My First Code

It was the first night shift of my ER rotation during my third year of medical school and everything was going pretty smoothly.  I had examined some patients, helped put in a few IVs, and tried my hand at my first arterial blood gas.  In the hallway I overheard one of the nurses mention that a cardiac arrest patient was en route to our hospital.  The call originally came in as a patient who was short of breath, but as we would later learn, he crashed pretty quickly and needed CPR.  I followed my attending into the room set aside for critical patients and found what seemed to be the entire ER staff in formation around where the patient’s bed would be in a few minutes.  Within an instant, a gurney was being rolled in by the paramedics as they quickly filled us in on what they knew about the man and his medical history.  Immediately, the nurses and techs descended upon the man and started trying to get IV access, with one person taking over chest compressions and another manning the bag valve mask.  Watching intently, I felt lost, hoping to get involved but unsure of exactly what to do and where to do it.  I was trained in Advanced Cardiovascular Life Support (ACLS), so I was very familiar with the treatment algorithms and medications used in these situations.  My attending asked me to switch places with the nurse doing compressions and I excitedly stepped up onto the stool.  I couldn’t believe that after multiple CPR classes, ACLS training, and many seasons of Scrubs, I was actually pushing on a dying man’s chest in a desperate attempt to keep his blood circulating around his lifeless body.  His skin was cold, his lips blue and his eyes wide open.  I was so focused on my technique I muted the conversations around me.  The entire experience felt a bit surreal.  Performing chest compressions correctly is extremely tiring, but I felt the adrenaline pushing me past my physical limits.  After 2 rounds, I was relieved by someone else.

Because the patient’s specific heart rhythm was not shockable according to the ACLS guidelines, we mostly relied on compressions, making sure the patient was getting oxygen, and the administration of epinephrine, a medicine which improves outcomes in these types of cases.  I remember imagining these situations in my mind many times and for some reason it felt different now than I expected it would.  There was a sense of organized chaos without the desperation that you see on TV and in the movies.  It seemed like everyone in the room knew what was inevitable but we were holding onto a glimmer of hope.  At one point, one of the nurses alerted the team that he felt a faint pulse.  Although we did not feel pulses anywhere else, the ER doctor retrieved an ultrasound machine to visualize the heart to see if it was demonstrating any organized motion.  I remember looking up at the screen and realizing that we were all looking at images of a dying heart, sputtering out its last few disorganized beats.  After 30 minutes of intense resuscitation efforts and a lack of any encouraging signs of life, the patient was pronounced.  The doc and I took off our gloves and left the room.  I was surprised by how little I felt at that moment.  Why was I not emotionally moved by these events?  Was my indifference a result of my medical education?  I felt guilty for not feeling much.  I wondered if the harsh nature of medical training has the potential to mold young students into doctors who no longer feel for their patients.  A few hours into the shift when things slowed down, I got a chance to let my mind wander.  I took solace in the fact that my numbed emotional state after the code was most likely due to my absolute focus on the medical side of the situation, rather than an unwillingness to empathize.  I thought about the patient in a context much broader than the narrow, medical one my mind originally placed him in during our short time together.  Even though I didn’t know him personally, I couldn’t help but think about how his death would affect many people close to him.  I thought about those who would be grieving the next day.  I thought about how he, like all of us, had his own unique struggles, victories and funny stories.  As I drove home from the hospital that morning I thought about how he would never know the extent to which he forever changed a young medical student in a West Virginia emergency room.

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17 Responses to My First Code

  1. Vignesh Doraiswamy says:

    As a fellow med student, I hope you keep writing. My first code changed my life forever. I just sat there crying for a good 10 minutes not knowing why.

  2. says:

    ACLS = advanced cardiovascular life support

  3. James says:

    As Vignesh commented, please keep writing. And you are superman…a super man becoming a super doctor.

  4. Pat says:

    ”and many seasons of Scrubs”

    I like you, keep posting

  5. Great article. I particularly like the lines ” the ER doctor retrieved an ultrasound machine to visualize the heart to see if it was demonstrating any organized motion. I remember looking up at the screen and realizing that we were all looking at images of a dying heart.” It reminded me of something that happend a few years ago.

    Before medical school, I worked in a lab doing cardiovascular research. We used cells harvested from heart transplant patients. When a diseased heart was removed, a team of techs moved in and carefully removed some of the coronary artery endothelial cells and froze them in liquid nitrogen. They shipped me the cells, I thawed them and was able to study them for several divisions before they entered senescence.

    I thawed one batch of cells and I noticed something else in the vial. As I grew the cells, this other material grew too. I was experienced working without antibiotics in sterile conditions so I had seen a couple bacterial infections, but this looked nothing like what I’d seen before. The cells were long dark spindles, much larger than bacteria. I tried to remove the contaminant, but each time it regrew. I figured out what I was looking at was a fungal infection.

    Fungal infections are rare in tissue culture. In the thousands and thousands of experiments I had done, I never had one and neither had my coworkers. It dawned on me that the fungus was from the heart itself. The patient had the fungal infection.

    It was a sad realization. No one would perform a heart transplant on someone with an active fungal infection, so the transplant doctors must not have known. After the transplantation, the patient would be put on immunosuppression and would die of the fungus if they survived the surgery.

    So I am sitting there, looking at these cells. Cells are just cells, they aren’t a person by any stretch. Still, it felt uncomfortable to watch the fungus destroy this person’s last few living cells. To witness that last moment, the “images of a dying heart” as you mention, was particularly meaningful. We think of death as a moment in time, but really it is a progression of system failures. Seeing the last flicker is really something special and haunting.

  6. Wow. I had my first code a week ago and I went through EXACTLY the same things as you described. It’s surreal. It really made me feel better about not breaking down crying and thinking I was being cold. In our case it was a 73 y/o female with a massive hemothorax. We were doing a thoracocentesis (I was super excited to see my first one) when she went into shock. We spent 40 minutes trying to revive her. I’m not familiar with ACLS but I was with basic CPR, and I did a few compressions. Exact same feeling as you of surrealness.

    For me though, the toughest part was watching just how much it affected my resident. None of us expected that code, and he had already had a few codes that week that ended badly. Seeing him so sad was strange, since he’s one of the most confident and strong people I know. I didn’t feel that bad during the hospital stay, but I did cry a bit on the way home thinking about the patient and felt like crap the next morning. Things got better after lunch with the family though.

    Thank you for sharing this.

  7. FYI: epi is used to induce and stabilise V-fib, not to induce a sinus rhythm.

    • Actually we’re both wrong. It doesn’t jump start the heart like I originally wrote, and it doesnt induce V-fib. It is merely a vasopressor that “can improve aortic diastolic BP, coronary artery perfusion pressure, and the rate of ROSC” according to the ACLS manual. Thanks for catching that sir, hope you keep reading.

      • Yes, you want to try to get and maintain a shockable rhythm by improving perfusion of the heart muscle. You won’t be able to improve coronary perfusion enough to get a sinus rhythm with epi alone, though, so ROSC is unlikely. That’s the theory behind it all, anyway, as far as what I was taught. I’m happy to admit that that was one doctor’s take on it, but it was one of those things that has stuck in my mind ever since.

  8. Pingback: Interesting Medical Perspectives | WRT 303.04: The Personal Essay

  9. Charles says:

    Keep writing, I aspire to also become a doctor and am deeply moved and relate to each one of these entries.

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