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t m c » p u l s e | j u ly 2 0 1 7 4 Running My First Code A resident's training kicks in A n e s s a y b y B e n j a m i n G o l d , M . D . "C ODE BLUE, 7 SOUTH. CODE BLUE, 7 SOUTH." I'm up and out of my call room bed before fully regaining consciousness from my light sleep. It's 4 a.m. I should feel ready; I've trained with simulations labs, mock codes, and test questions. I passed my CPR and advanced cardiac life support courses. I've done chest compressions as an intern. But this is different. I'm the resident on call, and if I get there first, I'll be run- ning the code. I've never run one before. I'm terrified. I'm not ready. Code Blue is essentially a euphe- mism for being dead. While it techni- cally means "medical emergency," it has come to mean that someone in the hospital has a heart that has stopped beating. The outcome statistics are grim. Even with perfect CPR, in- hospital cardiac arrests have a roughly 85 percent mortality. Those patients who somehow survive are often left with irreversible brain damage and lie in comas. Few ever leave the hospital. Death is greedy. Still, we have to try. I run down the corridor toward the patient's bed. My sneakers make little squeaks against the linoleum floor, echoing off the walls of the mostly quiet hospital. My mind is a zoo. The flooring makes this place sound like a gymnasium. How many minutes in between epinephrine injec- tions again? I should run more— I'm already out of breath. Think of causes, causes. The 5 Hs, the 4 Ts. What was the room number? I burst into the room, out of breath. It is pure, primordial chaos. I'm hit with the sounds first. Bed alarms, blood pressure alarms and heart rate alarms blare insistently, a Greek chorus to the unfolding drama. A string of unan- swered questions hangs in the air like a heavy fog. "Can someone page anesthe- sia?" "Where's the cards fellow?" "Do we need femoral access?" "Where's the EKG?" "Chest X-ray, stat!" "Who spoke to the family?" "Is this guy DNR?" "Who has a hemoglobin?" "Is he on blood thinners?" "What's his history?" I can hardly hear myself think. This must be what it's like in the cockpit of a nosediving plane. I take stock of the room. One nurse is on the bed performing chest com- pressions. A second is trying to steady the man's arm to place an IV, but is hav- ing a hard time. A third is struggling to hold an oxygen mask to the man's face while squeezing an ambu bag. Pharmacists are rifling through a large red chest of medications. Someone is desperately clicking at a frozen computer in the corner of the room. A gaggle of nurses, aids, and respiratory therapists stands at the door. The patient is staring straight at me. His eyes are glazed and unfocused. He's an older white man with a shaggy beard and sunken temples. His skin is a uniform, a lattice of mottled blue- gray. His head flops every second or so from the force of the compressions. Currently, he's turned to face the door, looking at whoever crosses the threshold. I take a deep breath. "Is anyone running this code?" There is only silence. Beautiful, terrifying silence. No one is standing at the foot of the bed, which is where the code leader would normally stand. I'm going to have to run it. It's only a second or two, but the moment stretches and stretches. And seconds matter. The brain is the most adaptable and responsive piece of biological engi- neering. It responds in real time to the binary input of billions of neurons to create sight, sound, and sensation. It can accommodate elevation changes, pH changes, temperature changes, vol- ume changes, infectious states, starva- tion, and fight-or-flight responses. But it has an insatiable demand for oxygen. There is no safe-mode, no low-power state. Four minutes without oxygen destroys 76 years of life. Here we go. "I'm Dr. Gold, I'm leading this code. You, keep time. You, continue compres- sions. Let's hook up the pads. Draw up one milligram of epinephrine ..." The training kicks in hard. Good hard chest compressions, with epineph- rine every two to five minutes. Pulse checks every two minutes. Shock the heart if it's ventricular tachycardia or ventricular fibrillation—a call that will be made by me. I hear a faint crinkling sound with every compres- sion. Ribs breaking. Then a voice: "Two minutes, doctor." "Pulse check!" The compression stops. Hands immediately reach for the femoral and carotid arteries, straining to feel the reassuring rhythmic pulse of life. All eyes turn to the cardiac monitor. It's hard to interpret while compres- sions are going, but now it's clear. The heart's electrical system normally con- ducts each beat with fanatical precision. Now it is in disarray, starved from a lack of oxygen. It's v-fib. Disorganized, random electrical discharge that is unable to produce heartbeats. "It's v-fib." I say it quietly, almost to myself. No one moves. "V-fib," I say again, louder. Still noth- ing. Why aren't they moving? Oh, right. They're waiting for me to say something. "Continue compressions. Charge the defibrillator. We're going to shock." We shock. The patient's body tenses suddenly and violently. It's strange to see him move so much. Strange that our muscles run on electricity. Strange that to save someone you hook them up to an outlet. We're more machine than The patient is staring straight at me. His eyes are glazed and unfocused. He's an older white man with a shaggy beard and sunken temples. His skin is a uniform, a lattice of mot- tled blue-gray. His head flops every second or so from the force of the compressions.