoms and now he is in ICU with severe pneumonia, full-blown Acute Respiratory Distress Syndrome and multiple organ failure. You’ve tried everything there is to try: maximum ventilatory support, Nitric Oxide and even prone positioning (turning the patient on his abdomen) – nothing is working. Transfer to the outside facility for ECMO (extra-corporeal membrane oxygenation) is simply unrealistic – the patient is not going to survive the transport. And now he is coding (developing cardiac arrest). This is one of those what I call a “Rolling Code”. The patient loses his pulse for five to ten minutes. CPR and ACLS (advanced cardiac life support) is initiated. He regains spontaneous circulation just to lose it a few minutes later. Every time you feel his pulse, you “reset the clock” and start all over again. Remember, you just can’t let him die, so you do it again and again and again.

The family was summoned into the room to witness the code. His parents are sitting quietly in the corner staring into space. Twenty, thirty minutes into the code the silence in the room is almost wicked. Nobody talks. All you can hear is the sound of chest compressions and bag-ventilation. If you believe in afterlife, every time the patient “dies” the soul is leaving his body.

You hold the chest compressions after another round of Epinephrine and Atropine – “yeah, we got the pulse”. Every possible medication is running into his vein to keep him alive. The periods between arrests become shorter and shorter. You check his pupils – fixed and dilated. The patient likely sustained a severe brain damage from the lack of oxygen supply. Now, it’s time to talk to the family again and stop. You have done everything you could and beyond, way beyond. Sometimes, it’s not up to us to decide who is not “supposed” to die.