Sunday, January 4, 2009

My first code blue

A week ago I coded a patient for the first time.  (For non-medical people, a code blue or "coding" a patient means essentially that a patient is dying and needs resuscitation.)  And to make things worse, my patient was only 11 years old.

Stephen had come to the hospital in critical condition about 2 weeks prior to the code event.  He had gotten a very serious infection resulting in septic shock.  He was found unconscious and when he came to the hospital he had an oxygen saturation of 35% and a pH of 6.9 (both of these numbers are nearly incompatible with life).  He was resuscitated the first night there in the hospital and miraculously seemed to pull through the initial injury.  He was placed on a ventilator and received all kinds of drugs and blood products to keep him alive.  When I left for Christmas, he was still very ill but relatively stable.

I came back on December 28, a few days after his 11th birthday.  Not only did Stephen spend Christmas hooked up to life support in the Pediatric Intensive Care Unit (PICU), he also spent his birthday there.  When I returned I found him on higher vent settings than when I'd left (not a good sign) and also on dialysis because his kidneys were starting to fail.  At this point the prognosis was becoming more and more grim.  His parents knew, but were holding on to the hope that Stephen might surprise all of us.  He had been a premature baby who had several complications in the NICU and doctors had predicted that he probably wouldn't live very long - Stephen proved them wrong.  He was a rambunctious boy whose little sister adored him.  Although he had a few medical problems stemming from his history of prematurity, he was otherwise a typical boy.

The next morning, December 29, I arrived to the PICU at 6:00 am to start my shift.  Stephen was on even higher vent settings and my colleague reported to me that he had been unable to correct Stephen's acidosis.  His lungs were starting to fail and were unable to exchange carbon dioxide for oxygen, so he was accumulating large amounts of CO2, which gets converted to acid.  He was also not oxygenating his tissues, so his body was using anaerobic metabolism, which also results in acid.  This is very taxing on the body after awhile, especially the heart.  We had maxed out all of his vent settings, as well as his meds.  Around noon on that Monday, Stephen's time came.  I looked at the monitor and noticed his CO2 was now in the 150's (normal is 40), and his oxygen saturation was in the 50's (normal is 100%).  His lungs were failing and his heart was starting to tire out.  Sure enough, about an hour after his O2 sats had dropped his heart rate started to drop as well.  It happened quickly.  When that happens the monitor makes this awful sound - three loud beeps, over and over.  One of the NICU nurses once told me it sounds like it's saying "I am dead, I am dead."  I looked around and saw my own feelings reflected in everyone else's faces: fear, panic, apprehension about what to do.  Thankfully, my PICU attending was there and she immediately took charge.  She began to bark off orders and we all immediately returned to our senses - no time to process emotions, now we just had to act.  One of the nurses wheeled the code cart in, I grabbed the back board and placed it under Stephen's back.  One of the nurses began chest compressions.  Another nurse started opening up code meds and pushing epinephrine.  Still, the monitor kept beeping "I am dead, I am dead".  My attending ordered me to keep an eye on the monitor and read off the numbers, then told the nurse to stop compressions and check for a pulse.  No pulse.  She looked at me and told me I was up next for chest compressions.  I jumped up to the bed, thankful to have a role and to do something useful.  I began going through the motions, just like I'd been trained.  I tried not to pay attention to the sunken appearance of his chest and the bruises all over.

Then I heard a sound I don't think I'll forget for a long time.  Stephen's parents had rushed to the PICU as soon as they were informed he was being coded.  In the middle of my chest compressions I heard a loud, sobbing wail come from the nursing station.  I looked over and saw Stephen's mom clutching her chest, crying uncontrollably, falling to the floor in horror.  It was almost nauseating to witness her pain.  I felt a hard knot in the pit of my stomach, but had to keep doing what I was doing.  It was one of the hardest things I've done yet in residency.

The rest of the code was like a dream - or rather, a nightmare.  Everyone did their job and we managed to pull Stephen through... the first time.  His heart started beating again and we stopped compressions.  But we knew it wouldn't last long.  My attending talked to Stephen's parents and they agreed that if/when it happened again, we would try everything we could for ten minutes but if Stephen still wasn't doing well, we would let him go.  And just as predicted, Stephen began to crash again.  Around 1:30 pm it happened the same way - his oxygen saturation dropped, then his heart rate followed.  Once again we began chest compressions and started pushing meds.  This time it was even worse because Stephen's mother came right up next to him, holding his hand and crying "Please Stephen, please don't go!!  I love you so much!!  Please baby!"  I stood right next to her checking for a pulse in between compressions and I hated having to say in front of her, "No, still no pulse."  After ten minutes, we stopped compressions and I checked again.  No pulse.  I listened with my stethescope - no heartbeat.  The monitor was flatlined.  We stopped.  Stephen's mother wailed again.

The rest of the afternoon was very strange.  I felt like I wasn't really there.  Like I was outside of myself, watching myself go through the administrative tasks of calling the organ donor service and writing a death summary.  After the adrenaline had worn off, I felt extremely exhausted all of a sudden.  And numb.  I saw Stephen's parents walking around in shock and pain, and I felt numb.  I wondered what was wrong with me.  Had I become calloused?  Why wasn't I feeling anything?  I saw nurses crying, but I felt nothing.  Just shocked.

It was on my drive home that it hit me.  I was staring straight ahead, replaying the scene in my head.  I was imagining what it must've looked like for Stephen's mother to walk in and see me standing over her son's chest giving compressions and my attending yelling for code meds to be given.  Then I thought about what it would've been like if it were my little brother on that bed.  Stephen was only a few years younger than my brother Jacob.  I couldn't even bear the thought of seeing Jacob like that... swollen, bruised, eyes falling open, skin turning blue, getting compressions and hearing the monitor beeping "I am dead".  I lost it.  I started crying uncontrollably.  I cried and cried, all the way home.  I had a hard time sleeping that night.  Thankfully I wasn't alone.  My roommate kept me company.  But I got into my bed and cried myself to sleep.

The next few days were strange.  I thought I was okay but then all of a sudden I'd see the image of Stephen dying in my head and I'd be overcome with grief again.  I broke down crying to one of my mentors.  She was gracious and listened to me with deep empathy.  I cried myself to sleep again the second night after Stephen died.

I'm doing better now, but my heart still hurts for Stephen's family.  I pray that God is bringing them comfort and that Stephen is in a better place now.  You know, as difficult as this week was I am thankful that God gave me empathy for my patient.  I wanted to write about it so that I will not forget Stephen and what I learned from his death.  I know I will probably see more children die in my life - unfortunately it comes with the job that I've chosen.  But I don't want to ever forget the pain it causes the family.  I don't want to grow desensitized and lose my empathy.  True, it is something doctors have to deal with all the time so I will need to learn to cope with it and move on.  But for each patient's family, it isn't something that happens all the time.  It is a life-changing, heartbreaking event.  I hope that I can always remember that.

May Stephen rest in peace.


g9ine said...


Thank you for sharing this.

Jamie said...

Linda, that is a very sad story. I can't imagine what it's like to go through that.

Sarah said...

Wow, Linda. I am wiping away tears as I read your entry. Though I cannot even imagine, I am thankful you are the doctor and parents have you, an empathetic, follower of Christ treating and loving their children. On another note, I'm bummed our Christmas breaks didn't coincide in San Antonio! I would have loved to meet up with you. Hope everything is going well.