My Job
"That pit in your stomach on the elevator on your way to a Code Blue is one-of-a-kind. The sick, sinking feeling of dread, anticipation, excitement: you're on your way to save a life or witness death. Walking into the unknown makes me queasy, but I have to admit, it's what makes my job interesting.
Every month, a different ICU's charge nurse in the hospital holds the code beeper. When it alarms, you're called to drop everything you're doing and spring into action. Every code on a med-surg floor must have at least one ICU nurse present who is certified in Advanced Cardiac Life Support. That day (actually, most days) it was me.
Codes on "the floor" are a clusterfuck, for lack of a better word. It's utter mayhem, with over-worked/under-staffed nurses scrambling for supplies they didn't know were needed, upper-year residents trying to call the shots all at once, students tip-toeing to get a look at the action, and little tired me wishing all these cooks weren't spoiling the soup at 7:30 AM.
"Does the patient have IV access?!" is always the first question I have to yell above the chaos as I push my way onto the scene. As usual, no one fucking answers and I have to fight my way closer to the bed to find out. Fortunately, in this case, the patient did have an IV. What he did not have was a pulse or an airway. Chest compressions and bag/mask ventilation were in progress as I made it to my spot on the stage: The 20 gauge heparin lock IV on the patient's right forearm. It's my job to push the drugs that will hopefully jumpstart this patient's heart and cause him to experience return of spontaneous circulation. I push 1mg of epinephrine into the vein as different medical students pound on this unfortunate man's chest to circulate the drug through his body. They form a short single-file line, each waiting ashen-faced and afraid until the student ahead of them grows too tired to effectively pump this guy's useless heart any longer. The transition is seldom graceful, and time lost is tissue lost, but we are a teaching facility.
"Let's hold chest compressions for a rhythm check!" the chief resident demands, switching his focus to the heart monitor on the code cart. I check for a carotid pulse and feel none.
"I don't feel a pulse," I say, to no one in the room's surprise. A jagged line on the heart monitor is interpreted as ventricular fibrillation, a non-life-sustaining heart rhythm that warrants a shock from the defibrillator. The defibrillator, attached to adhesive paddles on the patient's chest, alarms to tell us it's charged to 200 joules, and to get the fuck off of the patient unless we want to get zapped. Clear. Shock delivered. Flat line. Resume compressions.
The air smells like burnt hair.
More epinephrine. More chest compressions. 300mg of amiodarone. An accucheck reading a blood sugar of 30. An amp of dextrose 50%.
By this time, the anesthesiologist is on the scene to place an endotracheal tube, or "breathing" tube, and is demanding suction to clear the patient's airway. NOW! The wide-eyed night shift nurse brings it, looking terrified and even younger than me. You can see it all over her face: the words, "How could this happen? What did I miss?"
The what-did-I-do-wrong pit in the stomach trumps the going-to-a-code pit, big-time.
A glimmer of hope, the breathing tube is placed and after one more shock, the heart rhythm converts to sinus tachycardia on the monitor. A palpable pulse at the carotid artery! I even auscultate manual blood pressure of 153/70, this guy is perfusing the shit out of some tissue!
"We need to get this guy to the ICU right now!" the chief resident interjects. I tell them bed 10 is open and that I need a team with me in case shit does down on the elevator. It's 7 floors down to the ICU and I don't want to be stuck with a group of thumb-sucking baby doctors fresh out of school and a fumbling agency respiratory therapist who's likely to accidentally extubate this patient in transit, but that's what I get.
We all make it to bed 10 alive and my ICU doctors and nurse manager meet us there. The blood pressure in transit had dropped to 89/43, I know we need to act fast.
We get the patient onto our bed, and hook him up to our wall monitor. It's hard to interpret whether the patient's rhythm is as jagged as it is on the monitor due to all the movement and activity surrounding him, or if something more is going on. The carotid pulse is thready at best. I recycle a blood pressure, it reads 32/12.
I lose the pulse. Fuck. GodDAMNIT.
"He's coding again," I announce, initiating chest compressions. It's 8:15 AM and this guy has already died twice."
This was my patient. I wrote this maybe 5 years ago, just thinking of the day-to-day things I see in the unit. I wrote another story about the patient I assumed care of the very next day: a liver failure patient with huge esophageal varices who bled out and died. I wrote about the metallic smell of a room where there's been massive bloodshed, the rhythmic drip drip drip of blood from the bed to the floor like a sick metronome, the transition of skin tone from yellow to white to gray as we squeezed unit after unit of blood product into him in vain.
I had learned a lot before these stories and I've continued to learn a lot since them. The things I've seen and the situations I've guided patients and their families through have put so much of what I used to get frustrated and angry and sad about in the past into perspective. I grew up in the ICU. I've found challenge here. I've found balance here. I've become fluid here, going with the flow, sometimes crashing. It's influenced so much of who I am now at 31.
I guess it makes all the "melodrama" of my teens and early 20s (as written in livejournal) worth it.
Every month, a different ICU's charge nurse in the hospital holds the code beeper. When it alarms, you're called to drop everything you're doing and spring into action. Every code on a med-surg floor must have at least one ICU nurse present who is certified in Advanced Cardiac Life Support. That day (actually, most days) it was me.
Codes on "the floor" are a clusterfuck, for lack of a better word. It's utter mayhem, with over-worked/under-staffed nurses scrambling for supplies they didn't know were needed, upper-year residents trying to call the shots all at once, students tip-toeing to get a look at the action, and little tired me wishing all these cooks weren't spoiling the soup at 7:30 AM.
"Does the patient have IV access?!" is always the first question I have to yell above the chaos as I push my way onto the scene. As usual, no one fucking answers and I have to fight my way closer to the bed to find out. Fortunately, in this case, the patient did have an IV. What he did not have was a pulse or an airway. Chest compressions and bag/mask ventilation were in progress as I made it to my spot on the stage: The 20 gauge heparin lock IV on the patient's right forearm. It's my job to push the drugs that will hopefully jumpstart this patient's heart and cause him to experience return of spontaneous circulation. I push 1mg of epinephrine into the vein as different medical students pound on this unfortunate man's chest to circulate the drug through his body. They form a short single-file line, each waiting ashen-faced and afraid until the student ahead of them grows too tired to effectively pump this guy's useless heart any longer. The transition is seldom graceful, and time lost is tissue lost, but we are a teaching facility.
"Let's hold chest compressions for a rhythm check!" the chief resident demands, switching his focus to the heart monitor on the code cart. I check for a carotid pulse and feel none.
"I don't feel a pulse," I say, to no one in the room's surprise. A jagged line on the heart monitor is interpreted as ventricular fibrillation, a non-life-sustaining heart rhythm that warrants a shock from the defibrillator. The defibrillator, attached to adhesive paddles on the patient's chest, alarms to tell us it's charged to 200 joules, and to get the fuck off of the patient unless we want to get zapped. Clear. Shock delivered. Flat line. Resume compressions.
The air smells like burnt hair.
More epinephrine. More chest compressions. 300mg of amiodarone. An accucheck reading a blood sugar of 30. An amp of dextrose 50%.
By this time, the anesthesiologist is on the scene to place an endotracheal tube, or "breathing" tube, and is demanding suction to clear the patient's airway. NOW! The wide-eyed night shift nurse brings it, looking terrified and even younger than me. You can see it all over her face: the words, "How could this happen? What did I miss?"
The what-did-I-do-wrong pit in the stomach trumps the going-to-a-code pit, big-time.
A glimmer of hope, the breathing tube is placed and after one more shock, the heart rhythm converts to sinus tachycardia on the monitor. A palpable pulse at the carotid artery! I even auscultate manual blood pressure of 153/70, this guy is perfusing the shit out of some tissue!
"We need to get this guy to the ICU right now!" the chief resident interjects. I tell them bed 10 is open and that I need a team with me in case shit does down on the elevator. It's 7 floors down to the ICU and I don't want to be stuck with a group of thumb-sucking baby doctors fresh out of school and a fumbling agency respiratory therapist who's likely to accidentally extubate this patient in transit, but that's what I get.
We all make it to bed 10 alive and my ICU doctors and nurse manager meet us there. The blood pressure in transit had dropped to 89/43, I know we need to act fast.
We get the patient onto our bed, and hook him up to our wall monitor. It's hard to interpret whether the patient's rhythm is as jagged as it is on the monitor due to all the movement and activity surrounding him, or if something more is going on. The carotid pulse is thready at best. I recycle a blood pressure, it reads 32/12.
I lose the pulse. Fuck. GodDAMNIT.
"He's coding again," I announce, initiating chest compressions. It's 8:15 AM and this guy has already died twice."
This was my patient. I wrote this maybe 5 years ago, just thinking of the day-to-day things I see in the unit. I wrote another story about the patient I assumed care of the very next day: a liver failure patient with huge esophageal varices who bled out and died. I wrote about the metallic smell of a room where there's been massive bloodshed, the rhythmic drip drip drip of blood from the bed to the floor like a sick metronome, the transition of skin tone from yellow to white to gray as we squeezed unit after unit of blood product into him in vain.
I had learned a lot before these stories and I've continued to learn a lot since them. The things I've seen and the situations I've guided patients and their families through have put so much of what I used to get frustrated and angry and sad about in the past into perspective. I grew up in the ICU. I've found challenge here. I've found balance here. I've become fluid here, going with the flow, sometimes crashing. It's influenced so much of who I am now at 31.
I guess it makes all the "melodrama" of my teens and early 20s (as written in livejournal) worth it.