The First Code

I am physically and emotionally exhausted. It's only week 4 of a 10 week rotation, and I'm dragging my feet, counting down the days, and watching the clock during the day. For me, this is worse than surgery. It's the hours, yes. Most weeks it's 70 hours, and if long call falls on the weekend (which is does for at least 5 weekends out of the 10 weeks) then it's 80 hours of work. It's the patients also, not that I blame them for being so very sick. Heart disease, kidney disease, lung disease, liver disease, blood disease....all the diseases that I have learned about in the last 2 years of lecture and self-study. I try to remind myself that the hours spent at the hospital, and with these sick patients, will help me to become a better doctor. Their suffering and diseases will help me to do better on my next board exam. I try to daily keep up with the vast array of knowledge that I am reminded I do not remember, or have never even learned. Yes, I am trying to see the cup as half full, but the truth is that I am almost completely empty.

I'm still trying to process the first code I have ever seen. Code is synonymous with some one's heart stopping, and the subsequent attempt to resuscitate the patient. It occurred 3 days ago, on our long call night, and the images still flash in my mind, right before I fall asleep at night, right at the time that I am most wanting to shut out the pain from my daytime hours.

I see her listless hand flopping up and down against the sheet, in between the ten or more doctors that surround her bed, as my senior resident does chest compressions. I glimpse her face, stark in the absence of life, and yet her eyes are open. I see one of the doctors intubate her with a breathing tube. I see yet another use a drill to put in IV access into the tibia bone of her lower leg. I hear the shouting of orders from the doctor leading the code. "How much epi has been given?" "Stop compressions! Check for pulse!" "More epi!"

Thankfully she wasn't my patient. I'm not sure that I am ready to loose a patient. She "belonged" to another student, who had seen her just an hour before, and although the patient was sick enough to be in the hospital, she certainly didn't look like some one who's heart was soon to stop. We stood in the hallway, running to get supplies if we could, otherwise feeling completely powerless, not only in our ability to help, but also in our ability to turn away. It was like watching a car accident in process. I couldn't turn away, certain that I would miss something, certain that she would definitely be gone if I walked away.

45 minutes passed. We did get some electrical activity in her heart, from the drugs given, but there wasn't enough to coordinate contractions to get the blood moving into her now floppy limbs. The lead doctor eventually decides it's time to stop. One by one, each of the doctors relinquish their duties. The anesthesiologist takes out her breathing tube. The heart monitor electrodes are peeled off her skin. The IV line that was drilled into her leg is removed. One by one they all leave the room. The nurses stay behind to continue cleaning her up, to prepare her for her family who is on the way. The same family that had just left hours before, with plans on returning in the morning to find out what we had discovered about her disease process. I waited in the hallway until the nurses closed the curtain. I was allowed to watch this heroic and seemingly barbaric attempt to bring her back, and yet was not allowed to be a part of what I hoped was a gentle apology for what we had put her body through. And that's just it. At the point of the attempted resuscitation, it was just her body, so clearly empty of life.

Her family showed up and were taken to the room. Crying could be heard from the hallway. I don't know that I could ever get used to telling someone that their loved one died. How will I keep the tears from my own eyes? We have no idea why she died, so unexpectedly, and will never find out as the family did not agree to an autopsy. We returned to our workroom at midnight, shocked, tired, and still with lots of work to do. We talked about what we could have missed. What signs did she give us that she was this close to death? What lab tests could we have ordered to give us a better sense of her sickness?

If that wasn't enough for one week, we got another very sick patient, dying of liver failure. At least with this patient, it was clear that she was going to die, it was just a matter of when. She lasted about two days in the hospital, as her organs shut down one by one. First her liver went (she was very yellow from jaundice), then her kidneys failed (no more urine production), her heart faltered (blood pressure dropped), and her lungs struggled for the last breaths of her life. We went into the room yesterday morning, to give the dismal prognosis to the family, telling them she was not a candidate for liver transplant, that her organs were shutting down one by one, that it would most likely be hours, and not days, before she passed. The tension and grief in the room was palpable. All of her children were there, as well as both of her parents, as she was a young fifty something year old woman. The only way I could keep my own tears from falling was to pretend to not be in the room. To not be present at all. Will I ever get used to this? And do I even want to? For now, I return home everyday with a heavy heart, and reluctance to get out of bed the next day and do it all over again.