Twelve from Hell

8:25 PM

 

I left the medics without getting their final report since they had to find a place to put their patient and it’ll be a while until I can see her. I heard someone shout, “we need a doctor in here STAT,” and I walked behind curtain number four to find one of our Respiratory Therapists beginning to bag a guy who looked to be about forty. Bagging involves placing a mask over his nose and mouth and forcing air through a football sized bag into his lungs in order to keep him alive. Jaime, the Therapist says the patient is an asthmatic whom the triage nurse had ordered a breathing treatment on when he presented short of breath. The treatment had been completed and when she removed the aerosol device from his mouth and asked how he was feeling, he stared ahead with a blank expression. 

 

“How you doing sir?” I shouted. I waved my hands in front of his face but he was completely out of it. The condition is called CO2 narcosis and occurs when the ability to move air in and out of the lungs is so impaired that dangerously high levels of carbon dioxide build up in the body and the patient is moments away from a cardiopulmonary arrest. Nothing stirs up the bee hive that is the Emergency Room like a code. I never like calling them in the ER because usually we have everyone and everything we need in the room already. Nothing epitomizes the life and death struggle that is emergency medicine like a code. I’ll never forget my first one many years ago.

 

It was the early eighties and I had not yet embarked on my medical training. Uncertain what I wanted to do since becoming a grownup I walked into a hospital and took a job as a Respiratory Therapist. It was a great introduction to medicine and gave me my first taste of caring for others. I was put through a CPR class and was assigned to the hospital’s Code Team. My job was to respond to all in-house codes and assist in CPR and airway management including setting up and maintaining the respirators. Sounds impressive given the fact that prior to walking into the hospital I was barely able to apply a band-aid and had never seen a corpse never mind had the responsibility for resuscitating one.

 

The hospital itself was as small time as it got. Mostly older patients with even older doctors but magnificently young nurses who were my age and did I mention magnificent? So here I was fresh off my CPR training and awaiting my first cardiac arrest. I should mention that I’m scared to death since I’ve never seen a real deceased person other than at a funeral home and those folks were very dead as opposed to newly dead with a chance to be brought back to life if the CPR works. At the time I didn’t realize that the CPR rarely works and despite heroic measures on the part of everyone on the code team once the heart stops it rarely restarts and goes back to normal.

 

So I was sitting at the nurse’s station doing the one thing they did not need to teach me when I took the job. Flirting. It being a Catholic hospital every floor was run by a nun and if there’s anything that nuns are good at preventing, it’s flirting. I was just about to be thrown off the floor for the third time that day by Sister Agnes when over the intercom I heard, “Code Nine Fourth Floor” and at first it doesn’t register that this is my debut. Sister Agnes gets a relieved look on her face since my departure means she won’t have to separate me from the nurses.

 

My partner is a grizzled old vet who’s worked for years in the hospital and she sprints past the nurse’s station at mach one to the staircase and I’m right on her heels. We arrive on the fourth floor and there is a sea of humanity blocking the corridor but as my partner Cassy announces “Code Team” the seas part and we whisk our way into the room to find several nurses and aides starting to do CPR. Cassy grabs a resuscitation bag and begins to fit the mask over the face of a man who looked to be eighty years old. In retrospect he was probably younger than that but at the time I didn’t realize how being dead could age a person. A physician, whom I’ll call Dr. Dim, arrived who had heard the code called and then followed the commotion to the room and he suddenly found himself the senior member of the team and thus running the code. No one there questioned his authority and being the only doctor to respond to the code immediately put him on the short list of people in charge at a code. The fact that he had no clue what to do was lost on everyone there including me. In the Code Team pecking order he had MD after his name so he was the expert.

 

At any rate it was going the way I would learn most codes went which is to say no heart activity and no respirations and thus it came time to place an endotracheal tube into the victim’s airway. Most times that would fall to the Anesthesiologists who were expected to respond to the codes. This day for whatever reason, no one from Anesthesia showed up and the code was about to grind to a halt due to no one being able to intubate the patient. I was clueless as to the procedure and had only recently learned how to connect a resuscitator bag or respirator to the tube once it was passed.  The hard part was threading the tube through the mouth and down the back of the throat into the trachea. Since at this point no one with any more senior experience had arrived, the team turned collectively to Dr. Dim and waited until he realized it was he who was doing the intubation. 

 

Dr. Dim fumbled with the light source for a good thirty seconds until one of the older nurses removed the scope from his trembling hands and correctly assembled it. He now moved to the head of the bed and positioned himself above the patient and painstakingly moved the light source into the patient’s mouth which looked like a moving target given the tremors assaulting his hands. He rapidly and as it turned out, blindly, passed the tube into the back of the patient’s throat and then waited, unsure of his next move. For reasons unknown to this day the bag we were using to ventilate the patient was inexplicably lost as Dr. Dim passed the tube. I probably remembered only one or two facts from that first ever CPR course but I did remember that you could ventilate a victim of cardiopulmonary arrest by blowing down the endotracheal tube. What I didn’t know but was about to learn was that endotracheal tubes intended for the airway far more frequently are misplaced into the stomach when the person passing the tube is inexperienced or in this case just plain stupid. 

 

The next series of events had a time span of less than twenty seconds. I bent forward and placed my mouth over the endotracheal tube and gave it a mighty blow. My exhalation into the tube was met with an immediate rumble and as inexperienced as I was I knew we had a problem. Instantaneously with the rumble came an absolute geyser of vomitus that immediately filled my mouth. In the next moment I turned away from the bed and spewed a mouthful of yellow cling peaches onto the wall. That was followed by one of the younger nurses grabbing a garbage can and selling the Buick until her lunch was purged. Dr. Dim had seen enough and the time of death was announced ending the code. I spent the next five hours gargling with bottle after bottle of the hospital’s give away mouth wash. You would think with that kind of introduction to medicine I should have given serious consideration to another profession but no one had ever accused me of being a quick learner. 

 

Meanwhile back at my current job I tell Jamie to,”Call a code,” as I took over the bagging and got him in a recumbent position and prepared to intubate him. Within seconds the room was mobbed with ER staff nurses, physicians who were in the ER to admit their patients, lab and X-ray staff and more Respiratory Therapists. It took a few minutes to get the tube prepped, the suction connected and the non essential people out of the room. I was finally ready to pass the tube into his trachea when the patient decided this would be a good time to purge his lunch. If you’re sensing that this occurs frequently when intubating you are correct. It rarely surprises me anymore but the problem it creates when the mouth and throat are full of vomitus makes the procedure far more risky since there is now a chance that the victim will end up shooting some of that food into his lungs. The second problem is the visual difficulty that the vomit poses. In airline terms the landing went from a windless limitless clear sky day to a zero visibility, snowy, whiteout, instrument only landing.

 

I was able to blindly pass the tube and within a few minutes he was on a ventilator and his breathing was being controlled by the machine. We placed him on IV Propofol to keep him unconscious and ordered blood work and blood gases as well as a chest X-ray. He would be admitted eventually to the ICU but we’d be managing his critical status in the ER for hours while we got a Pulmonary doctor to come in and admit him. 

 

In the interim I headed out to the Waiting Room to speak with his wife who had no clue how dangerously close she came to being a widow. I tried to prepare her for the shock of seeing her young husband on the ventilator but despite my attempts to paint a graphic and grim picture she literally collapsed into my arms when she saw him. The next several minutes were spent making sure she didn’t pass out since the last thing I needed was another patient. My rule for that is they had to hit the floor to get a chart generated. Biting the dust in a chair or my arms keeps them out of the “to be seen” rack. Once I got her seated and focused on what we were doing, she seemed better and I left her with a...