Wednesday, February 28, 2007

As seen on TV. But not really.

Every week on network TV, there's at least one medical show that shows a code blue. At least that's what it seems like; codes make for drama and give the actors an opportunity to pretend to place ET tubes and shout a lot.

It's not like that in a real code. For one thing, everybody is impeccably polite. For another, nobody can keep track of what's going on. For a third, there are a whole bunch of people in the way--students, extra residents, extra nurses, respiratory therapists, you name it.

Here's what a code is like: (Note that I've not attributed dialogue to different people, simply because you can't figure out who's saying what. You just act on what they say.)

"I need the crash cart! Call a code!"

Three nurses rush in to the room to help the first nurse turn the patient, place defibrillator pads on her, and place a backboard. Somebody grabs an Ambu-Bag and tosses it through the open door, then calls the code hotline.

"Start compressions. Do we have suction?"
"Suction's right here."
"Who's starting extra IVs?"
"I'm recording. Code commenced 1722."
"You guys need me? Anesthesia resident."
"IV left AC infiltrated."
"I've got fluids running free on the right forearm."
"Could you remove the headboard, please? Thank you."
"Could I have suction? Thanks. I've got an airway."
"One amp epi, please."
"IV's infiltrated, I think. I can't push this."
"I've got an 18-gauge down here." (Usually on the foot or lower leg.)
"One amp epi, then."
"Mike, you need a relief?" (This to the person who started compressions.)
"How long since that first amp?"
"Four minutes." (This coming from the recorder, who's trying to see what's going on through the throngs of folks standing around, watching.)
"One amp epi. Do we have a blood pressure?"
"Stop compressions. Do we have a rhythm?"
"Damn. Start compressions."
"Ninety-four year old female, CHF, ESRD, compression fracture of thoracic vertebrae following MVA. Found down, no witnesses to arrest. Estimated time before coding 5 minutes." (This to the attending, who's just shown up.)
"How long since that last epi?"
"Two minutes."
"Do we have vasopressin?"
"One amp vasopressin here."
"Push it."
"Do we have a blood pressure?"
"Damn IV infiltrated again."
"Frankie, I have another one over here. Gimme that line."
"Al, I'll take over and push." (The guys on the chest switch places.)
"Suction, please. Jesus, she's got a lot of secretions."
"Do we have a pressure? No pressure? Stop compressions. No rhythm?"
"Continue compressions."
"She's 94, multiple medical problems, was anoxic for a minimum of five minutes prior to code. I say we call it." (This from the attending.) "Are there any objections?"
"Any objections?"
"Anybody?" (Looking around at all ten people surrounding the bed.)
We all shake our heads and the code stops.

There's a feeling of failure among the doctors, not so much for the nurses. We've known her for a week, taken her to dialysis, helped suction her. She hadn't responded to anything but pain for a day and a half. She had very little chance, given her age and condition, of getting out of the hospital alive. This is a bad ending to the day, but she's had a good long run.

So we disconnect the IV lines and the oxygen, remove the pads, and leave all the tubes and cannulas in place. We go out in a group to give our names and titles to the recorder. Somebody stays behind to find the sharps left in the bed. The patient is yellowish, waxy, slightly collapsed, with an endotracheal tube taped to her cheek. The chief resident calls the medical examiner and arranges for an autopsy; the secretary calls the ambulance service. Someone's already called the family, right after the code began.

Then three or four of us sit and do paperwork.

On the way home, I realize I started two large-bore IVs on somebody who was already dead.


Anonymous said...

Yes, you have that exactly. Thanks for setting the record straight.

shrimplate said...

What?! No external pacing?! I am enraged!

Call your senators now. STAT!

Just kidding. Sounds like this was an issue of establishing "no code" status well before the crushing of the chest. Thank god she didn't live to die on a vent.

But hey, look at the good news. You really ran up her bill before she choked off and died.

And that's what it's really all about, right?

GingerJar said...

Now if it had been Grey's Anatomy, she would have been lying in the bed, nurses, doctors or RT's in sight as soon as the spontanous breathing was restarted. Just a friend who wanted her to say something...anything..."Ouch"...well that told us a lot!

How about the codes where the family want you to keep doing've been doing chest compressions for 45 minutes, there is no pressure, no spontaneous beats, and she's been shocked 3 times...oh yes, Dialysis, DM, double amputee....what's the quality of life after all that????

beajerry said...

We coded someone who'd been found and probably dead for 30 or 40 minutes. It was a waste of equipment, but good practice.

Pagan Chaplain said...

And then the ward clerk pages the on call chaplain, hoping s/he can get to the hospital before the family does.