The incident took place during my 3rd week of hospital rotation. As I carried out my normal routine in the little intern office, my preceptor—Dr. H— yelled, “Code Blue Binh! Let’s go!” Moments earlier, I heard the code announcement over the intercom but never thought much of it—as if it would never apply to me. Feeling ecstatic with adrenaline rushing through my body, I quickly grabbed my coat and rushed out after Dr. H. He was already out the door with a bright orange, tackle box-like emergency kit in hand. I literally had to run after him in order to catch up.
We hopped into the elevator, where we were joined by an intensivist—a physician who specializes in the care of critically ill patients—and an officer of the law. I was thrilled; yet, felt anxious and sad all at the same time. I was excited over the opportunity granted to me, but I also felt melancholic knowing that it is at the cost of someone else’s’ suffering. To my surprise, everybody in that elevator seem relaxed and unusually calm. I wondered if they are no longer fazed by these events and somehow their body have miraculously developed some sort of coping mechanism to deal with the adrenaline rush.
The code response happened over a period of approximately 15 minutes—but to me—they were eternal minutes. I will attempt to retell the story in time sequenced manner to better illustrate my experience. The following event will be recapped to the best of my memory, perception, and estimation of time.
0:01 By the time we arrived at patient’s room, members of the “Code Blue” team were already congregating inside and outside the room. A crash cart—a cart containing emergency medications and equipment for emergency life support protocols— was already set up by the patient’s bedside. Because the patient was in isolation, we were required to gown up before entering. The respiratory team was already performing their CPR routine on the frail, lifeless body as we entered. Respiratory specialists and nurses were alternating to perform chest compression while a designated nurse gave the incoming team a quick verbal update on the patient. I cannot make much of the patient’s status from where I was standing. The verbal update revealed the following:
Patient X, an older AA female with chronic kidney disease (CKD), hospitalized with severe sepsis caused by a port-related infections from routine hemodialysis. The patient was recently transferred from ICU and was reported to be in asystole (colloquially known as flatlinning) just moments ago. No family members were present and DNR (do not resuscitate) order was of nonexistence.
0:02 As the nursing staff established the necessary IV lines, the intensivist shouts “Let’s give her 1 mg of epinephrine!” “I need sodium bicarbonate,” The intensivist followed up shortly, “Let’s get some sodium bicarb in her!”
Meanwhile, Dr. H motioned me to move closer towards the action scene.
“Come closer,” Dr. H instructed, “I want you to see this!” “What’s the idea behind the use of sodium bicarb in this patient?” he asked while keeping his eye locked in on the patient.
“To reverse her respiratory acidosis,” I responded quickly, but it was uncertain if I was heard over all the commotion and surgical mask covering my face.
0:03 The frail poor, frail women remained lying in her supine position without a breath or signs of life. At this point, sweats were coming down the faces of the respiratory team members as they rotate every two minutes to maintain quality CPR and minimize interruptions. Once again, the intensivist called for the administration of calcium gluconate.
Once again, Dr. H inched towards me and asked, “What’s the rationale behind calcium gluconate?”
This time, I did not know the answer.
“Find out and let me know,” Dr. H continued.
0:04 The intensivist shouts across the hall to one of the nurse, “Is it time for another Epi yet?”
“Almost!” the nurse replied after looking through her charts, “In one minute!”
0:05 Patient X, remained unmoved, motionless, and no signs of return of spontaneous circulation.
“Alright, let’s go ahead with that epi!” the intensivist instructed. The nurses complied.
0:06 As Dr. H and I stood in the back with the emergency kit in his hand, ready to go in a moment’s notice. My eyes remained glued onto the patient’s hands as I looked and prayed for signs of movement. My concentration broke when the intensivist screamed, “I need my pharmacist!”
Dr. H moved closer to the scene and reached to unlock the emergency tackle box in his hand.
“I need my pharmacist!” she requested again, “Dr. H, sodium bicarbonate!”
We reached inside the kit to pull out two pre-packaged sodium bicarbonate and handed them to the nurse to administer.
0:07 “I need you to quickly make a trip back to the pharmacy for some more sodium bicarbonate,” he instructed.
“Get me a pack of ten,” he continued, “and take the stairs, it will be faster!”
I was like a zealous squire, eager to execute his first mission. I raced down the staircase and returned with the sodium bicarbonate packages in hand.
0:09 Two minutes have gone by and the patient was as unresponsive as ever. The respiratory team and nurses continued their assigned duties. In a cloud of despair, I became increasingly pessimistic about Mrs. X’s chances of survival without resuscitation. “Nine minutes have passed—this cannot be good,” I thought to myself.
0:10 At this moment in time, the intensivist signaled the respiratory team to initiate preparations for intubation. Endotracheal intubation is a procedure in which a tube is inserted through the mouth into the trachea to the lungs to facilitate mechanical ventilation.
“Someone lube up the tracheal tube for me please,” the intensivist demanded as she positions herself directly behind the patient’s head.
Together with the respiratory team, the intensivist proceed to insert the tube down the patient’s trachea with the help of a laryngoscope—an instrument to aid with visualization of the upper trachea to guide physicians.
0:11 Immediately following successful intubation, the patient was breathing with the help of a mechanical ventilator. The machine was awfully loud; nonetheless, I still managed to make out the patient’s painful gasps as her bodies struggles for air supply. The patient’s heart rhythm can be heard again on the monitors and within moments, the intensivist declared the patient to be in stable condition.
The next day during rounds, I asked Dr. H for an update on Mrs. X’s status. It was grief-stricken to find that Mrs. X was no longer with us; and that she passed away that very morning. Upon receiving these ill-fated news, I cannot describe my feelings; I was troubled. It was reassuring to know the team did their best to extend Mrs. X’s life—but at the same time—would letting her go “naturally” aid in the avoidance of unnecessary pain and suffering? The question remains—to resuscitate or not to resuscitate? Do you let someone you love go with dignity or do you fight for the person’s survival until their last breath? As someone who had to do something I hope I would never have to do— signing a do not resuscitate order for my mother—it was one of the hardest decision of my life. And of course, I have so much to talk about on the subject but I will save it for another day!
Dr. H and I reviewed the ACLS Cardiac Arrest algorithm and medications. The tables below are what was discussed.
P.S.- This blog post was written a week ago but due to time restraint and my recent trips to NYC and D.C, I was unable to make it available until today. Thank you for your patience.
For more information on Advanced Cardiac Life Support Algorithms, please visit https://www.acls.net/aclsalg.htm