Calling It

Providence and Judgment

I am publishing this on Easter, the day in the Catholic faith which marks resurrection. In medicine, we do not use this word. We speak instead in a language of scientific precision, one that is empty of any meaning beyond the machinery of the organism. We speak of resuscitation, return of spontaneous circulation, neurologic recovery, and the outcome.

He was a man in his late sixties, previously healthy, the kind of patient emergency physicians quietly hope for. No long list of diagnoses. No brittle physiology. No slow-motion decline.

Days earlier, he had developed chest pain. He treated it like heartburn. Rolaids helped. The pain resolved. He moved on. He developed chest pain again, and this time, he decided to come in. He drove himself. He walked through the lobby. He joked with the front desk staff, people he recognized. He was roomed quickly. The nurses began attaching monitors, starting an IV, obtaining an EKG.

I spoke with him briefly, one or two minutes at most. As the EKG tracing printed, I watched it appear on the screen. It looked like an anterior STEMI, but he had a right bundle branch block, which complicates interpretation. Wide QRS complexes distort ST segments. I pulled up an old EKG from several years prior. The bundle branch block was there then. The ST changes were not.

I turned back toward the patient and his wife. She was already tearful, worried in a way that felt disproportionate to his affect. He was relaxed, almost amused by the attention. As I began to explain that I was concerned he might be having a heart attack, the monitor changed.

First PVCs. Then couplets. Then triplets. Then short runs of ventricular tachycardia.

I asked if he felt anything. Palpitations. Lightheadedness. He smiled and said no. He felt fine.

I started to explain the extra beats and why they worried me. His eyes rolled back. He arrested in front of us.

We began CPR immediately. The family was ushered out. We defibrillated. Gave epinephrine. Lidocaine. Amiodarone. He remained in refractory ventricular tachycardia. During compressions, he perfused well enough to regain consciousness. He pushed against hands on his chest. He moaned. He clenched his jaw. He felt the shocks.

After several rounds, I made the decision to sedate and intubate. I could not justify allowing him to experience that suffering, regardless of the eventual outcome. I gave etomidate and rocuronium and passed the tube. We continued.

At some point, I lost track of time. Twenty minutes. Thirty. Forty. We briefly achieved ROSC, only to lose it again. The rhythm degraded into something between ventricular tachycardia and fibrillation. This was a freestanding emergency department. No cath lab. Our goal was simple and nearly impossible: achieve sustained ROSC, stabilize, and transfer him to a PCI-capable hospital far away.

After nearly an hour, I went to the family. I told them I did not think we were going to get him back. I told them we needed to prepare to stop. They went to an office to grieve. I returned to the room and told the nurses that unless something changed, we would stop at the next pulse check. I asked for objections. There were none.

We continued CPR for two more minutes.

At the next pulse check, he had a sinus rhythm. A strong pulse.

We began post-arrest care, but I waited several minutes before going back to the family. I was convinced he would arrest again at any second. He did not.

When I finally opened the door, I said four words: he has a pulse.

They leapt to their feet. They hugged me. I told them not to thank me yet. I told them we were not out of the woods. I told them we did not know if his brain had survived.

It had.

I could not assess his neurologic status immediately because of the paralytic. But in the ambulance, he woke up. He followed commands. He made eye contact. He mouthed words around the endotracheal tube. He went to the cath lab. He received stents. He went to the ICU. Over the next days, pressors were weaned. He was extubated. He laughed with his family. They sent me a photo of him giving a thumbs up.

He will live with chronic disease as a consequence of this event. But he is alive. Neurologically intact. Present with his family during a season when he would otherwise have been mourned.

I am proud of the outcome. I am proud of the team. But pride is not the dominant emotion this case left me with.

It felt unmistakably like divine intervention.

I had just written an essay titled Proofless about the absence of God in my work. Then I was given a case that defied probability. I have never had a patient suffer a prolonged pulseless arrest at a freestanding emergency department, more than an hour from definitive care, and survive with full neurologic recovery.

Any other day, I would have stopped earlier. Forty-five minutes of CPR is rare outside pediatric arrests. Had I gone to the family even a minute earlier, this man would be dead. Had my internal sense of “enough” arrived slightly sooner, the outcome would have been entirely different.

So many contingencies had to align. He had to come in at all. He nearly turned around when his pain improved in the car. Had he done so, he would be dead. He arrested in front of me. Not in the field. Not unwitnessed. We had mobile ICU transport available. Often, we do not. The day before, a natural disaster had shut down ambulance transfers entirely. The roads had only just been cleared. Had his arrest occurred hours earlier, he would never have reached us.

Medicine presents itself as objective, scientific, governed by protocols and endpoints. In reality, it is filled with gray zones. Decisions are often not decisions at all, but continuations. There is no algorithm for how long to continue CPR, no guideline that tells us at the outset how many minutes a life is worth. We do not decide the duration at the beginning of the arrest. We go until it feels like enough. Until the room feels heavy. Until the interventions feel exhausted and nothing is changing. Until something internal shifts from effort to futility.

That internal sense is not purely clinical. It is shaped by human limits and by the environment in which resuscitation occurs. The emergency department does not pause for a single patient. Other patients accumulate. Alarms continue to sound. Time moves forward whether we want it to or not. Eventually, the question is no longer only whether another round might work, but whether continuing is still justifiable in a department that must keep functioning.

That arbitrariness is difficult to confront.

If this man lived because I continued, who died because I did not? How many outcomes hinge not on guidelines, but on whether the department was busy or short staffed that day, or whether the physician slept well, ate breakfast, felt hopeful that morning? It is an uncomfortable question, and an unanswerable one.

Yet this was not randomness alone. I continued for reasons. He arrested in front of us. He had signs of life. He had a reversible cause. This was not the frail nursing home patient found down with an unknown downtime and no fixable pathology. My judgment was not algorithmic, but it was not blind.

There is no actionable lesson here. No practice change. No algorithm to update. I will still stop when it feels like it is time to stop. I will still continue when there is reason to believe continuing is justified. I cannot eliminate the human element from these decisions, and in some sense I would not want to.

The analytical part of me wants to believe that the outcome was mere good fortune. Sometimes resuscitation works. Rare events are rare, not impossible. Given enough trials, improbable outcomes eventually occur. A prolonged arrest with neurologic recovery does not violate physiology. It merely sits at the far end of the distribution. From that perspective, the timing is coincidence and the outcome is luck. The interventions happened to work this time.

That explanation is tidy, and I am given to prefer tidy explanations.

Yet the same part of my mind that searches for signal in noisy data also resists the idea that randomness is always meaningless. I spend my professional life detecting patterns. I look for coherence where symptoms initially appear disconnected. It is difficult, then, to ignore the temptation to see a pattern here as well.

I have been struggling for some time with the emptiness of my work.

Emergency medicine places you in constant proximity to death and suffering, but paradoxically deprives you of meaning. The majority of my cases fall into two broad categories.

The first is the dwindling patient. Patients who are chronically ill and progressively worsening, with nothing that can actually be fixed. They move between inpatient floors, nursing facilities, and the emergency department in an endless loop. Each visit represents another small step downward. I treat electrolyte abnormalities, infections, fluid overload, confusion. The specifics change, but the trajectory does not. I am not restoring health. I am managing decline. My role is custodial, not curative.

The second category is patients who are not experiencing emergencies at all. They come for anxiety, hypochondriasis, entitlement, convenience, or because they face no financial friction to using the emergency department. They come for second, third, or tenth opinions. They come because outpatient physicians sent them to offload liability. They come because insurance barriers prevent outpatient care and the emergency department is the only remaining access point. Again, the details vary, but the conclusion is the same. They do not need an emergency physician. They need a functioning system, and they do not have one.

After enough years of this, the work begins to feel hollow. I am trained in emergency medicine, yet I treat true emergencies relatively infrequently. When I do, my role is often limited. I recognize a problem, make a phone call, and hand the patient off to someone else for definitive care. In most STEMIs, my involvement lasts minutes. The cardiologist quite rightly receives the credit. I become a conduit, not an agent.

It is difficult to build meaning out of that.

There are days I regret choosing this specialty. It does not pay as well as many others, and it rarely feels more significant. Some days, a quiet cubicle job seems appealing. At least I would have nights, weekends, and holidays with my family. At least the tradeoff would feel honest.

And then this case arrived.

Not only did I witness something extraordinary, I participated in it. Directly. Decisively. In this case, my role was not marginal. It was central. The stents mattered, but they mattered only because the patient was alive long enough to receive them. This time, I did not simply recognize an EKG and make a call. I kept a man alive through a period when almost no one would have expected meaningful survival.

It is impossible not to feel the weight of that.

I cannot escape the sense that this was something like a revelation. Not only for the patient, but for me. The timing was exact in a way that feels difficult to dismiss. Just as he needed to arrive at the emergency department at precisely that moment, avoiding the weather and resisting his instinct to go home and take more antacids, I needed him to arrive in my professional life at precisely that moment as well.

We needed each other.

I do not know what to do with that realization. I cannot operationalize it. I cannot practice medicine differently tomorrow because of it. But I cannot ignore it either. In a profession that so often feels stripped of meaning, this case reminded me that meaning still exists, even if it appears rarely, unpredictably, and without warning.

Perhaps that is the point.

Editor’s note: Some clinical details have been altered to protect privacy.