Winning the round in a patient’s fight to live

Some of our best moments as medical professionals come at the worst moments for patients. This was one such moment.

He had a foot in the grave, and the other held firmly in our hands; we had caught hold of it as he slipped over the edge of the abyss and we were not letting go. His heart and breathing had stopped and he was in full cardiopulmonary arrest. Some medical professionals call this a “Code 99,” others call it a “Code Blue” or a “Code,” but most of us call it “SOL” because we know the chances of survival are slim enough that you would not want this guy to have your name in the Secret Santa gift exchange.

If this was television the cameras would have been doing close-up shots of our tense faces, the orchestra would have played a dramatic score with a pounding beat, and Tom Cruise would be playing me. But it wasn’t TV; the stage was a small room in a small hospital in the sticks of Maine, the soundtrack was the rhythmic pounding of CPR, and the team was playing the ultimate game of Survivor with quiet desperation. The only thing the world would see of this “game” was an obituary if we failed.

I would have taken the nurses helping me that night over the best nurses working in the best hospital in the world. They knew this drill cold; by the time I got to the patient’s bedside they were wiring him with heart and oxygen monitors, had compressions going on his chest, and were telling me about him even before I got a chance to ask what had happened. They were hanging a second IV line too, because one IV in a code is one lifeline too few.

It may be a cliche to say it, but it’s a cliche because it is true; time really does feel as though it slows to a crawl at such moments. That’s in part because thoughts zing around your head like bombarding electrons, and decisions of someone’s lifetime get made in seconds:

Speed up the chest compressions and make them deeper, because we have to circulate the medicines we are pushing through the IV.

Have to intubate fast, but need to slow down and make sure we are ready to do that. Pick the right size breathing tube, make sure the light on the laryngoscope works, check the cuff on the breathing tube, get suction set up in case the patient’s airway is full of stuff, stop CPR and take a shot at putting in the airway but don’t stop for too long because every second without a compression is a brain starving for oxygen. Hold your breath while you try to put the breathing tube in, so you know how long the patient has been without air while you try.

The tube is in, but is it in the right place? Why aren’t there breath sounds in the left lung – is that because I put the tube down so far it went into the right lung, or is the left lung deflated and that’s why the patient coded in the first place? Is the tube in the esophagus – I don’t think so but if you put the tube in the esophagus instead of the windpipe, and miss that mistake, you can just call it a day, Gracie.

What caused this patient to go into cardiac arrest? Check the abdomen, check the lungs, check the chart for some lab test abnormality that helps explain what happened, ask the nurses what they think – I don’t find something obvious that we can fix but if we miss that something all of this will be for naught.

Push more epinephrine- How long ago was the last dose? – and more fluid – Are both bags of saline running wide open? – because this all probably started with septic shock, and it’s time again for atropine 1 milligram again to speed the heart rate up. Is that 2 milligrams total so far?

Then, suddenly, the patient’s heart started beating again, but rapidly and maybe too rapidly. We checked the patient’s pulse – it was there and bounding. We all watched the heart monitor as though it was an electronic Wizard of Oz with all of the answers; if the rhythm was ventricular tachycardia we would be reaching for the defibrillator to shock the heart, and likely to finish this night with long faces and a body bag. If it was sinus tachycardia, on the other hand, we may have won the first round in this patient’s fight for more life to live.

We watched the heart monitor, chest compressions stopped, room silent, patient unconscious, waiting for the mighty Oz to speak. The whole world outside this room did not exist. Oz answered; it was sinus tachycardia, the sweetest thing that ever blipped. The code was over and the patient was alive, so we turned to the work of securing his lines, airway, oxygen, and transferring the patient to a regional medical center. We had no idea if he would survive long term, but we were the first link in his chain of survival, and had done our job tethering him to this world for a chance at another Christmas.

At such moments it seems as though the world should pause to celebrate a life not lost, if only for a moment. It never does, but as we walked out of the patient’s room back to the routine of the rest of the night’s work, another patient who had seen some of what was going on from his room across the hall told us “You all did a good job, a good job.”

Damn straight we did, Jack, and thanks for noticing.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.