A code run well.

Narrative of a recent code. Resuscitation medicine rocks!

He looked like death. He was death. He was pale and ashen and limp and lifeless. His body moved like a sack of misshapen things as we swiftly pulled him from the passenger seat and heaved him onto the arriving gurney. Someone was already pushing on his chest. I stayed momentarily for a quick history from the spouse as the rest of the team whisked him through the waiting room and into the resuscitation bay. Just a few moments earlier a shrill voice calling for help over the unit radio injected life into the ER, the urgency was evident immediately. Usually, a radioed warning from the paramedics provided a few moments to prepare for an inbound coding patient, but today we adapted. His wife, standing beside the open car door, distressed and somewhat in shock, through tears whispered that he complained of chest pain that morning. They finally decided to drive to the ER, but while still a few minutes away he went limp and lifeless.

I hurried to the resuscitation bay where the team was in the middle of organized chaos. Everyone was rapidly completing separate tasks simultaneously. CPR continued, a bag valve mask joined the fray, pads were placed and connected to the monitor. A nurse was attempting IV access. I grabbed the EZ IO drill and stabbed for the tibia. Too short!!! I discarded the blue IO and the longer yellow IO easily drilled through the fat and bone and found the marrow. Epinephrine through the IO. Fluids through the IV. Calcium. Bicarb. My mind flashed back to the lectures of all the things that offer no benefit in these situations. But in that moment, when someone is dying, the endless academic pondering and nihilistic mindset seems comical. Maybe it will help this one? And what will it hurt? I reminded myself that “the credit actually belongs to the man in the arena, whose face is marred by dust, and sweat, and blood.” In my mind, emergency medicine doctors are the blue collar workers amongst the various specialties. We are in the trenches, slugging it out on the front lines of disease and death every day. In the emergent world, you are truly in the arena, there is no time for debate and indecisiveness, only action. You make life altering decisions rapidly with very little information, and I love this dynamic.

A short pause for a pulse and rhythm check, we studied the monitor. Was that asystole? Were those fine fibrillations? It was too difficult to tell. Resume compressions. More epinephrine. An endotracheal tube was effortlessly passed through the cords without stopping compressions, I was impressed. Good color change. ETCO2 indicated good quality compressions. More bicarb. Another two minutes passed quickly, and the nurse code leader indicated it was time for a pulse check. The cognitive offloading that the nurse code leader provided was invaluable. She indicated the timing for pulse checks and drugs, while the physician code leader focused on procedures and the big picture. During the pulse check, I placed the phased array probe parasternal and saw a faint cardiac quiver that correlated with occasional fine quivering on the monitor. Ventricular fibrillation? Not sure, let’s shock. CPR resumed while the defibrillator charged. Everyone clear? Clear! Shocking. A jolt of electricity shot through his body. The monitor showed a possible sinus beat right before CPR resumed. Another two minutes of compressions, another round of epinephrine. Time for a pulse check. The monitor showed sinus rhythm, and we had  strong femoral pulses. Awesome!

Post-arrest we optimized his hemodynamics and oxygenation. An EKG showed global ST depression with ST elevations in aVR consistent with left main or LAD insufficiency or occlusion. Cardiology was contacted for evaluation. Unfortunately, he began to brady down and the monitor and repeat EKG showed complete heart block. Then he became hypotensive and pulseless. More CPR, more epi, more bicarb, then ROSC. Cardiology and the family decided to admit and monitor in the ICU instead of heading to the cath lab. As the nurses wheeled him out of the resuscitation bay and toward the ICU, my adrenalized mind replayed the code. It was incredible what we did. We literally revived the dead, and only through incredible teamwork. Each individual of the team had a role and executed their duties flawlessly. This was our orchestra, our masterpiece. This was why I truly love Emergency Medicine.

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