Tuesday, August 14, 2007
If you watch medical shows on TV -- and who doesn't? -- you can be excused if you think CPR regularly raises people from the dead. What could be more dramatic? All those close-ups of concerned (and uniformly handsome/beautiful) doctors, nurses, medics, heroically pounding on chests, turning to look at a monitor as it suddenly changes from flat-line to perfect wave-forms. Like nothing had happened. Sadly, it doesn't work that way very often. On the other hand, surgeons have a better crack at it than most, literally.
I've written before, so I won't again now, about the drama of cracking a chest in the ER, clamping the aorta or putting a finger in a hole in the heart. Take a young person with cardiopulmonary collapse from a non cardiopulmonary cause (like exsanguination from an injury), or from just the right cardiac injury, and make the circumstances perfect -- like arrival quickly at a well-run and properly equipped ER -- and you can be part of something memorable. A person in profound shock from sepsis: with the help of many people -- intensivists, nephrologists, ICU nurses -- a well-timed operation can be a part of a heroic rescue of a life that was nearly lost. These things are a part of surgery, and can be exhilarating in the looking back. In my case, it's hardly a high-five'n sort of thing. It's about being in the right place at the right time to be involved under the right set of circumstances in doing the right thing. As opposed to how it usually goes. Which is why "heroic" really means "lucky." A reader asked about what it's like to resuscitate someone. I hope she won't be disappointed.
"Code Blue, room 326; Code Blue room 326; Code Blue room 326...." My first response is to run the room number through my mind to figure if it could be my patient. And whether it could be, or clearly isn't, it's always a sense of dread and doom at what I'll find. Being painfully honest here, I'll also admit that if it's a medical floor my response is slower: I figure there'll be plenty of people more capable than I at running the show, and I may sidle up slowly to see if they need something mindless like inserting some sort of tube or access line... "Oh boy!!" is the last thing I -- or anyone but maybe a student -- think when I hear the call. Odds are, it's not going to end well. In fact, various particulars aside, one can get pretty good mental image of what will be found, based on many repetitions of the same thing.
Chaotic and crowded, the room will be full of people and machinery; a "crash cart" with drawers gaping open in disarray, popped vials strewn on top. A couple of nurses with clipboards, documenting. Possibly three or more docs, one at the head of the bed; likely having run up from the ER. Pharmacist, respiratory therapist. Students, maybe (in my situation, only nursing students). Thrilled; and horrified at being thrilled. Shocked, too; wondering if this is really what they'd had in mind. Disorganized from the broad view, there's usually in fact an overall calm in the principals, deriving in part from the fact that those responding most immediately have done it many times before; and maybe also from a realistic sense of the inevitable.
Remember this: people who arrest in the hospital must already be pretty damn sick. When they fail despite whatever it is that's being done for them, there's already been a stark selection.
Some things are nearly constant: protruding from under the patient is a polished board, maybe maple or oak. Cut-out handles visible at the edges; tubes, sheets, maybe bloodied, draped crazily. Someone kneels on the bed or leans over the edge (backs of knees aching within moments), hunching, with elbows locked, onto a bare chest (in the frail and old, the feel of ribs breaking, sternum cracking are among the more sickening sensations I've ever had). With each compression, the patient's arms flail a little, the belly shakes, the legs shudder. Looking at the feet, one sees ominous blue mottling, heading up the calves. The thighs are webbed with blue veins, as if spidery Death has been there, laying claim, marking territory. The more tubes already there, the worse the outcome. A bandage on the belly is like an address label to the morgue. The defibrillator is no Trekkian transporter. If it works, it bespeaks a particular set of circumstances. And you might be surprised to know this: the word "clear" is said, all right. But unlike those TV shows, it's not a shout. It's a question.
The call at three in the morning: "Dr Schwab, your patient Mr Jones is coding." "What, who, what's.... Nevermind, I'll be right there." I got into the habit of hanging next day's clothes on a hook, to save time rummaging, and to avoid turning on a light and waking my wife, because on a typical day, I left in the dark. It's useful for this situation, too. Holding the clothes in my hand, squirting a finger-tip of toothpaste and sticking it into my mouth, heading downstairs, dressing in the hall. Running possibilities over in my mind on the drive in. I always figured if flashed down by a cop I'd hang my stethoscope out the window and keep going; it never happened.
The feeling is horrible: it's a rarity, really, because most people do well. Or if they don't it's not unexpected. But on those awful occasions when there'd been no reason to expect it, it feels like you're driving with a boulder in your lap. When you get there -- from phone to floor it was give or take twenty minutes -- and enter the room a scene not unlike the above, eyes all turn your way. "What happened, how long has it been?" you say. "Anyone have any idea what's going on? Who's his nurse tonight?" She gives a review of the preceding events. A call like this, out of the blue, is extraordinary. If things had been changing, there'd have been contact; I'd likely have already come in. So this is a catastrophic event -- a stroke, a heart attack, a major blood clot in the lungs. You get a sense of the air in the room, the time. Feel the belly -- because that's what you do -- look at the pupils. Glazed and fogged, pupils black and wide as pools. Lips purple. Ears, too. Purple ears. "Anyone want to keep going? Any suggestions?.... OK then. Let's call it."
Sometimes it's not so bad: it's loss of blood pressure with a persisting heartbeat. A post-op bleed, some sort of infection. Then you can slam in a couple of extra lines, tilt the bed head down, squeeze bags of fluid or blood, watch parts pink up. See the eyes come open, feel feet get warm. Not to mention sense your own heart slow down, your armpits dry a little. It'll be OK. This time, it'll be OK.