An excerpt from Blood Poison: The Untold Story of Sepsis.

Eduardo’s blood pressure failed to respond to one fluid bolus, then another, and another. We instructed his nurse, Jenny, to start a vasopressor called dopamine while Alex and I prepared to place a central venous catheter in Eduardo’s internal jugular vein. (Dopamine also increases heart rate and cardiac muscle contractility. Although doctors classify drugs as vasopressors and inotropes, many of these drugs have mixed effects.)

I steadied my nerves as I watched Alex carefully move through each step of the procedure with novice hands. After locating the jugular vein with an ultrasound probe, he advanced the needle and drew a flash of dark, deoxygenated venous blood. He then threaded the guidewire, dilated the tract, and slid the catheter in place.

“Looks good,” I said, letting out a sigh of relief.

I exchanged a thumbs-up with Jenny as we finished. Deb popped her head into the room, informing us that Eduardo’s family had arrived.

Eduardo’s family filled the waiting room: his wife, Anita, their children, and several of his siblings, all anxiously awaiting my update. After introducing myself, I pulled Anita aside to explain what had happened. There was no way to soften the blow. Eduardo was on the brink of death. Tears poured down her face as she tried to maintain her composure. After doing my best to console her, I assured the rest of the family that someone would be out shortly to update them when Eduardo was more stable.

Back in the ICU, everything was unraveling. Deb and Jenny scrambled to hang IV bags of fluids and medications as Eduardo’s life support monitors chimed dissonantly. He lay near comatose, his blood pressure plunging dangerously again. Across the room, Alex reported the escalating disaster: Eduardo’s organ systems were failing one by one. The dopamine had failed to raise his blood pressure, and his CVP had climbed to 12 mmHg, suggesting his tank was full. Alex had ordered a second vasopressor drug, norepinephrine, while Jenny moved quickly to start the infusion.

I was afraid we were losing Eduardo, so I paged the on-call critical care fellow, Mark, now in his final year of ICU fellowship.

“I’m on my way,” Mark said.

In the meantime, he recommended maximizing vasopressor support and administering a dose of the steroid hydrocortisone. Though the use of steroids in sepsis was still an ongoing debate, he explained that the latest evidence suggested a potential benefit, especially for a patient as critically ill as Eduardo.

We followed Mark’s suggestions to the letter, but it didn’t matter. Despite being on maximum doses of two vasopressors, Eduardo’s blood pressure refused to rise. Meanwhile, his respiratory system was failing, forcing Sandra to increase the ventilator support to hazardous levels, risking direct injury to his lungs. Eduardo’s skin showed a bluish-red lace-like pattern known as livedo reticularis, an ominous sign that his microcirculation was collapsing, and his intravenous lines began oozing blood, a sign that his clotting system had shut down.

Jenny hung the hydrocortisone. I asked her to start a third vasopressor. There was nothing left to do.

Mark arrived shortly after. He shook his head as I delivered my bleak report. Without a pause, he grabbed the portable ultrasound, performing a bedside exam to rule out other potential causes of shock, such as a heart attack or pulmonary embolism.

“It’s just bad septic shock,” he said, resigned.

Despite filling Eduardo’s tank, maxing out multiple vasopressors, and infusing steroids, his blood pressure was abysmally low, barely capable of sustaining life. All we could do now was watch, wait, and hope.

Eduardo’s heart finally gave out at 6:00 a.m., just as the day team began trickling in. His heart monitor displayed a lethal arrhythmia: ventricular fibrillation. A team of nurses rushed to his bedside, initiating chest compressions, while Mark and I moved swiftly through the ACLS protocol.

We shocked his heart once, twice, three times. Nothing changed. We repeated the cycle again and again. I kept time: ten minutes, then fourteen, then twenty. As we passed the thirty-minute mark, his heart’s tracing weakened, fading into a faint agonal rhythm, then flat.

“It’s time to call it,” Mark said, exhaling.

I stared at him, disbelieving. I was exhausted and reeling from the emotional roller coaster of the long night at Eduardo’s bedside. I pushed back at first, almost reflexively, clinging to the hope that Eduardo could pull through, that we could somehow save him.

Mark gently patted my shoulder, a silent acknowledgment that it was over.

Alex’s face turned red, his eyes filling with tears. I wanted to scream. But I snapped back to reality. I had to keep it together for Alex’s sake.

Mark pronounced Eduardo, and we met with his family. We explained what had happened and offered what little comfort we could. Afterward, we had no time to process it. We had to rejoin rounds. When we had finished, Mark sent Alex and me home for the day.

As I headed out, I returned to Eduardo’s room one last time to say goodbye to his family. Only Anita and Marta were left. They thanked me for taking care of Eduardo. I didn’t know what to say.

Instead, I hugged them both and whispered, “I’m sorry.”

Before I left, Marta put her hands on Eduardo’s face, kissed his forehead several times, and softly said, “Goodbye, mi hijo.”

Parsa Shahinpoor is an internal medicine physician.