Chapter 6: Code Blue

My 2nd month of my 3rd year of medical school was in the medical intensive care unit. During my first week I arrived promptly at 6:45am 7am to help the residents compile data such as vital signs, urine output, and labs from the last 24 hours. At 7:05 AM the overhead paging system announced: “Code Blue Karmanos Cancer Center 4th floor, Code Blue Karmanos Cancer Center 4th floor, Code Blue Karmanos Cancer Center 4th floor”. The residents immediately stopped what they were doing and walked quickly out of the room. Not wanting to be left out I followed them. I had no idea what I was doing or where I was going.

We arrived in the inpatient unit of the Karmanos Cancer Center, a cancer hospital affiliated with and connected to Wayne State University School of Medicine. Our patient was an 89 year old women with stage IV lung cancer metastatic to her brain. She was thin, pale, and frail; her vitality was consumed by the uncontrollable, rapidly-dividing cells in her lungs and brain. Her skin looked like white paper-mâché. The residents told me to “get in line for chest compressions”.

I had practiced chest compressions on a mannequin but this was my first time on a real person. When it was my turn I was shocked how little resistance I encountered. I felt several popping sensations for the next 90 seconds as I manually pumped blood around her body. Suddenly the residents pushed me away from the patient. I thought I did something wrong so I immediately apologized. The resident assertively said: “we have ROSC”, pronounced “rawsk”. I learned later ROSC means return of spontaneous circulation- her heart started beating again.

On rounds that morning the residents joked I “had the hands of God” and “I should be required to do chest compressions on all their patients”. I didn’t understand their joke, so our attending kindly explained it to me. Chest compressions are part of a larger strategy called cardiopulmonary resuscitation (CPR). It is the initial steps of chest compressions and ventilation after a cardiac arrest and before more advanced medical management. She also explained the popping sounds- those were broken ribs. There is a common phrase in residency training when teaching CPR: “if you’re not breaking ribs you’re not trying hard enough”. This phrase exists because high quality chest compressions are the most important factor for survival after cardiac arrest.

Advanced cardiac life support (ACLS) is the medical management of life-threatening cardiovascular emergencies like heart attack, stroke, and cardiac arrest occurring after CPR. It is taught to every resident physician in the hospital because when emergencies occur we are the ones who direct care. ACLS is a way for strangers to coordinate effective emergency medical care within seconds of arriving at the bedside. The success of ACLS is mixed. For in hospital cardiac arrests 25% survive to hospital discharge. That means in 75% of people it would not have made a difference. However it is impossible to tell who that 25% will be. I think of those residents snickering at me during rounds whenever one of my patients die despite high quality CPR and ACLS. The 25% success rate is consistent with my personal experience.

During my first call as an intern I had two patients code at the same time! One was a sick elderly man who recently had a partial lung resection. His oxygen saturation continued to fall despite non-invasive ventilatory support (BiPAP machine). He briefly lost pulses. As I arrived at that code another one was called across the hall. Multiple nurses asked questions at rapid fire speed as my pagers continued to go off. Drowning in pages with no idea what to do I called my junior resident for help. Despite her multiple consults in the emergency departments she came to help me, her pink shoes moving at 2x speed through the hallway.

She took one look at the patient, rapidly read his chart, gave direction to 2 nurses and 2 respiratory technicians, then made 3 phone calls- all in the span of 5 minutes. She told me what happened, what to do about it, and then gave me the phone number of the surgical ICU. She had already diagnosed the patient, ordered the relevant labs and imaging, and arranged for an ICU bed. After that she quickly dealt with the 2nd code before I cold process the first one! She then circled back, gave me an empathetic look and said: “one day you will be in my shoes, don’t worry”, then walked away at 2x speed back to the emergency department.

11 months later I was again on call with the same junior resident. I was paged by a nurse to see a colorectal surgery patient who had increased work of breathing. Her respiratory rate was 45 and heart rate 140. I arrived at the bedside took one look at her, directed 2 nurses, and rapidly absorbed her medical history from the electronic medical record. Then I managed her hemodynamics, ordered the initial laboratory tests and imaging, and arranged for her transfer to the surgical ICU. I presented the patient via phone to my junior resident. She said: “sounds good now come to the ED we have a trauma.”

I diagnosed the patient with a pulmonary embolism. Because she could not have a CT scan for definitive diagnosis, the SICU team preemptively treated her. She slowly improved over the next week. A subsequent imaging study confirmed my initial diagnosis! 2 weeks after my diagnosis I saw my junior resident in the resident lounge. I told her about my first call and most recent one. I had come so far since the beginning of intern year! I thanked her for her patience and guidance over the last year. Admittedly my random expression of appreciation was a little awkward; but I wanted her to know she made a difference in my training. She smiled for a brief second, her eyes softened. Then she told me about 2 recently admitted patients I needed to see on the floor.

I never did buy pink shoes but I did become better at managing cardiopulmonary emergencies. During my PGY-3 year, 4 years after I saw my first code blue, I was called to intubate an elderly man in the coronary care unit, an ICU managing heart failure patients. He had an extensive medical history including heart failure, kidney failure, sleep apnea, peripheral vascular disease, and pulmonary hypertension (pHTN). Any small changes in his physiology can be a disaster- this was bad news for me because anesthetic drugs and intubation cause large changes in cardiac and pulmonary physiology.

At first he was awake and talking. He could ventilate and protect his airway. Initially we decided not to intubate him because the intubation could cause more harm than benefit. For now he was struggling but still breathing on his own. 30 minutes later they called again. Now he was rendered unconscious by the high level of carbon dioxide in his blood.

I knew he was at very high risk of deterioration so I immediately directed the nurses to bring arterial and central line kits- I needed to place invasive lines to monitor his physiology. I quickly guided a needle into his femoral vein- at that point in my training I could feel the difference between the wall of an artery and vein. I threaded a flexible metal guidewire into the vein and removed the needle. I knew he was at very high risk of deterioration so I never took my hand off of his femoral pulse…then his pulse disappeared. With one hand holding a wire in his femoral vein I called a code blue.

I directed my junior resident to place a breathing tube while I led the nurses, respiratory therapists and pharmacists in the proper ACLS protocols. During his 9 minutes of CPR he received epinephrine to raise his blood pressure and stimulate his heart, bicarbonate to decrease the acid content of his blood, and multiple shocks for a deadly heart rhythm called ventricular fibrillation; the whole time receiving high quality chest compressions. While directing the code I managed to place a large central line in his femoral vein as nurses were doing chest compressions. After 9 minutes his heart started to beat again. We had ROSC.

After I talked to the patient’s family and debriefed with the ICU residents and nurses I thought of my first call sitting with my head in my hands while my pagers went off. Maybe my junior resident would be proud? More realistically she would tell me I should have intubated the patient earlier. In cardiovascular emergencies the difference between life and death can be seconds.

Published by Nabil

Nabil Othman, MD is an anesthesiology resident physician at Cedars Sinai Medical Center in Los Angeles, CA. As a Michigan native he advocates calling carbonated, sugary beverages "pop". When he is not an indentured servant in the hospital he enjoys CrossFit, telling everyone he meets about CrossFit, and attempting dangerous hikes in Hawaii with his college roommates.

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