Coda: On Call

Came in Thursday night to see a patient encephalopathic from liver disease, no longer responding.  He was breathing and his vitals were stable.  "He just won't wake up."  I scanned him - some ascites, some nodular densities on the intestines, giant liver - declined to do a paracentesis (nowhere to put the needle), offered the family an NG tube dose of lactulose.  I don't need a lab to tell me when someone is hyperammonemic.  We talked for a while about hepatic encephalopathy, and with my limited skills I tried to explain that he was sleeping - not suffering - and that if we did nothing, he would eventually sleep until he died.  He fought the NG.  At 5 in the morning the ward called to ask if the family could take him home.  Better now than paying for a car for a dead man.  I gave the OK.

Our smallest NICU baby died yesterday morning.  My exchange transfusion did nothing but hold her bilirubin at 30; I came in and looked at her, barely breathing, with an occasional gasp.  All 775 grams of preterm infant, with nothing left to give.  A fighter.  I called her mother in and talked it over with her - do you want me to keep trying to breathe for her?  She's just too small.  And her mother shook her head.  We knew, starting out, that this was an uphill battle, and she's an intelligent woman who understands that we've done everything we can.  So I put in a stat call home to print out a picture of her for her mother, who sat and stared at it, and thanked me while I prayed for her baby to die without pain.  Dear darling Baby of Dorin.

Spent my lunch hour on Friday researching oral methotrexate for choriocarcionoma and how to dose it, since our methotrexate tablets are in-date, while the newest methotrexate injectable we have is over 2 years out of date.  Got some suggestions off the Internet.  Wished I could just call up my friendly neighborhood gyn-onc doctor and ask him.  Wished we had the right medication to begin with.  There's leucovorin in the chemo fridge, at least - thanks to some anonymous donor who sent us their medicine after there was no longer need.

Got called up from home at the end of lunch time for another baby, "6 months, born at home", who was in respiratory arrest on arrival to the nursery.  No spontaneous respiratory effort after being bagged the whole time it took me to go up to the nursery.  He was very young - no creases to his feet, no descent of testicles, skin fragile and delicate.  I estimated 28 weeks or so.  I tried pushing epinephrine - after a quick recalculation of dose, we had only 1:1000 instead of 1:10,000 - and did compressions and used my Neonatal Resuscitation skills and accomplished nothing, in the end.  Another baby too small and too late to come.  Who knows if we could have done anything to begin with?

Came home to an email from someone I deeply respect, reminding me not to make technology my god: you well know that even WITH all our technology, we sometimes lose them [...] God's in charge and we may never know the why's...   sometimes it's enough just to know he's there.....sometimes it's not.... 

And she's right.  But it still hurts, here, knowing that maybe there's something more we could have done, somewhere else.  I feel sometimes like the expression on the nursing students' faces when I tell them to stop a code - as if, somehow, they think I have the magic medication to save lives! and have been withholding it.  And I wish I did.