Some things you just can't explain. Like why do some people just die? No warning. No days of misery. They just die. And they do so within the walls of the hospital.
One of my roles as a hospitalist is to respond to all in patient cardiac or pulmonary arrests. Whenever a heart or lung stops working, I respond. The Code Blue Team. And I am the team leader. It's a big team. The ICU nurses. The respiratory therapists. The pharmacist. The lab people. The EKG tech. The rooms are often small. The people are many. And the equipment is everywhere.
Monitors. Paddles. Vials. Medications. Clipboards. IV poles. Endotracheal tubes. Oxygen tubing.
Everybody seems to know what to do. They are all doing their own dance. For me? My job is to bark out orders while the ICU nurses prod me for orders.
"Is it time for epi?"
"Yes", I say.
"Give epi."
"Give an amp of bicarb"
"Open the fluids wide open"
"Give an amp of calcium"
"Resume compressions"
It's not like your ACLS class. It's not even close. Once you are there the adrenalin kicks in. For me, my mind is wandering left and right, up and down, thinking hard. Concentrating.
"Why is this guy coding? What's his rhythm? What were his morning labs? Was he on telemetry just before the event? What was THAT rhythm? What are his medical problems. How old is he?" And I have just minutes to make all these determinations. Because minutes count. For every minute you fail to shock a patient in vfib, their chance of survival decreases by 7%. It's a dance of seconds.
My mind is constantly in action during a code. Trying to remember my med tree. Actually, screw the med tree. It's epi. Its' atropine. Push 'em full of fluids. Give them some bicarb. Stabilize their endocardium with some calcium. Make sure they aren't on digoxin. And go for it. All the while watching the nurse to make sure compressions remain deep and rapid. All the while watching the heart monitor. All the while checking for pulses. All the while thinking, "Why is Mr Smith coding?". All the while counting, Stayin' Alive, Stayin' Alive. Ah. Ah. Ah. Ah.
"Resume compressions."
"Stop for a second."
"What's our rhythm?"
"How long has it been since our last epi?"
A code is never as smooth as your ACLS event. And no two codes are ever the same. It's organized chaos. It's a dance. A physical dance with fifteen pairs of elbows each doing their thing. A mental dance with minute to minute reevaluation of the situation. Everybody has learned a different dance. I often like to imagine myself in their role.
What's it like to be the guy intubating?
What's it like to be the nurse drawing up the meds?
How about the lab person trying frantically to get a butterfly in the hand?
Or the charge nurse writing frantically the course of events.
The nurses running down the hall grabing the chart. Or printing the labs.
What will a code be like once everything is computerized? And nothing is printed. The ultimate goal of digital medicine. A paperless system. Will precious minutes be wasted while the doc asks "Why is this patient in the hospital?" Waiting for a secretary to log in to the multimillion dollar computer system to hunt down Mrs Smith's H&P. To hunt down her labs. To hunt down her medication list. Some things are best left on paper.
Sometimes we all look at each other and wonder why the hell we are doing this. The nursing home bound, walking corpse with an EF of 15% and two pneumatocytes, fighting each other for that last molecule of oxygen. That dialysis dependent diabetic with no legs, in and out of the hospital 15 times this year for everything from heart failure to sepsis. Why are we resuscitating the inevitable failing of all of our human bodies. Just because we can, does not make it right. And so many patients and families don't understand that.
The misery I have inflicted on patients. Getting them through that code. To survive another 4 weeks of pain and suffering in the ICU, only to be released to a nursing home with a trach suction in one hand and a can of Ensure for their feeding tube in the other. That is no way to live.
Whenever I hear a code blue in Happy's Hospital, my wheels immediately start to turn. Is it my patient? Is it one of Happy's partners' patient? What will the rhythm be? What are they here for? How old are they? Should we be coding them? When I am forced to code a pacemaker that is surrounded by a 95 year old, because the patient and family have been dissociated from reality, I am forced to wonder in every code if it is appropriate. Often times, the patient and family just don't understand why we shouldn't do a code resuscitation. They see a guy on TV with twelve bullets in his chest at noon, a couple compressions later , an amp of super sexy IV juice and the guy is eating steak for dinner. In reality, that steak will be pureed.
Is this a time for a slow code? That term we all learned in residency. When we all looked at each other in disgust and said, "Why on earth are we coding this person." It's cruel. It's futile. The slow code was the last ditch effort to offer comfort care for futile patients with futile families.
"We did everything we could Ma'am to save your mom."
Sometimes funny things happen during codes. And laughter ensues. A joke is said. Saline is squirted on your head. A cap from a vial flies across a room. Somebody trips. Somebody falls. Somebody gets elbowed. Sometimes body characteristics, fully exposed, leave no stone unturned. There is no modesty in a code. We are human. We deal with death in many different ways.
We hear families outside the room crying. We hear them screaming. Sometimes they want to come in. To see for themselves we are doing everything we can. Sometimes I think, 'How could you let us do this to your mom?" We are cells. We are not robots that you can replace a piston and make better.
Years ago we had a few of Happy's hospitalists run like Olympic sprinters at the Code Blue Horn. I found it quite humorous. Running up four or five flights of stairs. Wasting no time to be the first responder. Often the Code Blue Horn is a false alarm. Followed quickly by a "Cancel Code Blue". So much for the effort.
Besides. I hate to be the first responder. Without a team there. Without a crash cart. I am but a bystander. I am worthless.
For my safety and the safety of others around me, I will never run to a code. I will walk briskly. It is my time to gather my thoughts. Sometimes I wish I carried the Bat Key to commandeer the elevator. An express way to the top floor of the hospital. Time alone to take a deep breath and let my 12,000 hours of residency and daily experience in the hospital take over.
I used to get nervous for codes. That was years ago. Not any more. I do my best to bring them back from the brink of death. With the marvel of science and technology, we still have only atropine and epinephrine (and Vasopressin) to kick start a failing heart. And they work like crap. Pulseless electrical activity (PEA) is a terrible rhythm to have. The worst possible code to run. Because quite often a PEA heart fails because it wants to. And there is no explanation why. The treatment is to fix the underlying cause. Which nobody every knows.
So we all stand there. And we bang on their chest for a half hour. And we give a medicine. And we count. And we give another. And we count some more. And we look at the heart monitor. And we count again. At some point I have to make a decision on when to give up.
When do you call a code? When do you stop beating on the chest? There are no rules. There are no guidelines. We all usually look at each other. We ask how long has it been. We look at the patient. We think about how sick they would be if they survived. We wonder about what happened. Why did they code? And then we just call it. Usually the doc says to stop. Time of death is declared.
And everything is shut off. Is age factored into the equation? I'd say it is. But I don't know if it has ever been studied. I would be willing to bet that there is a linear relationship between age and length of resuscitative efforts. There has to be. Coding a 90 year old just feels so different than coding a 40 year old.
It just does.
If granny doesn't die, she ends up in the ICU with anoxic brain injury. And if she survives the ICU, she ends up in a nursing home. Grandpa has to sell the house to get on Medicaid. Granny can't talk to you. She can't hear you. She can't eat. She can't see. She can't feel. She can't live.
She just is.
There are no winners in PEA arrest. Only heartache.
If I'm 80. And I have PEA arrest. Don't you dare touch me.
It's the most peaceful way anyone on this earth could possibly die.
One of my roles as a hospitalist is to respond to all in patient cardiac or pulmonary arrests. Whenever a heart or lung stops working, I respond. The Code Blue Team. And I am the team leader. It's a big team. The ICU nurses. The respiratory therapists. The pharmacist. The lab people. The EKG tech. The rooms are often small. The people are many. And the equipment is everywhere.
Monitors. Paddles. Vials. Medications. Clipboards. IV poles. Endotracheal tubes. Oxygen tubing.
Everybody seems to know what to do. They are all doing their own dance. For me? My job is to bark out orders while the ICU nurses prod me for orders.
"Is it time for epi?"
"Yes", I say.
"Give epi."
"Give an amp of bicarb"
"Open the fluids wide open"
"Give an amp of calcium"
"Resume compressions"
It's not like your ACLS class. It's not even close. Once you are there the adrenalin kicks in. For me, my mind is wandering left and right, up and down, thinking hard. Concentrating.
"Why is this guy coding? What's his rhythm? What were his morning labs? Was he on telemetry just before the event? What was THAT rhythm? What are his medical problems. How old is he?" And I have just minutes to make all these determinations. Because minutes count. For every minute you fail to shock a patient in vfib, their chance of survival decreases by 7%. It's a dance of seconds.
My mind is constantly in action during a code. Trying to remember my med tree. Actually, screw the med tree. It's epi. Its' atropine. Push 'em full of fluids. Give them some bicarb. Stabilize their endocardium with some calcium. Make sure they aren't on digoxin. And go for it. All the while watching the nurse to make sure compressions remain deep and rapid. All the while watching the heart monitor. All the while checking for pulses. All the while thinking, "Why is Mr Smith coding?". All the while counting, Stayin' Alive, Stayin' Alive. Ah. Ah. Ah. Ah.
"Resume compressions."
"Stop for a second."
"What's our rhythm?"
"How long has it been since our last epi?"
A code is never as smooth as your ACLS event. And no two codes are ever the same. It's organized chaos. It's a dance. A physical dance with fifteen pairs of elbows each doing their thing. A mental dance with minute to minute reevaluation of the situation. Everybody has learned a different dance. I often like to imagine myself in their role.
What's it like to be the guy intubating?
What's it like to be the nurse drawing up the meds?
How about the lab person trying frantically to get a butterfly in the hand?
Or the charge nurse writing frantically the course of events.
The nurses running down the hall grabing the chart. Or printing the labs.
What will a code be like once everything is computerized? And nothing is printed. The ultimate goal of digital medicine. A paperless system. Will precious minutes be wasted while the doc asks "Why is this patient in the hospital?" Waiting for a secretary to log in to the multimillion dollar computer system to hunt down Mrs Smith's H&P. To hunt down her labs. To hunt down her medication list. Some things are best left on paper.
Sometimes we all look at each other and wonder why the hell we are doing this. The nursing home bound, walking corpse with an EF of 15% and two pneumatocytes, fighting each other for that last molecule of oxygen. That dialysis dependent diabetic with no legs, in and out of the hospital 15 times this year for everything from heart failure to sepsis. Why are we resuscitating the inevitable failing of all of our human bodies. Just because we can, does not make it right. And so many patients and families don't understand that.
The misery I have inflicted on patients. Getting them through that code. To survive another 4 weeks of pain and suffering in the ICU, only to be released to a nursing home with a trach suction in one hand and a can of Ensure for their feeding tube in the other. That is no way to live.
Whenever I hear a code blue in Happy's Hospital, my wheels immediately start to turn. Is it my patient? Is it one of Happy's partners' patient? What will the rhythm be? What are they here for? How old are they? Should we be coding them? When I am forced to code a pacemaker that is surrounded by a 95 year old, because the patient and family have been dissociated from reality, I am forced to wonder in every code if it is appropriate. Often times, the patient and family just don't understand why we shouldn't do a code resuscitation. They see a guy on TV with twelve bullets in his chest at noon, a couple compressions later , an amp of super sexy IV juice and the guy is eating steak for dinner. In reality, that steak will be pureed.
Is this a time for a slow code? That term we all learned in residency. When we all looked at each other in disgust and said, "Why on earth are we coding this person." It's cruel. It's futile. The slow code was the last ditch effort to offer comfort care for futile patients with futile families.
"We did everything we could Ma'am to save your mom."
Sometimes funny things happen during codes. And laughter ensues. A joke is said. Saline is squirted on your head. A cap from a vial flies across a room. Somebody trips. Somebody falls. Somebody gets elbowed. Sometimes body characteristics, fully exposed, leave no stone unturned. There is no modesty in a code. We are human. We deal with death in many different ways.
We hear families outside the room crying. We hear them screaming. Sometimes they want to come in. To see for themselves we are doing everything we can. Sometimes I think, 'How could you let us do this to your mom?" We are cells. We are not robots that you can replace a piston and make better.
Years ago we had a few of Happy's hospitalists run like Olympic sprinters at the Code Blue Horn. I found it quite humorous. Running up four or five flights of stairs. Wasting no time to be the first responder. Often the Code Blue Horn is a false alarm. Followed quickly by a "Cancel Code Blue". So much for the effort.
Besides. I hate to be the first responder. Without a team there. Without a crash cart. I am but a bystander. I am worthless.
For my safety and the safety of others around me, I will never run to a code. I will walk briskly. It is my time to gather my thoughts. Sometimes I wish I carried the Bat Key to commandeer the elevator. An express way to the top floor of the hospital. Time alone to take a deep breath and let my 12,000 hours of residency and daily experience in the hospital take over.
I used to get nervous for codes. That was years ago. Not any more. I do my best to bring them back from the brink of death. With the marvel of science and technology, we still have only atropine and epinephrine (and Vasopressin) to kick start a failing heart. And they work like crap. Pulseless electrical activity (PEA) is a terrible rhythm to have. The worst possible code to run. Because quite often a PEA heart fails because it wants to. And there is no explanation why. The treatment is to fix the underlying cause. Which nobody every knows.
So we all stand there. And we bang on their chest for a half hour. And we give a medicine. And we count. And we give another. And we count some more. And we look at the heart monitor. And we count again. At some point I have to make a decision on when to give up.
When do you call a code? When do you stop beating on the chest? There are no rules. There are no guidelines. We all usually look at each other. We ask how long has it been. We look at the patient. We think about how sick they would be if they survived. We wonder about what happened. Why did they code? And then we just call it. Usually the doc says to stop. Time of death is declared.
And everything is shut off. Is age factored into the equation? I'd say it is. But I don't know if it has ever been studied. I would be willing to bet that there is a linear relationship between age and length of resuscitative efforts. There has to be. Coding a 90 year old just feels so different than coding a 40 year old.
It just does.
If granny doesn't die, she ends up in the ICU with anoxic brain injury. And if she survives the ICU, she ends up in a nursing home. Grandpa has to sell the house to get on Medicaid. Granny can't talk to you. She can't hear you. She can't eat. She can't see. She can't feel. She can't live.
She just is.
There are no winners in PEA arrest. Only heartache.
If I'm 80. And I have PEA arrest. Don't you dare touch me.
It's the most peaceful way anyone on this earth could possibly die.
When did Pharmacists get added to the Code Team? I know at my hospital they sort of just started showing up one day, giving themselves away when they refused to do chest compressions...Worst was when the Pharmacy Resident(who knew they had residencies) gave an amp of Lo-Pressor instead of Atropine....THAT code didn't turn out to well......But they never do anyway.
ReplyDeleteExcellent, Dr. Happy. i wish there were a way to r e q u i r e every person to read this entry.
ReplyDeleteThank you,
tracy
i'm curious about your perspective because from where i sit, pea is one of the few we can resuscitate people from--if we can find the proximate cause.
ReplyDeleteanon. Rarely do good things happen when you're 80 and you code.
ReplyDeleteVF/ VT shock 'em.
PEA? My experience is not yours.
I decided to de-lurk after reading this post.
ReplyDeleteThis is excellent. I really wish I could share this with my classmates in my RT class. Do you mind?
I've seen many codes in the short time of 7 years that I've been in medicine...and every single thing you said in this post is true.
Thanks Junkie. I don't mind a bit.
ReplyDeleteGreat entry! I think you summed up the thoughts of those who participate in codes.
ReplyDeleteI always like to refer to a code as a 'goat rodeo': lots of movement going on but little getting accomplished. I am more comfortable in codes now but I guess I am still worried about the time I will miss that critical sign, the window to give that one shot of vasopressin will close or I will forget something painfully obvious (good thing there are lots of people present to help, or at least arm-chair quarterback after the fact).
BTW: intubating during a code stinks! The patient is usually morbidly obese, has a poor airway and large tongue, not to mention a moving target as the chest is being compressed.
"When did Pharmacists get added to the Code Team"
ReplyDeleteI don't know Frank, the at least the early 1990's. When is the last time you ran a code?
Heads-up displays built into glasses and/or contacts. Seriously.
ReplyDeleteIt's gonna be rad.
They're developing the technology for fighter pilots, but I think health care is the next stop.
Gesture or voice commands to pull up live or past ekgs, labs, vitals, should be fun.
A built-in EEG could even detect when the user's getting overwhelmed and produce an auto-consult from another practitioner who's more clear-headed.
Thank you for letting us in on the inner experience of a code for the doctor and the team. It's a privilege to now understand what it's like for you.
ReplyDeleteIt's funny when someone codes on the floors and everybody except God himself shows up inside the patient's room. All of them want to help but none of them know what to do.
ReplyDeleteI absolutely agree with you on this matter. A very thought provoking post that should be read by all health care providers.
ReplyDeleteExcellent post. You described the inner workings of a code perfectly.
ReplyDeleteI have got to say too that the codes I have seen and been present at, I can't remember ever seeing a pharmacist present. ER doc yes, respiratory yes, ICU nurse yes, house supervisor yes, some times security, but not a pharmacist, that's interesting. I will now be on the look out. I never look forward to codes, i used to be so afraid, but over the past years unfortuanetly you have to over come, ready yourself, to be ready to go. I feel much more confident now, still have much too learn though, best thing to do study most common causes of codes, electrolyte imbalances, clinical s/s and just try to watch your pt like a hawk to prevent such happenings, although sometimes no matter how much you study or try to prepare yourself, some times it is sudden and out of your hands. You just do what you can, knowing you tried your best for the patient.
ReplyDeleteI hate PEA. I've said that so many times to colleagues. I hate PEA. One of the annoying things about PEA is being the person to check the pulse. You can almost convince yourself it's there sometimes, and then it fades. At least VT/VF you kind of don't care about the pulse (as much). The answer is obvious, and it sometimes works. Shock, shock, shock.
ReplyDeleteWhen I'm 80, I'm strongly considering having a DNR except for shock for VT/VF. I'm allowed three shocks. No success, let me go.