I remember years ago when I was a Pediatric Resident rotating through the Pediatric Emergency Room and a 2 year-old had been brought in after drowning at home… “EMS has been coding him (performing CPR/chest compressions) for 30 minutes, they’re on their way.” I will never forget watching my Attending gracefully brace for the impact of the unknown situation being brought into us. Our team gathered in the trauma bay in an organized rhythmic chaos, the emergency room resident was at the head of the bed, ready to place an emergent breathing tube in the child as soon as he arrived. Roles were assigned, a plan was discussed, and then there was a lull that seemed to be both infinite and ethereal simultaneously…

“They’re here.” The secretary shouted.

I watched as a small child on a stretcher was being rushed in, with a paramedic kneeling above his body on the stretcher passionately giving chest compressions. He was moved to the bed in the emergency room, he was intubated (a breathing tube was inserted), and chest compressions continued. He received multiple doses of epinephrine, multiple minutes of chest compressions, and then as we were about to abate our valiant heroic efforts, the ER attending called one of the Attending Doctors from the Pediatric Intensive Care Unit (PICU). At close to another 20 minutes of chest compressions, he placed an emergency central line (an IV inserted into one of the extremities and advanced close to the heart for more rapid administration of medication)… He was successful and pushed more epinephrine and suddenly, as if jump starting a car after multiple turns of the key, a heart beat came back… A pulse was felt…

ROSC… Return Of Spontaneous Circulation… He was, Alive.

*****

For years, I have dreamt that one day, I would be the one to call out ROSC… For years, I have hoped to one day be like Dr. M, and lead a CODE and CPR that would be successful at bringing someone back from the dead… For years, I envisioned the feelings I would feel at being able to do the unthinkable…

And then, one night I finally did it...

A mother that had reported she didn’t know she was pregnant had gone into a quick delivery at home of an extremely premature baby, that’s all we were told. EMS had responded, the ER had emergently paged my team down for assistance, and just like Dr. M did so many years ago, I walked into the Trauma Bay, my heart racing, and I took the helm. We ran through roles, we ran through our plan, and we braced ourselves.

“They’re here.” The secretary shouted… De ja vus.

A paramedic came in with a space blanket holding a small fragile life that we knew nothing about. He quickly placed him down on the radiant warmer, and we guessed at a weight and age… Ah, i’m not sure… 25 weeks of gestation? 26? 800 grams? 900 grams? There was No heart beat. Within 2 minutes of the baby being transitioned to the warmer, I had placed a breathing tube in just like the ER resident had years ago… An emergency chest Xray confirmed placement, we continued chest compressions, an emergent IV was placed in his umbilical cord, and epinephrine was pushed… Again, and again, and again…

***

First invented in 1960, the concept of CPR (a.k.a. cardiopulmonary resuscitation), was to continue circulating blood around the body in hopes that there was some sort of “reversible” cause placing a human in cardiac arrest that could be identified – it was always meant to attempt supporting oxygen delivery to reverse these causes… But, if too much time goes on, the body doesn’t get oxygen where it needs to, despite the most efficient attempts at CPR… And when this happens, parts of the body die… The kidney… The liver… The heart… But most unfortunately, The Brain. At a certain point, CPR is stopped, because, we are not gods, and not everything is reversible. Not all damage can be undone and not all life is meant to continue.

***

With the most recent edition of the Neonatal Resuscitation Program at the time of this incident and writing, the science had supported possible (not mandatory) continuation for 20 minutes of CPR as a point to abandon heroic measures due to inevitable truth of irreversibility of a devastating situation.

We didn’t have a clear idea of what time the baby had been born, but in my hands I looked up at the clock… 19 minutes… I prepared to stop CPR, I prepared to accept that this was yet another life that I was not meant to bring a heart beat to… I was prepared for this… Unfortunately, I’d done it before. But, what I wasn’t prepared for was the nurse doing chest compressions stopping and saying, “I can feel a pulse, the heart rate is going up… He’s breathing.”

ROSC… Return Of Spontaneous Circulation… He was, Alive.

My heart sunk. I watched as the heart rate went up and up. I watched as the oxygen saturation started to improve. But, with how long we had been doing CPR, I could feel my heart break thinking of the likely brain damage that had occurred… I could feel my guilt set in as the reality of what my decisions had done to not stop earlier… I had flashbacks to so many situations I remember as a Pediatrician of those that had undergone significant events at birth that had left them dependent on mechanical ventilation, fed exclusively by tube feedings, with cerebral palsy that required lifelong dependence on multiple forms of help… What had I just done?

The baby was stabilized, just like that 2 year-old years ago. He was brought up to the intensive care unit on a prayers, just like before. As I left the emergency room, the ER resident came up to me and asked, “Oh, did you call it? You stopped right?” I turned to her, my voice mildly proud yet simultaneously more regretting… “No. I got ROSC,” and walked away.

***

One reason I started this blog was to share with so many people what it was like to be a locum tenens traveling doctor. It has grown to hopefully share with you what it is like for me to BE a Doctor. There is not a single hour, awake or asleep, that I do not think about, live with, or question the decisions I have made… Every experience haunts me, for better or for worse. There is not a single choice I have ever contemplated that has been “easy.” My bad days and my good days, likely look different than most. For years, I envisioned that I would feel like a hero if I ever was successful at achieving ROSC. For years, I prided myself on this crazy goal to truly Save someone. But when it actually happened, I was humbled beyond all belief. What does it actually mean to ‘Save’?

As I walked out of the ER that night, the charge nurse, who had run more than one of these disaster code events in the ER with me before without ROSC, looked at me and said, “Hey… Take care of yourself.”

*****

Just as had happened years ago, I kept this child alive… I didn’t understand Dr. M back then, I didn’t understand why he kept going… But this night, I kept him alive until his mother could make it to the hospital and meet him and hold him. Just like the PICU Attending had done years ago for that 2 year-old.

As she came to his bedside, his heart rate started to go down… His oxygen saturation slowly dropped… He was dying and there was nothing we could do. The time he had gone without oxygen, the amount of prematurity he faced, was insurmountable… Repeating a code and CPR was likely to be futile and traumatic. After a long discussion with that mother, a team decision was made that it was time to stop interventions. We can’t save everyone and fix everything.

His breathing tube was removed, his breathing slowed and soon after he died… But his mother had a chance to meet him, and I understood viscerally and deeply at my soul afterall, so many things that had been less clear to me years ago…

I understood why we had fought so hard for ROSC.

Image Credit: ChatGPT