Code Blue II

This is a continuation of yesterday's post.

In some respects, "running a code" is not hard. In a Code Blue, the first procedure is to take your own pulse (a mantra of the Fat Man in House of God). This is true. Everyone witnessing her first code feels her heart drop to her feet and panic take its place. We are frozen with paralysis, both physically and mentally. We forget the simplest things. We fixate on stupid details. We aren't helping the patient.

I took my own pulse. Then, I went to the head of the bed, ready to intubate. This is not the most important thing in a code; it's not even the first step in the new algorithm (which starts circulation, airway, then breathing). But in the ED where help is abundant, I recognized that the unique skill I contributed was airway management. The fellow "ran" the code, going down the algorithm. The patient was pulseless. Chest compressions were started immediately. I got my airway equipment out. I could mask ventilate the patient. The cause of the cardiac arrest was clear; he was bleeding to death. He had blood in his mouth and bloody bowel movements. We were transfusing as fast as we could, but to no avail. To secure the airway and protect him from choking on blood, I tried to intubate. I took me several attempts before I could do it; intubating in a code situation is never ideal and always stressful. I took my own pulse. Once I secured the endotracheal tube, my job was to bag the patient. Lots of other things were going on, but I kept my role. The ED resident and attending both tried to get venous access, a very challenging thing to do in the middle of chest compressions in a patient with no blood pressure. We activated the massive transfusion protocol, trying to give as much blood product as we could.

This went on for twenty minutes. With ongoing compressions, ribs were broken, the lungs were lacerated, blood started coming up the endotracheal tube. We got a weak thready pulse briefly, but it disappeared. At one point, we shocked the patient for a ventricular rhythm. We got central lines in and transfused more and more, but eventually we realized this was futile. After about twenty five minutes, we called the code and noted time of death.

There is a point in codes, amid compressions and shocks and needles and shouting, that the process sickens me. It is dehumanizing. Rarely, those situations we live for, the insult is easily reversed and the patient is revived. But more often than not, it is a messy prolonged protracted process, something we would never wish on anyone. It is why I think it is so important to talk to everyone about he'd want when he dies. Such things can be avoided, or pursued, but this decision needs to be made by an informed consumer. Medicine needs to empower patients to choose what they want for themselves.

At the end of codes, I also think debriefing is important. I had so many emotions that night. There are so many things about seeing someone die, being a part of the process, trying my very best and achieving so little, that I wish I had time to let it out. In medical school, there were people who tried to do this, but in the middle of the night in the emergency department, we simply did not have that luxury. So here it is. I don't think I could have saved that patient. And it is that vulnerability, that loss, admitting that very fact, that frightens me.