October 26, 2004
But a breath, and he is gone...
I just watched a man go into cardiac arrest this evening. He was extremely elderly, and around 6:30 he was trying to climb out of his bed, IV lines still running. He was put back in bed by the nurses, and he seemed crushed when I told him I wasn't a doctor. About 15 minutes later he went into arrest. The place immediately started humming with urgent activity, and for something like that to be noticible in any ED, something really important must be going on. All visitors were cleared from areas A and C, and the house staff went to work. There were two physicians who ran the code, one of whom had just stopped in after finishing a shift at another location. He wanted to check out the new ultrasound machine that had come in that morning. He wound up giving it a pretty decent workout.
The code lasted for about 45 minutes. The physician who was volunteering his time called his collegue "The Queen of Long Codes", because as long a there was a flutter of valve movement on the echo, she wasn't giving up. Saved his life. Took about 7 epi stims, 3 saline drips open all the way, 25 minutes of CPR, and a total of about 3 hits with the defibrillator, but they got him back. While the attendings and residents worked on his chest (you'd really be surprised how far it will compress if you really want it to) another resident inserted a catheter in the groin area. That's a pretty delicate process, one which I had seen for the first time last night, so I knew what he was doing. Afterwards a urine catheter was inserted. I've never seen anything that looked more uncomfortable, but in this case it was the least of the patient's problems.
After a few minutes the patient was successfully intubated, though it took over half an hour to establish anything like a sinus rhythm. They eventually had to use the defibrillator as a pacer to keep his heart beating at over 30 beats a minute with any regularity. They took the pacer off at about 7:45, but started it up at 8:00 again.
Once the patient was something like stabilized, the female attending set out to get the man admitted to the CCU. No dice. When I left about fifteen minutes later, she was trying to track down the CCU attending at home, because the resident on duty wasn't cooperating. The sickest man in the hospital couldn't get a bed. Brilliant. The male attending was using the ultrasound machine to instruct the residents on what catheters look like on echo images when properly placed as this one was.
Afterwards I got one of the residents to fill out a National Emergency Airway Registry (NEAR) study form to record the intubation.
This is the second time I've seen someone code. The first time, I was about 12 or 14 years old, and had gone into the ICU with my dad to watch him round. Freaked me out. But hell, that was 10 years ago. I didn't really know what to feel this time, but I think I kept it together pretty well. I was directing patients out of the area, helping the nurses keep track of the number of epis they'd used, and getting more when they ran low. I'm just glad that tonight wasn't the first time I saw someone die. I don't think I'm quite ready for that yet. Give me a few more months. Please.
