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Codes are always a flail. This is the fourth law of thermodynamics.
It was close to midnight. The new interns had started three days before. I had just removed my shoes and was sitting on the edge of my call room bed, anticipating the joy of five hours of sleep.
"Code blue - Ward MB2A - code blue - MB2A".
Shoes on. Through the ICU, down two flights of stairs, out the front door, down the sidewalk and the steps, into the covered walkway, out of the covered walkway, down the sidewalk, up the wheelchair ramp, in through the double doors, down the hall. Nurses point me into the room halfway down to the right.
By the time I arrive, the respiratory therapist is standing at the head of the bed, holding a plastic oxygen mask tightly to a face I can't quite make out. With his other hand he is squeezing a blue self-inflating ambu-bag. I can see the chest rising and falling. "Good airway management," I say.
As I get closer I can make out the patient - an elderly Filipino man. I know him because about a month ago he was taken to the OR emergently. I don't remember why. All I remember is that it was midnight and the case lasted 4 hours and I only got 30 minutes of sleep that night.
"What happened," I fire this question in the wrong direction - at the respiratory therapist.
"I don't know. I heard the code call. I just got here and he was apneic."
I redirect the question at the nurses standing by the foot of the bed. Before they give me an answer, I've checked for a pulse and barked out five orders:
1. Start chest compressions
2. Get him on a monitor
3. Get me a laryngoscope and an 8.0 tube
4. Start a big line
5.Get me some suction
The unmistakable sound of cracking ribs assures me that we're under way. By now about 20 people have gathered in the room- a collection that includes the SICU fellow, CCU resident, a junior medical resident and his intern, a surgical intern, medical students from several different medical and surgical services, the nursing supervisor, the code pharmacist and five or six floor nurses. Five members of the patients family are outside.
"What the hell are these people doing in the hospital at this hour," I think to myself. Obviously, they knew the end for this poor man was approaching fast. None of them, however, were willing to let nature take its course.
"He's a full code," I hear someone say. By now the leads are on the chest and I can see severe bradycardia - heart rate in the twenties. Narrow QRS complex. No pulse with electrical activity.
"One amp epi and 1 milligram atropine IV. Where's that laryngoscope?"
The nurse hands me the requested equipment. I ask the RT to remove the patient's mask and I tell the medical student to hold chest compressions. The laryngoscope goes in - always on the right, sweeping the tongue to the left - the epiglottis falls into view. I lift up and the vocal chords are staring me in the face.
I love the sight of vocal chords.
Tube in. Balloon up. Laryngoscope out. Tape down.
"Resume chest compressions - rate 120. Bag him at a rate of 30. Check for breath sounds bilaterally."
I notice that of the twenty people in the room, ten are motionless and ten are scurrying like rats. Better percentage than usual. Bad sign. Still no pulse.
Five more orders:
1. Another 1mg epi.
2. Another 1mg atropine.
3. Open fluids wide open.
4. Mix an epi drip
5. Get the transcutaneous pacer
"You know, the transcutaneous pacer. The pads on the chest thing. The external - yeah - the external pacer. That's it."
I've made a connection. An order has been understood. A few nurses dash out of the room and down the hall to get the defibrillator that has the built-in pacer.
I know it's hopeless. I look up at SICU fellow. He knows it's hopeless too. He's trying to get a blood gas from the right femoral artery. We can both hear the wailing from the family outside the room. The external pacer arrives. We stand back and let the nurses apply the large patches to the chest and back.
I notice that the man has a tube down his throat, tourniquets on both arms, needles in both hands, syringe sticking in his right groin, 14 gauge catheter in his right external jugular vein, electrical leads on both shoulders and large defibrillator patches on his chest. And he smells really really bad.
"Code brown. Code brown," mutters somebody - it could have been me.
I can tell the senior residents from the interns because they're all chuckling. The interns are not really sure what to do. Everybody reaches for the box of laytex gloves.The code keeps going on and on.
Unfortunately, the external pacer has managed to capture and the patient actually has a pulse.The less experienced in the crowd take this as a sign of victory. It's a victory, all right. Another victory of futile gestures over sleep.
Soon, however, the pulse becomes threadier and threadier. Now it's only palpable with every third or fourth beat. Fianlly, it disappears. We check for signs of sponaneous electrical activity. Nada.
"OK, let's call it."
There's a collective sigh of relief. It's been 47 minutes. My, how time flies.
I'm hungry. I walk to the vending machines and buy a Milky Way.
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