code blue

at 23:36 tonight, I watched a man die...

0700: Morning rounds

We visit Mr. Walker. He is not looking well. He has leukemia, and
had been doing better. His leukemia should not be at the point to
make him sick yet, but he has had several surgeries for other
conditions and his body just hasn't responded well. We're treating
him for a lung effusion.

As we walk in the room we see him holding a pan up to his mouth. He
is vomiting horribly, and the vomit smells terrible. It is not normal
vomit, this is vomit that should be going out the other end. He was
supposed to go home today, but obviously something is wrong. He's not
going home today. Maybe tomorrow if he stops vomiting.

He looks like a ghost. As I leave, I think to myself, "wow, I'm not
sure he's going to make it."

23:08

I'm working on the computer, reading up on some of my patients,
checking their most recent lab data. "what is the padres score?" I
get on the internet and see that the padres are tied going into the
bottom of the 9th. "dang. I hope they find a way to win."

Tommy, the other medical student on my team walks in. "what are you doing?"

"just reading" i tell him. "i hope i can get this crap done at a
decent hour so I can get some sleep. I'm going to be ticked if I
don't get a few hours of sleep, but I have a lot to do before morning
rounds."

Just then, Nnenna, one of the the interns, walks in. "Tommy, you need
to go see Mr. Walker... NOW!"

Tommy is tired, and doesn't want to get up: "Why?"

Nenna: "Because he's going somewhere."

Tommy: "where's he going?"

Nenna: "south. go now!"

Tommy and I sprinted out the door of the dr's work room and headed for
Mr. Walker's room. As we run down the hall we hear a bell ringing.
Several interns and residents are running down the hall with us.
Somebody yells, "he's coding."

We enter the room and find a team of nurses trying to resuscitate him.
One is doing compressions on his chest while another is trying to
hook up a battery of medical monitoring equipment.

Orders are flying around.... "I need a femoral line!" "Does anybody
have an ABG?" "Where are those paddles?" "What's his code status?"

Allison, one of the critical care interns, enters the room and begins
to place the femoral line. He is totally naked now, except for a
diaper protecting his modesty, with a team of probably 12 people
surrounding him, each performing a task to try to save his life. The
questions begin to fly... "What's his story?" "What's going on with
him?" "Is he full code?" Tommy answers the questions. I stand
behind the crowd, observing, wishing I could somehow help the team.
What do I know? Nothing. Watch and learn. The doctors worked on a
dying man like a mechanic works on a blown engine. The only
difference was the pace. The pace was rapid. There was no pausing to
think, only action and decisions. And questions. "What did his last
KUB look like?"

Just then, one of the interns points at me and asks, "Can you do
compressions?" I step behind the dr. doing the chest compressions,
and wait for him to get tired.

"hold." He steps back and I step forward. "Anybody have a pulse?" nothing.

"resume compressions." I begin to compress just like I learned when I
was in boy scouts and took first aid CPR. Just like they taught me my
first year of medical school. 1.. 2.. 3.. 4.. 5.. 6.. 7.. 8.. 9..
10.. 11........ 44... why am I counting? 1... 2.. 3.. 4.. 5.. 6.....
20... 1.. 2.. 3.. "wow, this really is tiring," I think to myself. I
realize I'm counting not to count, but to pace the beat.

With each compression there is a grunt coming from the man's mouth.
He is intubated, and somebody is puffing air into his lugs with a
squeeze of a small plastic bag. There is a very foul odor in the
room. I look at the team. Allison is still working on the femoral
line. Blood is now pouring down his leg. We get an ABG reading.
"hold compressions." pause... I'm not thinking about anything...
just watching. My arms are getting very tired. There is a little
sweat on my forehead.

As I look around the room, I realize that this whole team of doctors
is nothing but a bunch of kids really. In fact, they're probably all
younger than I am. The nurses are older of course... they have a
weathered look. They have seen this many times before. One of the
nurses looks at me. He's about 45 years old and shakes his head
slowly. I know what he's saying.

5.. 6.. 7.. 8.. 9........ 35..... 50.. start over... 1.. 2.. 3.. "HOLD"

I step back... The intern who seems to be barking orders steps up with
a syringe. He sticks it right in between the ribs and directly into
the man's lungs.

"HOLD"

"resume compressions"... 1..2..3..

The smell is foul. The man's body jerks every time I pump his chest.
He is making noises like he is coughing, but by now I realize it's
only because we are pumping his heart and his lungs for him. His body
is cold. Each doctor is focused on their task. Allison has placed
her femoral line. Now she's reading ABG values. Several other
doctors have placed various syringes into various arteries. One in
each leg, one in each arm... They're injecting chemicals to try to
jumpstart his heart and taking blood out of various sites to measure
critical values. Nothing. The doctor who has taken charge shakes his
head... He looks younger than me.

"HOLD"

he looks around the room... "anybody have ideas? I'm out of ideas.."
Nobody says anything. "does anybody object to me pulling the code?"
Nobody says anything. He watches the monitor... there is no response.
He pauses. He looks up around the circle one more time. My eyes
were first. I don't move. Then several of the other interns and
residents just kind of make a soft approval. Nobody says it
specifically, but there is a soft sound... the sound of
agreement--agreement without anybody actually saying a word.

He pulls the monitor plug.

"What time is it?" 11:36pm.

The room slowly empties. People filter into the hallway. I walk out
into the hall and wash my hands.

A man walks up to me and asks my name... "The Wolf."

"are you MD?"

"No. MS3."

"I need your name on the code. I need everybody who was in the code."

I look back in the room. There is a pale body lying on a bed. The
room is a mess. There are wrappers and papers all over the place. It
looks like somebody died in there.

I make brief chit chat with a couple interns before I walk back to the
work room with Tommy and our two interns. "He was suffering." "It's
probably best this way." "That was no way to continue living."

I sit down at the computer... I have lots of work to do, but instead
of writing a patient report, I write an email.

My First Night on Call (as a med student)

Thursday, July 7, 2005 (Internal Medicine Rotation, Day #3)

Medicine heirarchy is as follows: lowest on the totem poll is the 3rd year rotating student (me) followed by any 4th yrs, the intern (first year MD), the resident, and finally the "attending." the attending is some grand poo bah of medicine or something. Each totem poll represents a "team" that is assigned certain patients to admit, follow, treat, and ultimately discharge. I like my team. I work
closely with an intern named Jane who has been very patient with my ignorance and inexperience.

Yesterday was my first day "on call" which means our team picks up all the new patients. We got there early and immediately started seeing the new patients. By 8am, i was already exhausted. remember, it's already been a long week for me at this point. By lunch, I could barely hold my eyes open anymore. All I wanted to do was find a corner of the hospital where nobody could find me and go to sleep. I
knew I would snap out of it if I could get over the initial hump, and sure enough, by early afternoon I was cruising!

Around 9am the sirens started going off. i had heard vague reports of another terrorist attack in europe, so at first I wondered if something had happened in america too. "Code Red! Code Red!" turns out, it was only a tornado. "move away from the windows" and continue on. I never saw it, but the skies were BLACK. I don't know if it was just a warning or if it really touched down.

By 8pm we were really humming. Seeing patients left and right. I wasn't tired anymore. By midnight, I was hungry, so the team sent me out to find some food. Everything was closed except sonic. I took orders and brought the food back. While I was getting out an old black man who looked homeless came limping over... "oh no" I thought, "another homeless bum looking for money." I live in downtown dallas
and my school/hospital and the VA where I'm currently assigned are all in very bad parts of town. At first I ignored him, because I didn't want to deal with it. But then I realized he was limping very badly so I watched him walk towards my car. His legs were pretty deformed, and he was carrying a bag of ice. I rolled down my window and he said, "I'm SO sorry to ask you, but my legs don't work, and this
restaurant is nice enough to give me ice because my refrigerator don't work. but my house is far, and it hurts to walk that far. could you please give me a ride?" Ofcourse I did, and while doing so I learned he had been afflicted with polio when he was very young. His house was several miles away. He doesn't have a car, so he walks everywhere on those polio legs. I was glad I could do something to help, since
all day I had felt like a burden to my team. I was also reminded of what a blessing health is. just being able to run and play as a child... something he never had.

I brought the food back to the hospital and it was gross. we all thought so. Then we went back to some patients to draw blood, put in iv's, etcetera. One of our patients was an old medic from the vietnam way. while my intern was putting an iv in his neck, i was talking to him. he couldn't talk too well, because he had much of his mouth removed thanks to mouth cancer. he was very sick, and in a lot of
pain. he told me he had wanted to become a doctor, an anethesiologist after vietnam, but fell into trouble while he was in college. now here he was, laying in a bed, in pain, barely able to get himself to the bathroom, with doctors trying to put an iv in his neck, telling his story to a med student at 1 in the morning. Soon we were done seeing patients, but we still had a lot of paperwork to do.

By about 2:30am, I decided I wanted to try to find the "call room" which is a bunk bed for students/doctors that want to crash for a short time while they're on call. I knew I would have to get up early to finish my paperwork and check on my patients before rounds, but I was tired. I wandered the desserted halls of the hospital trying to find it. I walked past the surgical icu. several families had made
makeshift cots out of couch pillows and blankets. It was obvious they were waiting for somebody in their family to come out of emergency surgery. A middle-aged, blue-collar looking man was pacing the hall. I nodded as I walked past him, looking for my bunk bed. Eventually, I found the room, but I needed a code to get in, and since nobody had given me one, I decided I would have to go back to my work room and
crash on the couch. I was slightly frustrated at how tired I was, how late it was, how i hadn't seen anybody i really loved in days, and how I was looking at 2 hours of sleep on an old couch before starting all over again tomorrow. Walking back through the hall I again passed the surgical icu. The same man was standing there, but this time he was different. He tried to hide his face from me and I noticed that tears were streaming down his cheeks. I walked back to my couch, took off
my shoes, set my alarm for 5am, and went to sleep under the flourescent light.

5am came and I launched out of bed groggily and in disbelief at how much I would have to get done in a short period of time. The attending was coming and I needed to orally present one of our patients. An oral presentation is when we tell the entire history of the patient and what we think the diagnoses could be, and how we think he should be treated. It's easy for an experienced doctor, but for a
know-nothing 3rd year student, it's hard. I brushed my teeth and got back to work.

Without blinking it was already 7:30 and the attending was here. I presented, and everybody else presented as well. I knew I was a little disjointed, but I didn't think it was terrible. Not bad for my first time--or so I thought. After presentations, the attending went with the whole team to visit each patient. This took several hours.

After "rounding" the attending asked he other student and me to come to his office. He totally laid into us on our presentations, said they were "terrible." At first I wasn't offended, but by lunch time, after the offense had settled in a little, I was pretty ticked. I had worked my tail off all night, took 2 hours to sleep, and some
doctor who's been practicing medicine for years tells me I suck? Thanks for the help!

Well, by 3pm I was finally done with my responsibilities and free to
leave for the day. That's over 33 straight hours at the hospital.
Tomorrow morning at 5:30am I'll be back there.