Sometimes nothing works.

Bad is having a patient with no IV access who is currently critical, and on whom starting an IV is like sticking a rock.

I'm not a bad IV start, really. I manage to get crazy shit on veins in the thumb, for Christ's sake, when nobody else can get anything. You give me a coding patient with a foot that's unburnt and relatively perfused (for a foot) and I can start a 20 gauge.

Really bad is not being able to advance a catheter, and having to give meds through the sixteenth of an inch that you've managed to float into a vein with prayer and incantations and maybe a chicken waved over the patient.

Worse is the situation where they've been okay, then not okay, then sort of okay while the labs say they're not okay, and the clinical signs say they're really touchy, but you still sort of think they're okay, maybe, but suddenly they crump.

Worst is when you acknowledge that they've crumped. You've got eight channels running in the CCU and they're not getting any better, but you keep playing with the Levophed to try to keep their BP within range.

Oh shit is when you realize it's all over. You can't do anything more; you've used up all the tricks in your particular bag o', and it hasn't been enough. All you can do is watch this thing, this person, go down the drain. Slowly. Despite all interventions.

No matter what you do, sometimes it isn't enough. Sometimes, in the face of all your training and all the things you've picked up over the years and even all the little crazy tricks you've tried that might not be in the protocols and might even be a bad idea, it isn't enough and the person, the life you've tried to save, the thing you've invested so much time and emotion in, they die.

It started out fine. She weathered a few bumps in the road, what with electrolytes and pressures going nuts, and she did okay. Then she fell over and there was not a damned thing I could do. I'd known her for two years, with her pulmonary hypertension and her crazy blood sugars and her dialysis, and I knew what had to be done.

None of it worked. None of it *worked*. Something, somewhere, ought to work in cases like this. Nothing does.

I guess, once you have enough experience, that you shrug and go on and say, "It just wasn't meant to happen." You deal with the next thing that has to be done and you put that last thing behind you, no matter how big it was.

I can't do that yet. I don't know that I'll ever be able to. This is where I feel most alone: I can't call Beloved Sister or Sainted Mother and say "I lost somebody tonight," because, for one thing, it's not something they could understand. For another, it was less a failure of things I did or didn't do, but more a recognition that nothing at all was working.

Sometimes nothing at all works. You do the debriefing and the root cause analysis and you go back over your charting and your actions, and everything is right, but nothing worked. You know it's not you, specifically--that the human body has tricks up its sleeve that we can't even imagine--but you still feel like you weren't enough.

Sometimes nothing works. Those are the times you remember when stuff that you did *did* work, and you wait and hope for the next time that that might happen.

The times that you fuck up through comission or omission are better. The times when there is nothing at all in the world to be done are the ones that keep you up.