Code blue!

0725 is when it happened. I'd arrived at the hospital at ten of seven, put my overnight bag in the lounge, and chatted with some of the other residents before starting rounds. Just as I wrote an order for a U/A for another patient with hematuria, I heard the overhead announcement: "Code blue--Four west! Code blue--Four west!"

I dropped my pen without even signing the order and jogged to the stairs, up one flight, and to the patient's room. Even with my recent Advanced Cardiac Life Support (ACLS) training, I was hoping to see at least one white-coat clad person in the room. There was none. The room was crowded with nurses and resipiratory therapists (RTs) already. In the flurry of activity, I tried to slow my racing mind, steady my shaking knees, and review the ABC's (Airway first, then Breathing, then Circulation) I'd been taught.

Working my way toward the patient's bed, I observed RT's mask-bagging the patient already and a nurse performing chest compressions. In my training protocols with dummies, I'd practiced codes from the start. Where to start here? The initial ABC's seemed to be already in place. I asked the nurse to hold compressions while I checked the pulse; meanwhile two other interns entered the room and one handed me gloves.

No pulse. "Resume compressions," I instructed the nurse as I donned the gloves. Still trying to think, I realized I needed to get a heart monitor on the patient. The resident's appearance at the door brought a sense of relief. Chest leads were applied. "Let's get this guy intubated!" the resident instructed, "Jonathan, you're up!"

At the head of the bed I felt much more comfortable after having had a few months of anesthesia training. "Doctor, what size tube? 8.0 or 7.5?" If I'd had time to think about it, I'd have requested an 8.0 endotracheal (ET) tube, the size typically used in male patients in the operating room. "I'll use a 7.5," I said without hesitation, simply picking a number and trying to hide my nervousness with a confident tone of voice. "Oral airway, please," I requested, when I realized the RT was having diffulty bagging the patient.

"Ready?" my resident asked. Another RT had just lubricated ET tube and placed the cold, metal laryngoscope on the sheet beside the patient's head. I opened the tool's blade, checked that the light was working, and removed the patient's upper dentures. This was going to be the easy part...

In the meantime the defibrillator pads had been placed. The monitor showed PEA, which is Pulseless Electrical Activity of the heart. The heart, in other words, was barely attempting to beat, but was not effectively moving blood. ACLS protocol is to give epinephrine for this cardiac arrhythmia. No dramatic shock was necessary.

Meanwhile, Clay and my resident had been working on starting a central line for venous access, through which to give the epinephrine. With a thready pulse from the CPR, finding the femoral vein by approximating its location medial to the femoral artery was nearly impossible. Instead, multiple well-placed jabs with a syringe proved to be the most effective technique.

Steading my left hand and applying pressure on the laryngoscope toward the foot of the bed, the vocal cords came easily into view. I grasped the tube at the end and watched it slide between the cords. An RT inflated the cuff on the interior end and my resident listened for breath sounds as another RT began bagging. "No breath sounds. You're in the esophagus."

I withdrew the tube, surprised since it had seemed an easy intubation. Another attempted yielded the same results, though the chest appeared to rise and fall with bagging. Another senior resident stepped in. After his intubation, still no breath sounds were heard. It was decided that with all the patient's respiratory secretions, airflow was difficult.

Three or four doses of epinephrine were given as CPR continued. I reached again to check the patient's radial pulse. His had was cold and clammy. The nurse performing chest compressions had tired, so I took over. There was little resistance to my effort as the patient's ribs had certainly cracked. I performed steady compressions for a few minutes. By this time, CPR had gone on for 20 minutes, with no response to the epinephrine. The attending physician had appeared, and since the room had quieted down since the initial rush, it was easy to hear his implicit instructions, "I think we've done everything we can do."

Everything suddenly seemed to stop. The RT stopped bagging. A few people left the room. And I ceased my compressions, stopping bloodflow to this patient's brain, lungs, and heart. He was dead.

~ ~ ~ ~ ~

Turning back for one last look before I left the room, I saw the patient's cast on his left arm. He was a gentleman in his 70's who had been admitted for a broken wrist. That was it. This patient's hospital course was not filled with dire straights. He'd simply had a broken bone and it had been set in a cast. And his heart had suddenly stopped, likely due to a massive blood clot to his lungs, called a pulmonary embolus. Cancer, strokes, pneumonia...these diseases kill in a matter of days to weeks to months. In this case, however, death came in seconds even though everything that could have been done had been done.

Later that morning I heard that this fellow's wife had arrived. This reminded me that he hadn't lived his entire existence in his hospital room. He was a husband, and likely a father and grandfather. Even though we'd never met before, I knew he had a story. But for a mere thirty minutes in that raucous room filled with shouts, blood, and the incessant rhythm of compressions, our story was our lives intersecting in one violent finale. And then it was over. The music stopped. We picked up our coats, gathered our things, and went on our way.