Code Blue

This piece, in a slightly edited version, was recently featured on the AAPA website - American Academy of Physician Assistants. 

The man in bed #9 told his nurse that he was going to die. He felt "impending doom" and didn't want his family called to his bedside. In fact, he just called the nurse in the room because he thought he was going to die and wanted to tell someone. 

Less than one hour later, it happened. 

My first code blue.

In a hospital setting, when a patient "codes" it usually means the patient is in need of resuscitation from respiratory or cardiac failure. Any medical professional may respond to a code, but generally those responders should be trained in advanced cardiac life support (ACLS), which I am. These "ACLS teams" are made up of physicians who "run the codes" and anesthesiologists, internal medicine docs, respiratory therapists, pharmacists and nurses. And, in this case, me. 

I didn't know what to expect as I ran down the hall after hearing "code blue" over the intercom. I knew that I should go, because I could help. But I was also well aware that I had never participated in a code.

When I got to the room I saw a man vomiting up a great deal of stomach contents and then inadvertently swallowing them back down into his lungs—a severe aspiration and very, very bad. He was in acute respiratory failure. The oxygen saturation of his blood was dropping. His heart had an unstable rhythm. Then, with nearly no notice at all, he collapsed, his heartbeat a calm flat line. Right then and there, quite simply, he died. 

We had roughly 20 minutes to get him back. 

I began chest compressions. I was terrified, exhilarated. Adrenaline was turning my ears hot, my body an immediate sheen of sweat. I’ve never felt such tangible energy in a room as others began arriving—ER docs, nurses, other critical support staff, pharmacists and relief CPR staff (a person is only allowed 2 minutes of deep, fast and even chest compressions before relief—you would be amazed how exhausting 2 minutes of sustained compressions can be!).

What I didn’t expect

As a first-time code participant, and PA student, these were the things I didn't expect:

·      I wasn't prepared for the sound of the ribs breaking in the man's chest. It sounded like stepping on stiff dry twigs in the park. Deep chest compressions are required to "squish" the heart in a person's chest hard enough so that the heart continues to somewhat "beat" and move blood around the body. To compress that hard, you break bones. Chest compressions are critical. Mortality (death) and morbidity (co-occurring medical conditions) are significantly reduced when chest compressions are begun immediately and sustained. The longer the team can sustain blood "squishing" around the body, the more time it has to literally work magic and bring the patient back. 

·      Time stops during a code. During the time I was in that room I swear I only took a handful of breaths. I could have been anywhere in the world, doing anything: watching a show, napping, preparing dinner, taking a walk, daydreaming. But instead I was in that room, with that man's heart and broken ribs below my hands, and compressing like hell with both forearms on fire. 

·      They say that people who are about to die know when their end is near. They can sense it. They feel it. Patients who have come back from the brink of their own death tell me that this feeling is an enormous awareness and nearly inescapable. And while I never had a chance to speak to this patient in particular,  his nurse told me he said the very exact thing.  

·      The heart is somewhat scandalous and completely unpredictable.  During the code, the patient's heart experienced multiple difficult arrhythmias that could easily lead to death, including ventricular fibrillation (where the heart resembles a “bag of worms” and does not contract properly), asystole (flat line), pulseless electrical activity, ventricular tachycardia (a fast and dangerous rhythm where the ventricles may become unable to adequately fill back up with blood), Torsades de pointes (literally, a “twisting of points” and an uncommon variant of ventricular tachycardia, resulting in lengthening of the QT interval), complete heart block, back to ventricular tachycardia and then, finally, the pharmacists were able to externally pace his heart—essentially triggering the muscle to beat at an electrically sustained interval. 

·      Watching a human being die is one of the most memorable, strangest, fascinating and incomprehensible experiences I have ever encountered. The patient died several times while I was in the room with those 15 other healthcare providers. And I have no doubt he was out there somewhere—in the great beyond, the Divine Mystery—floating around, maybe happily disconnected from his ill and failing body and considering his own next bold move. 

·      The more chaotic the situation, the calmer I felt. And I sensed the other providers in the room felt the same. In the seriousness of the situation, there was even a bit of humor to ease the overall tension. I was elbow to elbow with trained professionals, and I was proud. The ultimate goal is to respect that something is happening, something very much beyond our control. After all, death is as natural to our existence as breathing. Still, the idea of death is uncomfortable, even on the critical ward of a hospital. As Jimi Hendrix put it, "Life is pleasant. Death is peaceful. It's the transition that's troublesome." 

·      As a student, you want to be in on the action during a code, especially if it’s your first. The key is to stay out of the way until you are needed. A student’s best shot to participate is to get in the CPR line and wait for your turn to fire off 2 minutes of the best chest compressions of your life. After that, tuck into the wall somewhere, make yourself small, do what you can to stay in the room but out of the way, and be at the ready should they need you again. In the meantime, you will learn ACLS better than any textbook or mock code will teach you.

Aftermath

I stood back once my contribution was over and took it all in. I pressed myself against the wall and stayed out of the way. I mentally checked off the protocol in place—the scheduled dose of atropine, dopamine, epinephrine...the shock and CLEAR of the paddles.

Twenty-two turns of the hands of the clock occurred while time was stopped.

During those 22 minutes the patient was gone from this earth.

One minute before, at 21 minutes, the physician was ready to call the code.

But he didn't. And at 23 minutes the patient came out of his many dysrhythmias and stabilized.

Alive. Like the rest of us. For one more day.