Monday, August 8, 2011


The first entry in this blog described what generally happens in a code. What I did not make clear is that there are "good" codes and "bad" codes. The quality of the code has nothing to do with patient outcome; rather, it has to do with the organization, teamwork, and clinical judgment of the team involved. A "good" one is almost boring; everyone present has a role, and they're performing it to the best of their ability. The code concludes when either the patient's cardiac function is restored, or it's determined that death is imminent regardless of efforts.

This was not one of those codes.

I was living pretty fat on this shift. At this particular facility, the techs were relied upon to do a lot of the grunt work (vital signs, feedings, hygiene and so on), so at 1215, I'd finished up a lot of what I had to do for my patients; now I just had to figure out what to write about them on the archaic paper charts. I was doing my best to ignore some of the background noise around me, but I'm terrible at that; I ended up eavesdropping on a couple of nurses discussing a patient that had recurrent seizures and seemed to be having one now. "Don't go look," I reminded myself. "I don't have to be ambitious every day."

Just as I was refocusing on manually writing a narrative (quelle horror), I heard a commotion from across the hall---the seizure patient's room. I threw my chart and pen down and jogged over as someone was yelling to call a code.

A code? How do you get from a seizure to a code? They're almost exactly unalike.

Patient was pale to dusky colored, unresponsive, and trached. His heart rate was in the 40's; bradycardic, but otherwise normal. No clonic, no tonic. There was a nurse on either side of the patient, and an RT standing at the head; I wasn't totally sure what any of the three of them were doing right then.

Me: "Did anyone check his pulse?"
No answer. I pulled his gown up and checked his femoral pulse. There it was, under my fingers, consistent with what I saw on the monitor. Strong, too. I looked toward the RT and nurse closest to Patient's head. "He's got a pulse. Has anyone tried to suction his airway? Are you gonna bag him?" I asked.
"We're having a hard time passing the cath," one answered.
"I think if you can get whatever's plugging it, that'll fix this," I offered.

Patient's nurse decided to start (initially very pathetic) CPR then. "Wait! He's got a good pulse," I repeated. Puny compressions continued. The charge nurse was yelling, "GIVE HIM ATROPINE! GIVE HIM ATROPINE!"

Fuck it. Not my house. I looked behind me to see if there's a crash cart coming; good, there it was. I told the nurse pushing it to pass me the pads in case we needed them. "GET THE BOARD! GET THE BOARD!" bellowed Charge Nurse. (She was referring to the back board normally placed under patients during CPR---which was being done, but badly.) "I think we really need to see if we can clear this guy's airway first, since he has a pulse," I the air and no one else. I grabbed the object out of the torn package offered to me; what should have been AED pads were just...wet, pink rubber thingies. (???) "What the fuck are these, dude?" I snorted. Freeman, another nurse I knew from my old ICU and the one that handed me the...things...started laughing too. "I have no idea." I tossed them aside and turned to the Cart Pusher. "Have you found pads? We should have them." She ripped another package open. Pads! Okay. I got Enthusiastic Bad CPR Giver to stop so we could get the pads stuck on Patient's front and back. I directed the Cart Pusher to plug the pads in to the AED. CPR Nurse resumed compressions.

Fine. Board too. Might as well. Someone passed me an amp of atropine. I looked up to confirm the order with---(god, who's in charge?)--- and tell the recorder that I'm about to push the amp.
No recorder.
Now I was annoyed. The room had become an abyss of panic.
Me: "Who's in charge of this code, anyway? And is anyone charting anything? Who is recording this?"
A ragged, loud chorus of "yeah, who's in charge?" followed. As my eyes swept the room, there was a physician at the foot of Patient's bed. Just standing there. Saying nothing. He could have been twelve years old. He was even shorter than me, and I'm no giant.
"I'M IN CHARGE! GIVE THE ATROPINE! WHO'S RECORDING?" Charge Nurse bellowed. Al Haig revisited. I guess since the only physician in the room wasn't saying anything, this was constitutionally correct. I pushed the atropine. "Pulse check!" squeaked Mystery Nurse on the other side of the patient. "...hey, he's got a great pulse!" I started to tell her that she was feeling CPR Nurse's now more energetic compressions, but, well, she looked so happy. CPR Nurse, too, was in the zone.

Freeman sighed, put aside the drug box that he had taken charge of, and asked me what had happened so far.
"Okay," I asked CPR Nurse, "when did this all start?"
"Uh...1226, I think."
"Good. You called a code at 1226. Freeman, code was initiated at 1226. Pulse was detected. I don't know what his sats his PulseOx even on? Compressions initiated. I pushed one amp of atropine for a heart rate in the 40's at 1229. Pulse check also at 1229."

It didn't look like anyone had cleared Patient's airway yet, but a different RT was trying to re-insert the suction cath to try. I turned to the cart pusher and asked if she got the AED fired up. She hadn't. As she turned to the cart to flip it on, I followed the cord to make sure the pads were at least plugged in. No, they weren't. I grabbed the cord and demanded the AED end. As I started trying to fit them, Cart Pusher said, "I couldn't make them fit."

(oh, no)

The AED pads belonged to a totally different system. We would have had more luck with jumper cables and hot glue.

Just as I started to wonder about the ethics of abandoning a goat rope, there was a tremendous sucking sound. "I got it! Plug's out," the new RT called out. And like magic, Patient's heart rate bounced into the 120's and he pinked right up. One of the other nurse managers took the code sheet from Freeman. He and I both offered to sign the sheet, but she waved us away. Freeman looked like he was fleeing the scene of a crime. I felt like he looked.

I walked out of the room and into the hallway. A frail older woman, Patient's wife, sat in a chair just outside; she was crying silently, like someone who had cried a bit too much for a bit too long. Sorry, lady.

But you know, we saved him.
Time to chart.