The way of all flesh

You'll hear residents everywhere refer to "codes" as both the most terrifying and the most exhilarating experiences they have during training. "Code" is short for "code blue," or "code red," or whatever term each hospital applies to situations wherein help is needed in resuscitating a patient. It's used as a noun ("I wet my pants during the code today") and a verb, both transitive ("Rounds were so boring today, I nearly had to code my attending") and intransitive ("Your patient probably coded because of the Tylenol you wrote for"). Codes are often chaotic, and, I won't hesitate to tell you, often kind of fun.

Let me tell you what a code is like. It starts with five bell tones sounding overhead. At this sound, residents all over the hospital put their coffee down, lift their heads up from tables, and shush their interns. After the bells comes an announcement about the type and the location of the resuscitation, by which time the hallways and stairwells are already filled with residents in long white coats, all of them running in the same direction.

When residents run to a code, it is only partly because the patient's life depends on it. The reality is, only about 1 of every 5 adult patients who get CPR in the hospital will live to leave the hospital, even if they are successfully resuscitated (1, 2). The more compelling motivation to run to codes is the desire to be involved.

If you are not among the first ten people to arrive at a code, you spectate from the doorway, craning your neck around the wide hips of the anesthesiologists and over the skinny shoulders of the neurologists. But if you arrive early enough, you have a shot at actually being involved in the code. It's like playing a game of pickup basketball in front of an NBA playoffs crowd. If you succeed, it is before an audience that matters. And if you fail-well, it was like that when you got there.

Cardiopulmonary resuscitation is directed toward two big goals: restoring breathing and restoring circulation. The chest compressions and mouth-to-mouth that you've seen on Baywatch (admit it!) are only part of the complicated algorithms that guide resuscitative efforts in the hospital. Tracheal intubation, electrocardioversion-applying shocks to the chest-and rapid infusion of medicine and fluids also play a large role in in-hospital CPR.

In most hospitals, anesthesiologists or emergency medicine doctors are responsible for intubation and ventilation during codes. The responsibility for restoring circulation falls to the medicine people, which means that we do the chest compressions and the electrocardioversion, and we put in the central access lines, which are essentially really large IV's.

The other night, my senior resident and I were the first to show up at a code. The patient was a 92-year old man with several end-stage diseases, and his heart had stopped beating.

Now, my medical school was very heavily invested in teaching a holistic approach to the patient. We spent more time than I care to quantify learning about the impact of social, cultural, religious, and familial environments on health. Despite the occasional mawkishness of it all, I bought it, and I feel that modern medicine is an incredibly engaging profession precisely because of its extracorporeal dimensions.

Still, the second I walked into the room, this guy was, to me, a container. He had gone the way of all flesh, but for the next twenty minutes, his body would be close enough to living to function as an experimental field. At the urging of my resident, I opened a central line kit, and began digging around for a femoral vein. I was not alone; within minutes, three other residents were lancing in and out of his wrists and his groin as voices shouted for atropine, epinephrine, chest compressions, oxygen.

Three minutes passed, then seven minutes, and I had not found the vein. I took over chest compressions, kneeling on the bed next to the man's head. I was smiling, a little embarrassed, in the same way children are when they are caught playing with imaginary friends. This was not for real, and we all knew it.

When we paused to reevaluate for a heart rhythm, I nearly fell off the bed in shock: he had one. The residents poking at the large veins in his groin poked with greater urgency. Although he still didn't have a central line, the drugs came now in rapid succession. But at thirteen minutes, his rhythm was slowing. At fifteen minutes, it was gone for good.

Not many codes last longer than twenty minutes. My resident looked at me and whispered, "It's over." And then, "Do you want to try for the line again?" I exchanged looks with the charge resident running the code. "You can try," he said, "but fast."

I didn't change into sterile gloves. With my right hand, I stretched the loose skin on his inner thigh, and with my left, I pushed a needle deep into his groin. "Seventeen minutes," said the charge. On my second try, there was a flash of blood in the chamber of the syringe, and a hoot from the foot of the bed. I unscrewed, threaded, introduced, nicked, rethreaded, and drew back on one of the line ports. As I watched dark venous blood flood the syringe, I heard the charge shout again, "Twenty minutes. Let's stop resuscitation."

The room deflated, with people dispersing to make calls, write death notes, and get back to saving lives, or whatever it is they do. I stayed behind to clean up used needles and other debris, and as they passed me, several residents said, "Nice job with the line." I glowed.

If I were a better person, I'd be getting very metaphysical at this point, musing over the conflicts inherent in having obligations both to care for people and to learn to care for people. I would probably feel a little guilty about so easily abstracting my own goals from this rather undignified end of an entire person's entire life.

But I won't, and I don't, because this is what we do. We learn by practicing on patients, whether living, dead, or somewhere in between. The learning is fun. And although patients might not want to know it, and doctors might not want to admit it, the joy of discovery is there even when the outcome for the patient is bad.

It was fun to put in a central line, even in a dying man. It was fun to do it again, shortly thereafter, in a living woman. Even if it is not fun, it is somehow satisfying to diagnose a coagulopathy; a rare, genetic lung disorder; a stroke. If it weren't, many of us wouldn't come in to work in the morning. And none of us would run to codes.

1. de Vos R, et al. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Archives of Internal Medicine. 1999 Apr 26; 159(8): 845-50.

2. Nadkarni VM, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006 Jan 4;295(1):50-7.


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By Thomas Klaüs (not verified) on 29 Jun 2007 #permalink