Tuesday, August 14, 2007

See? P.R!

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.


Lynn Price said...

As usual, you take my breath away at how artfully you weave medicine and prose. Brutally lovely, Sid.

rlbates said...

Very nicely said. Don't think I can add anything.

Marianas Eye said...

Hi Sid,

Enjoying your blog from the South Pacific.


Anonymous said...

Dr. Schwab,
Thank you so very much for your insight! I truly appreciate it! Also, a note to the med students who read your blog who may in fact be so blessed as to bring someone back from the dead one day...I've spoken with a few other people who have been resuscitated (in a quest to understand the emotional affects), and they say that, like me, they tend to be generally grouchy/cranky/crabby for the rest of their lives (constantly having to work against that). I just thought it may be important to know not to take that personally. Much patience is needed.

Anonymous said...

My goodness reading that post sent my own heart into a race! This perspective gives me all that much more respect for medical professionals. You truly have a way with words!

Anonymous said...

I knew TV series were over-romanticising it.. Thank you for this beautifully written and informative post.

SeaSpray said...

And yet another powerful post.

When the hospital I worked at was going to have the ED renovated they put my dept at a new "temporary" location. My desk was right near the ambulance entrance, actually pt walk in too. The stretchers literally rolled by about a foot from my desk. I have seen many CPR's in progress that arrived as you described -blue/purple and obviously dead. Still,they rolled them right into the cardiac room where staff followed through on their end. I don't remember anyone surviving who came in in that state. I give you all so much credit for what you do.

Sometimes the families would be there before the rigs and other times immediately after. I think in their guts they knew the person didn't make it but they would still try to be hopeful, even through their tears. We always tried to get the family in a different room and away from the area.

Unknown said...

The first time I saw one was on a little kid. As the call was coming through I was so excited - that didn't last long. The child made it, but you're not kidding about tubes. There were tubes and packages everywhere. It certainly isn't nice and clean. I no longer get excited about a code blue call - lesson learned.

Anonymous said...

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.

Strange as it may sound, i needed to hear this today, because that unexpected code last night was my patient.

Thank you.

Paramed said...

Very well written. Apart from the immediate chaos it is very gratifying to meet with the very lucky ones that benefit from these usually senseless actions. That one person makes it very much worthwhile.

Anonymous said...

another great post, and a particular fav - from a medical students perspective.

mscriver said...

The first code I witnessed as a hospital chaplain was shocking -- an older woman who came in for simple varicose vein surgery on her legs. They put her legs up to do a pelvic -- she was anesthetized and may not have know they were doing this, but it was a teaching hospital -- she threw a clot and that was the end. Their attempt to revive her was quite desperate and in a small room. She was overweight, naked, bouncing. I grinned with shock, couldn't gather my wits. They sent me to stop the family from arriving. It took me a long time to work through that.

When my brother had a massive heart attack last December, as a near-anonymous street person emergency, and was coded in ICU, I knew what the odds were but my other brother did not. He thought coding was magical -- that all would be well. He died in January, wouldn't have wanted to live on, so compromised and without resources. (Earlier he'd had a forehead injury that amounted to a trauma lobotomy and left him too paranoid to accept help.)

I do think the focus on "Code Blue" as a magical resurrection is more than just a dramatic device for ER shows. I think our whole culture wants to believe that technology can make flesh immortal.

Prairie Mary

Sid Schwab said...

nurse bear: a comment like that makes this worthwhile. Thank you.

prarie mary: what a beautifully written thought. Thank you, too.

Thanks also to everyone for such nice comments.

Bongi said...

prairie mary"she was anesthetized and may not have know they were doing this, but it was a teaching hospital"

i had heard about this practise, but i just couldn't believe it. what a total violation! if this were to happen in my country i'm convinced the people involved would be struck from the role and rightly so in my opinion. does this really happen? how do they justify doing this without informed consent? because without informed consent how is this different to rape? and rape while drugged?

i still find it difficult to believe.

Jo said...

Sid, you missed one thing: the way time stretches in a code. You can start and finish one in fifteen minutes by the clock, but it feels like four hours.

Occasionally it feels long enough that a resident will make some small side comment, like "Nice to see you again", and nobody will notice. After all, we've been coding that patient for hours.

SeaSpray said...

I agree with Bongi - I don't think that is right without knowledgeable consent.

Anonymous said...

Dr. Schwab,
I thought the comment about the trajedy that occured in the teaching hospital was startling, especially since I felt like my first baby was almost killed in a teaching hospital because they wanted to research situs inversus (made us afraid of docs for a long time concerning our kids). Your blog sheds light on otherwise mysterious topics, and I truly appreciate it. I wondered if you might write a future post about these deadly mistakes that seem to happen more in teaching hospitals? Can't med students still practice surgery on corpses like in the movies or is that illegal now and it has to be an actual living patient?

Anonymous said...

i am equally appalled as bongi as i read praire mary's post on how the women was put under for a simple varicose vein surgery (WITHOUT CONSENT!)

this is a big no no and we've certainly been drilled in medical law in my 1st year at monash. the repercussions are great, and now that she threw the code it would even be worse if/had she survives/survived.

regardless of the outcome, i guess it is only courteous in seeking permission before you do something to someone (especially if its invasive and might not only intrude the personal space but also goes thr the natural orifices, or worse, an incision is made),

(this is just injection of another perspective to the whole informed consent business)

mscriver said...

I'd better hasten to say that this unexpected death of the woman receiving a pelvic while unconscious happened more than 25 years ago. I think that today's protocols have reformed.

But one DOES sign a waiver permitting such events -- maybe not fully realizing what the implications are. One of the countervailing realizations is that people sometimes are marginally aware when they are under anesthesia, especially hearing words.

Certainly no one at the hospital would discuss this event with me. A chaplain is often seen as a person who keeps order rather than one who raises ethical issues. A force for conformity.

Prairie Mary

Bongi said...

i realise that this is now a side topic and possibly deterring from sids work of art, but on the consent thing:- informed consent means informed. they know what they are consenting to. how many women would consent to having 'pelvics' while under and totally vulnerable. waivers is just not good enough, in my country at least. but here i doubt any doctor would consider such a thing.

i realise what you are saying that it was a long time ago and probably doesn't happen any more.

sorry sid. i'll drop it now.

Sid Schwab said...

No problem, bongi. I sort of skimmed over that part of the original comment; the discussion was a good one. I'm glad to see it was 25 years ago; I really doubt such a thing would happen today, "implied consent" or not. And, just for completeness, if the lady had a PE when her legs were manipulated, the clot was already there...

SeaSpray said...

Dr Schwab - I think you have covered this before so forgive me for not remembering at the moment but I am confused regarding the care at teaching hospitals.

Is the care better if you go to the more prestigious teaching hospitals vs a lesser known teaching hospital?

Or is it just the human factor or both?

Just wondering.

Sid Schwab said...

seaspray: I don't think you can generalize. At any given moment, for any given situation, in any given location you could see the whole spectrum. Most care is fine anywhere you go, including community non-teaching hospitals. The hospital in my community has just been ranked #1 in the state for certain cardiovascular care, and it's a non-teaching hospital unaffiliated with any school.


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