By J. Kasen Lisonbee
“Code Blue, ER,” the page game over the PA system.
As we are expected to respond to codes I, a first year resident, made my way to the ER with my senior resident. There we found the ER physician, nurses, and other staff doing chest compressions on an obese woman in her early 20’s with a known history of asthma. We joined the crew to help and got more of the story. We were told she had been experiencing shortness of breath, came to the ER, and had gradually worsened. Eventually, despite appropriate treatment measures she decompensated, her body and heart giving out. This was when they had called code blue.
Chest compressions, on schedule medication administrations, and pulse checks continued as we followed the ACLS algorithm trying to save this woman’s life. Eventually we were able to feel a pulse again. Unfortunately, as we continued to monitor her closely, we watched her heart rate decrease and felt her pulse disappear. We resumed ACLS again with chest compressions, medications, pulse checks, and the other items in the algorithm. At one point the ER doctor stepped out of the room to work on getting more information and try and talk with the patient’s family. My senior stepped out with her and I was left at the head of the bed. At the next pulse check we stopped compressions to see if the patient’s heart was beating strong enough to produce a pulse. “I can’t find a pulse,” said one of the nurses, and then all eyes turned on me. I suddenly realized I was the only doctor in the room, the new leader of the code. “Let’s resume compressions” I said, feeling the sudden weight of responsibility. We continued to follow the ACLS algorithm again with CPR, pulse checks, epinephrine, etc. The ER doctor popped in and out from time to time checking to see how things were going, and my upper level came back to offer support.
We reviewed the H’s and T’s (mnemonic for causes of cardiac arrest), monitored saturation levels, blood pressures, attempted other medications, and got fluids running. We coded the patient for over an hour. We got a pulse back several times, but each time seemed more fleeting. Despite everything we could think to do, and all the valiant efforts put into saving this patient’s life, it became clear she would not survive. Eventually we talked with the ER doctor, and the decision was made that this would be our last round of CPR. After a final round of unsuccessful lifesaving efforts, we halted resuscitative measures, and I watched as the heart’s electrical activity on the monitor slowed, fading gradually.
We went with the ER physician and spoke with the patient’s father in a private consultation room. He was obviously devastated by the news. We discussed what had happened and reviewed all that we had attempted for the last hour in an effort to save her life. He appreciated our efforts. We left him, tearful, after extending our condolences, and began the post-mortem paperwork. In the end, the cause of this patient’s death had been the flu.
This experience remains forever cemented in my mind for several reasons: First, this patient was and remains one of the youngest people I have ever coded. It was also one of the first times I was directly responsible for running a code. The question remained, why had she been taken so young and in this way? Her risk factors obviously played a role, was there any way this could have been prevented? Was there anything we had missed or anything else we could have done to try and preserve her life? I was not the only one to ask similar questions. My senior resident discussed the whole scenario with our attending, who reassured us that we had done everything we could given the situation and that, unfortunately, there was nothing else that could have been done to change the outcome. None of this changes the horrible reality faced by a father, and other family members of losing someone they love.
The reality is that mortality is painfully short and unpredictable at times. It felt unfair that someone so young should die from something so seemingly commonplace as the flu, and this despite excellent and guideline directed efforts from everyone involved in her care. This experience gave me pause, and I learned lessons that day that continue to influence me. I came to realize on a new level the key role of lifestyle changes, the importance of anticipating and working to prevent medical crises such as this one before they become emergent, and the weighty responsibility placed on those of us who have chosen to work in healthcare. We hold an awesome burden, and we should take time to reflect on this and work as interdisciplinary teams to help patients make meaningful and sustainable changes to their lives. As we continue to move forward, we must also remember that, despite all we do, there are some problems that all the medications in the world unfortunately can’t overcome.
James Kasen Lisonbee, D.O., is a family medicine physician who will be practicing in Oklahoma. He enjoys outdoor activities, reading, and mostly spending time with his family.