I am still processing my first full code experience. I had previously been involved in a “chemical” code in which the family chose no intubation and no compressions. The patient did not survive, but he was in his 90’s and probably ready to go. I had another code called during seizures, but the patient’s heart never stopped. This was my first full on ER code blue experience. There are some potentially gross details in this story. Read at your own risk. Portions of this story (i.e. room numbers, times, names, etc.) are adjusted and no private information is given in this scenario.
All Emergency Departments have that phone. Some are red, some are white, all of them are loud enough to pierce through the chaos of a busy shift. There’s a phrase that makes everyone stop what they’re doing and prepare for the worst–“CPR in progress, ETA 10 minutes.“
“Room 1? Room 1. Let’s go.“
In our city, ETA 10 minutes via EMS usually turns into 15-20 minutes. Our preparation was like clockwork. The intubation box was set up and opened. Crash cart plastic ripped off. Body bag placed under the sheets. We didn’t want to use it, but EMS reported asystole and 4 rounds of epi at the scene. I grabbed a handful of gloves, pocketed my stethoscope and badge, tightened the drawstring on my scrubs, and set up the stool. I was set to begin compressions upon arrival.
Upon arrival EMS is vigorously performing CPR on Mr. X. He is easily twice my size and no more than 10 years older than me. “Who else is rotating compressions?” I ask. I have help. We transfer the patient and I immediately begin compressions. It’s a whirlwind. Something came over me. I’m pushing as hard and as fast as I can. I’m exhausted after a minute. But I kept going and had excellent quality compressions.
My team is organized. Methodical. Everyone has a job and knows their job. Hands and arms are working around me, placing stickers and pads, getting lines and blood. The patient’s torso is wet from whatever he vomited before arresting.
“Two minutes! Time for a pulse check!” Our recorder says assertively.
I stop compressions and check a carotid pulse while other team members check for radial and femoral pulses. Nothing. The code leader calls for another round of epi. My colleague knows I need to switch out. Five seconds later, compressions are resumed and I snap out of “compression mode.”
This guy is laying here and we don’t know anything about him. We have little to no history. We don’t even know his name.
I look at each person in the room. Everyone is hyperfocused on their task at hand. One nurse is documenting. Another nurse is keeping track of time with that person and giving medications. Another nurse is at the crash cart drawing up everything imaginable. Respiratory is bagging the patient. Another tech is standing near the door. The doctor is setting up the ultrasound and attempting to get a gown on. Two minutes goes by faster when you’re not the one doing compressions. It’s already time for another pulse check. Nothing.
I’m resuming compressions and I notice that the second time around is much harder. My upper body is already exhausted from the first round. I readjusted my position so that I was nearly on the bed. I need as much leverage as I can get. The doctor says that at the next pulse check he will check for movement with the ultrasound. This requires that three of us move our position, one person takes the front pad off, and another person squirts the ultrasound jelly on the patient’s chest. We only have 15 seconds to coordinate.
“Two minutes! Time for another pulse check!“
To me our movements seem choreographed. To an onlooker it probably looks chaotic. But the job gets done. No heart movement. More medications are pushed. My colleague is resuming compressions and the team gets ready for rapid sequence intubation. “This should have been done at the scene,” I thought.
“Two minutes. Time for a pulse check and more epi.“
Mr. X is having PEA. It’s not really a rhythm. It’s not shockable. It’s my turn for compressions again.
By the third round, I feel like my whole body is going to give out. My hands are slipping around everywhere because of the vomit and ultrasound jelly.
“I can’t continue compressions!” I yell.
“Do you need to switch?“
“No, I need friction!“
I lift my hands up for half a second and someone geniously throws a towel over the patient’s chest. Perfect. This is perfect. My compressions are now high quality again. Everyone is ready for intubation. A mask. I need a mask. This guy probably aspirated and I don’t want whatever that was all over my face, too.
“Can someone please put a mask and shield on me?“
I continue my compressions as my colleague places a mask on me. He did a great job considering I was half on the stool, half on the bed, hair astray, and using all of my body strength to try to bring this guy back. I’m exhausted. I’m thinking to myself, “How much longer can I do this?” It isn’t about me. Everyone in this room is busting their ass for this patient. I’m not going to be the one to give out.
“Two minutes. Pulse check!“
Asystole. No pulses. No sign of life. Intubation is done and there is a significant amount of fluid coming out. CO2 monitor said 7 but now there are just dashes. No movement on the ultrasound. The doctor wants to resume compressions but he says it will probably be our last round. It has been a total of 45 minutes counting EMS time.
My colleague resumes compressions. He and I are both dripping in sweat.
We have given everything we can. H’s and T’s are checked. Bicarb, calcium, D50, fluids, etc. We have exhausted everything. As a team we were thinking massive pulmonary embolism which is very hard to come back from, if not impossible. I don’t think he was really moving any air.
“Are there any objections? Does anyone have any other ideas?” The doctor asks the room.
We all look at each other and realize there is nothing else we can do for Mr. X.
“Time of death 1148.“
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