Like a glove

I stayed in the hospital late last night to finish some paperwork. As I was nearing the end of the pile, the code bells went off. I didn't have to, but I ran, anyway, and when I got to the room, I was the first one there.

I took a deep breath. "I'm with internal medicine. How can I help?"

I'm an upper-level resident now, and that means that when I find a situation requiring resuscitation, I'm expected to know how to manage it. A nurse practitioner holding the chart looked up and recognized this, and me. "Signout! She just went unresponsive. They were concerned she was brewing sepsis earlier in the day and started antibiotics, but they just found her not breathing."

I've been worried about how it would go, running codes. On one hand, resuscitation is very formulaic and follows strict algorithms, which we carry around on little pocket-sized fold-out cards in our white coats. (I used to refer to mine like a show program during codes, fighting the impulse to point at one side and shout, "Oooh, next is 'Pictures at an Exhibition!'")

But I've been to plenty of codes where events took an unexpected direction. In those cases, it was inevitably the instincts of the people present that drove the intervention. New to this role, I am not sure how my instincts are. As I called for a central line kit, I patted my coat pockets for the cards I'd need, and found that the only one I had was for identification and treatment of stroke. I was on my own.

Running the code felt comfortable in an unexpected way, like a glove that looks scratchy but feels like your own skin. I knew what I wanted, asked for it, and kept my surprise to myself. Things unfolded quickly: two nurses worked on peripheral IV's, another resident prepared to put in a central line, and the anesthesiologists ventilated the patient with a bag-mask setup.

Because she was not taking breaths on her own, they prepared to intubate her. As they cocked her head back to gain access to her airway, she woke up and said, "What's wrong with you people?"

I stopped the resident with the central line intentions and the room, as a whole, craned its neck. "You scared us, ma'am," I said. "You passed out pretty good, and weren't breathing so well. We were all trying to get you breathing again."

"Are you better now?" she asked.

I laughed. "Yeah, we're better now."

And I was.


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I'm curious about why you went for a central line instead of intubation as your first move. Will you tell me about that?

For Jeb, FCD:
1. The anesthesiologists were there or due to arrive in seconds. Better that they intubate unless it's absolutely necessary.
2. If the patient is getting ventilation with a bag, there's no screaming rush to intubate. I'm sure she was being bagged by the nurses before the anesthesiologists arrived.

By T. Bruce McNeely (not verified) on 22 Jul 2007 #permalink

Thanks T. Bruce. My experience is limited to smaller, rural hospitals where the MD intubates as nurses are getting IV access, if needed.

To add to and confirm what T. Bruce wrote, this patient was oxygenating well with bag-mask ventilation. There was indeed no screaming rush to intubate. Although we're taught to think of this as a sequence, in reality many things often happen at the same time, especially when you have a large team at work: one group usually works to secure an airway while another focuses on supporting circulation.

In our hospital (and, I suspect, most academic institutions), the internists don't make many/any decisions about the airway. As long as a patient can be oxygenated with a bag-mask setup, we wait for the anesthesiologists to come decide whether and how to intubate.

What an unearthly experience. Hope this patient continues to do well.

I'm jealous. As a senior resident, I'm expected to run the codes as well, but in our hospital, the interns are minimally involved (as in, if you're passing by, you can wander in and watch, if there's room). Number of (actual) codes I've actively participated in: 2. And it's been a year since ACLS. I'm terrified of when it's going to be just me there. I carry around the AHA's flip book and read it in spare minutes, but without the actual practice of it? It's a scary thought.

Codes? On real people? Not just the simulator? You do that? [imagine look of frustration here] peds...

I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.