(adapted from my blog, a tale of my second call night on Critical Care)
…other days the bear fucks you straight up the ass.
The nice thing about working in the ICU is that all the information you need–flow sheets, charts, computer data, etc.–is usually within reach of the patient, and if you need to know anything, the nurses are hovering right around you. The bad thing about it is…the nurses are hovering right around you.
“Are you covering Critical Care?” “Are you covering Critical Care?” “Are you covering Critical Care?” Fingernails on a chalkboard have nothing on this piercing sound, pelting the resident at least every five minutes while he has the misfortune of being on the unit. Most of the time, these are not important things; they’re small items they certainly wouldn’t call you about if you weren’t sitting right there on the floor. But, you know, since you’re there…
Other times, these interruptions are for slightly more important matters.
“Are you covering Critical Care?” the nurse asked, as I sat down to start the first of three admissions we got all at once. She didn’t really wait for my answer. “12 has been a little tachy all day, and her heart rate just dropped to about 30 with some ST elevation on her rhythm strip.” I really wished that the answer to that first question didn’t have to be yes. The patient in 12 was a fairly young but very sick patient whose chances of ever leaving the hospital were slim to none, but who had at least been stable for a while. What the nurse was telling me, in layman’s terms, was that her heart was trying to quit.
“That ain’t good,” I said. Part of the dark humor that doctors engage in to get them through the day is dramatic understatement; we will look at a man with a rusty spike driven through his skull and say, “Wow, that probably smarts a bit.” “That ain’t good,” in nearly all cases of MD-ese, can be translated as “That’s really fucking bad.”
I ordered a stat 12-lead EKG before I asked the operative question: “Is she a No Code Blue?”
“Well, she’s a limited code blue.” Fuck.
A word here about code status. At least one study that I know of has suggested that code status ought to be like pregnancy–either you are or you’re not. Limited codes–in which particular things like being intubated or being shocked or certain drugs are to be held, but everything else done–are almost never successful. There are many reasons for this, not the least of which is the time lost while the exact wishes are clarified.
I walk in, and she’s as unresponsive as she’s been since I’ve seen her, but her heart rate was indeed in the 30s. Fortunately, there were some family members there, so as I waited on the EKG and tried to find a pulse, I tried to grill them for exactly what she might or might not want. In about fifteen seconds, I managed to get from them that she didn’t want CPR and she didn’t want to be shocked.
That’s where we were when she went into asystole.
We couldn’t shock her, but there were a few things we could have done at that point–we could use epinephrine and atropine, and we could try pacer pads, which is technically shocking them but isn’t like defibrillation. So here I was, faced with my first real split-second life-or-death decision. To my credit, I feel like I acted swiftly, decisively, and appropriately.
I did nothing.
“I’m not coding her,” I told the nurse, as I turned the alarm off on the monitor and listened to the silence of her chest. Her pupils were already fixed and dilated. This was a woman whose chances of recovery were slim to none before she arrested, much less afterwards. The main reason I didn’t push things any harder, though, was the look on the faces of the family members who were there, which was not one of fear, but one of acceptance. The time had come, and it was never going to get easier for them than that. “I’m sorry,” I told her sister, as I pronounced her at 6:25 PM.
Her grandmother, who had raised her, did not take it so well. She collapsed in the middle of the room with a blood-curdling wail. It tore me up; I instinctively left the room, fearing that I’d be seen as the one who did it. I had nothing more to offer at that point but pain.
Would everyone agree with the choice I made? No; some doctors would have put pacers on her or pushed the drugs despite the asystole and the pupils, or would have called a code so her final moments could be spent in a frenzied swarm of medical personnel and shouted orders. The end result would have been the same–if not right then, probably within hours or a few days. My attending (who finally showed up an hour or so later) said that he would have done the same thing. If I had it to do again, so would I.
A lot of things about this job keep getting easier. I hope that making decisions like that one never does.