Once in a while

It's been twice in the last couple of months now.  Someone who shouldn't be sick is sicksicksick.  No previous medical history.  No risk factors.  No reason.  Nothing isolated, nothing cultured, absolutely no reason at all.  But there they are, in the ICU.  Sedated, morphine or dilaudid drips, possibly paralyzed to boot so they don't buck the vent and we try to slow down the insidious progression of ARDS.

So down down they go.  And because they're young they compensate until they just can't.  So the spiral is quick and tight.  Quick, intubate.  Quick, start pressors because the addition of PEEP and propofol has knocked their blood pressure in the gutter.  Try to maintain a MAP that will keep their kidneys and brain alive.  Quick, run fluids wide open.  Quick, draw labs.  Quick, start every broad and narrow spectrum antibiotic, antifungal, and antiviral we can throw at them just to be sure everything's covered.  Quick, get that specialty bed.  Then everything slows down to an interminable crawl.  

Now we've got APRV and CVVHDF and IPV and the kitchen sink on standby.  CPS is a possibility.  We're flogging the heart with pressors because we hope it can take it.  It's only 20 ish so it... should anyway.  Day by day try to wean APRV to A/C.  Try to wean PEEP from 15 to 5.  Try to wean FiO2 from 100%to 75%.  Try to wean pressors.  But their kidneys just aren't coming back.  So quick, change the dialysate or replacement fluids.  Quick, try to keep up with their bicarb, calcium, potassium then quick, take them back off.  Then wait some more.  And the mothers and fathers who thought they got their kids past the "dangerous" ages of crossing streets and stranger danger and high school drugs; parents who just want to rewind and get a do over or fast forward to the day when their son or daughter opens their eyes with recognition.

And when you get home at the end of the day, once in a while, for these kind of patients, you aren't just spinning your wheels.  You aren't intubating 88 year old grandma with more effusion than lung tissue.  You aren't maxing out neo, levo, and vasopressin on grampa with an EF of <10%>

So once in a while, you throw everything you have into your shift, use every brain cell at your disposal, tax your body to its limits and give a part of your heart to a boy or girl you've yet to meet but lovingly change sheets and wipe eyes and perform passive ROM on.  And you hug mom and put your hand on dad's shoulder.  And instead of coming home depleted from all of this giving, you come home wired and excited at the small gains he or she made that day.  He kept is PaO2 > 50 on FiO2 100%.  Her K came down from 5.7 to 4.9 just by changing the dialysate solution.  

Once in a while you come home with more than you left with in the morning.