Thread by @TheRealDoctorT

TW: Adult Code Blue, cardiopulmonary arrest and resuscitation protocol in graphic detail.

It’s been my experience that many (not all) people who haven’t seen a Code Blue up close have a sanitized understanding of it.

Details have been changed, but this story happened. 1/

Code Blue teams save lives every day. Their hard work is essential. This piece is not to disparage them or accuse them of cruelty.

This is just a reminder that the work of bringing a fellow human being back from the edge of the precipice is often brutal, and we all bleed. 2/

It’s late Fall in Boston, and the air is crisp.

I’m on the Subway, Orange Line, heading in to downtown for a night shift as the senior medicine resident in the ER.

As I sit on the train, I work the daily Metro Sudoku puzzle. It wakes me up, yet somehow also relaxes me. 3/

This particular train always has its fair share of medical folks on board. Boston has 15 acute care hospitals, and 24 hospitals in the suburbs.

It’s a medical Mecca, and that’s why I chose to train here.

Nobody pays any attention to my scrubs.

Nor my dirty white sneakers. 4/

Walking into the hospital, I steady myself psychologically for the ER shift ahead.

I always envision this moment as the soldiers in the landing craft from “Saving Private Ryan.”

As the elevator doors open I can hear Tom Hanks yelling “gogogo!”

“I’ll see you on the beach!” 5/

The outgoing resident signs out the pending cases, the patients still in the ER awaiting admission or workup.

As she leaves, she gives me a fist bump.

“You got this,” she says, “I’ll see you on the flip side, soon.”

I offer a smile, and then take a deep breath. 6/

The adult ER is covered tonight by a medical resident (me), a Physician Assistant, an Emergency Medicine attending, and a Psychiatry on-call resident.

We make a decent team.

I have a secret arrangement with the PA to take all my laceration cases.

I can’t stand suturing. 7/

Unfortunately (and inevitably) the attending has figured out our little under-the-table deal and gives me a laceration to suture right off the bat.

He then forces the PA to treat his worst nightmare: an elderly woman complaining of dizziness.

The night is starting well... 8/

A bit of clarification here. The hospital I’m training at is in the heart of Chinatown. A significant portion of the patients speak only Cantonese or Mandarin.

For elderly Chinese patients, “dizzy” is often the only translation we get for their complaints.

It is inaccurate. 9/

“Dizzy” could be anything from mild general malaise to rapidly approaching unconsciousness. It is a diagnostic quagmire.

Fortunately this patient is also coughing and feverish, so a diagnosis of some sort of respiratory infection seems likely.

I move on to my suturing case. 10/

My problem with suturing isn’t that I’m not good at it. I can do a fairly painless and effective job. It just takes me F-O-R-E-V-E-R.

I bite my lower lip as I stitch the wound edges together carefully, taking my time.

I finally finish up, and the patient is discharged. 11/

As I sit back down at my workstation, I eyeball the PA’s patient. Sure enough she had a clear infiltrate on her chest X-ray and was diagnosed with pneumonia, then started on antibiotics and IV fluids.

Currently she seems to be resting.

I work on my unending charting. 12/

Suddenly a nurse calls out for help. My gaze snaps up and it’s the “dizzy” patient.

Her eyes are wide open, bulging, and her heart rhythm is suddenly erratic. She lets out a low moan.

I hear the PA next to me say the same words I’m thinking.

“Oh no...” 13/

We both run to the bedside, and I know enough medicine now to understand that this is an imminently catastrophic situation.

Almost in slow motion I can see her skin changing color and mottling as her cardiac output drops.

Her chest jerks in an agonal breathing pattern. 14/

I yell for the ER attending, and the crash cart with the resuscitation equipment. I also ask if she has any family with her or an advanced directive; she has neither.

And now.... she has no pulse.

“Call a code!”

Suddenly, the room is full of people, and hectic activity. 15/

The ER attending is there and assumes the running of the code, but it’s a team effort.

A Code Blue resuscitation is a highly structured event, with team roles clearly assigned.

Everything from chest compressions to meds to documentation to IV access is quickly delegated. 16/

A nurse is placing a large-bore IV, while the PA is placing an intra-osseus IV directly into the patient’s tibial bone.

I’m first on chest compressions.

I push hard and fast.

A surge of nausea rises within me as I feel ribs crack. 17/

She is in a cardiac arrest rhythm known as pulseless electrical activity or PEA, based on the heart monitor.

As we administer medications, I swap with someone else to continue to push on her chest.

Her thin body ragdolls with the force of the compressions, and I wince. 18/

The defibrillator pads are applied for an attempt to shock her heart’s electrical system as she goes into a different rhythm (known as ventricular tachycardia).

Everyone stands clear.

Her delicate frame jerks as 120 Joules of electrical energy course through her, then 200. 19/

Her rhythm is again erratic. Compressions resume. A breathing tube has been placed down her throat, and she vomited while it happened.

She is also bleeding from her mouth, and each compression brings another pulse of deep crimson.

She is so small in the bed, so frail. 20/

The Code is interminable.

We go through many many rounds of medications, and multiple shocks, and constant compressions. The intensely unpleasant scent of burning skin is in my nostrils.

Blood from a skin tear drips onto the floor, and me.

Sweat trickles down my neck. 21/

Miraculously, she survives.

Her heart finally sustains a viable rhythm and she is rushed to the ICU.

Unfortunately, given the duration of the Code, she’s at high risk for at least some degree of hypoxic brain damage, if she manages to survive her hospitalization. 22/

The rest of the night is mercifully uneventful. Everyone is feeling shell-shocked.

We don’t say much to each other.

I reassure the PA it wasn’t his fault. If she had been my patient, she would have coded on my watch.

Nothing can destroy a psyche like guilt.

We all bleed.. 23/

At the end of my shift I sign out to the incoming resident. She takes one look at my face and says, “I’m sorry.” I am so glad to see her.

On the train home, I’m deeply exhausted.

Smells are lingering.

Nobody pays attention to my sweat-soaked scrubs.

Nor my bloodied sneakers.