I am currently in a VA (Veteran's Administration) hospital for my second month of medicine after a month in a public hospital. The population is very different - mostly older men, usually Caucasian, who are (obviously) veterans. There are three medicine teams, each named after a prominent physician of the hospital. Every third day we are designated as the "rapid response" team for emergencies in the hospital.
Today, we had two simulated emergencies, three false alarms, and one full-blown code. Luckily, we had a simulation early in the morning with two scenarios: one with a seizing "patient" (robotic mannequin), and one with a "patient" who lost a pulse post-surgery. In the first, I noticed that the patient had what looked to be a pager attached to his hip under his gown. I was confused and began to look at it, but I got distracted when the team leader told me to look up the information for drugs in a seizure. The patient kept seizing, even after we kept upping the doses of anti-seizure medications. In the end, it turned out that this "pager" was in fact an insulin pump, the patient had type 1 diabetes mellitus, and we had missed that he had an excess dose of insulin and was hypoglycemic (had low blood sugar, which can cause seizures).
The leadership talked about "learning scars" and that we would remember the results of those simulations forever. What I learned was that it was important to speak up and help the team leader keep situational awareness - even if I felt that as a medical student, I had no idea what was going on.
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After three false alarms for rapid response in the lobby, we were called to a rapid response on the medicine floor. It was an older man who had a gastrointestinal bleed and was found to have blood in hi stool. His blood pressure was dropping, and when he arrived, he was groaning and crying out for us to do something because he felt dizzy, even lying flat on his back. He had already received one unit of blood. I fished my bag of blood draw supplies out. Each morning that our team was on rapids, we medical students would carefully comb through the supply room to create or resupply those bags with everything needed for a set of blood draws. But although I had brought bags of supplies to multiple rapids, for the most part they simply functioned as extra supplies for when I missed a blood draw and needed an extra butterfly needle or blood tube for labs.
I felt a rush of emotion and sadness - can't we help this man? This is terrible - he is suffering. I could feel the pressure of tears and had to breath deeply - it wouldn't help anyone to start crying because I could feel all the emotions swirling in the room.
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The rapid response turned into a full-blown code when the man lost his pulse. They could not find the blood tubing in the crash cart to give him the second unit of blood. A nurse ran to find it.
Usually I was shooed away as an extra person cluttering the room, but today, the code leader had a few of us medical students line up for chest compression. One of my classmates who knew my feelings and fears about CPR offered to take my place, but I shook my head. I knew that it would be sooner or later my turn to step up and be part of a code, and that we would all have to be involved.
The man regained a pulse before it was my turn, but I had ended up on the other side of the room for better positioning. I handed out blood draw supplies and bagged the patient (squeezed the bag attached to the mask supplying oxygen), did not quite manage to observe the anesthesiologists place an airway. I wasn't able to leave because I was on the far side of the bed from the doorway, but I did give out supplies and attempt an arterial blood draw, unsuccessfully. (I think I should have tried a little longer and harder. I have successfully managed three, but became rather anxious to have someone else try.)
The man lost a pulse again, and this time it was my turn. I was terrifically afraid that his ribs would break, as my friends had described in performing chest compression on other elderly patients, but they held with surprising recoil. I was very afraid that he would die under my hands, as I knew that resuscitation often (usually?) fails in the hospital.
I locked my arms and pushed. From the simulations, I knew that I needed to push at least 2 inches deep and let the chest fully recoil. I knew that we were supposed to compress at 100 beats per minute, but the CPR leaders told me to slow down. They don't tell you that you should take off the stethoscope draped around your neck because it will start bouncing off, but the PA student took it from me and put it away.
I had a moment where I was very, very glad that I had been working on my upper body strength during workouts. It was shockingly tiring to compress, and the reason there was a line of people waiting to compress was that it was very difficult to maintain compression at the recommended rate and rhythm. I could feel myself sweating profusely under my white coat, forehead and underarms dripping with sweat.
His chest was so bony. This man was thin. His upper thighs were the size of my arm. I have no idea why he was sick, but eventually when we paused CPR for a pulse, it came back. He was resilient and started to groan and move his arms. I wanted to comfort him, but I was grateful that he became unconscious again.
The whole world narrows to chest compression, my green nitrile-gloved hands against his bony sternum, switching, waiting for the pulse to come back. When it came back, I placed my fingers on his throat, feeling his pulse come back to life, willing his heart to keep on beating. The team kept calling for pressors to get his heart going, and it kept restarting. The man was not on vitals monitors any longer, so our fingers on his arteries were the monitors. When the pulse stopped, we started chest compression again. The femoral pulse (in the crease of the leg / groin area) was the best, with radial pulse first to go. The carotid pulses in the neck were difficult to find.
He finally stabilized enough for transport up to the ICU. The team leader told me to keep my fingers on his pulses and not let go. We could not fit the bed and team through the doorway, so I had to transfer pulse observation to another person to get through the door. Other team members moved to other tasks, so there was a moment when I was the only one on my fingers on the pulse, and I realized that this man's life was literally under my fingers. If I lost the pulse and failed to alert the team, he would die in front of us. Pulses can be hard to find and be lost, but all they needed was me to monitor and alert.
I could not fit on the elevator, so I transferred the task to another person. One thing I learned in aviation training was positive exchange of flight controls: "You have the controls" / " I have the controls" / "You have the controls." So transfer of critical tasks was something I tried to mimic when transferring pulse and ventilation tasks.
I did not know where the ICU was, so I ran back and asked the nurses where to go, following the code team upstairs. The man lost his pulse as they were wheeling him into the bay, so one of the other interns or residents literally jumped onto the bed and kept compressing as they sent him in. I followed them in and rotated through the code again, then taking the pulse. His pulse came back for a fourth time.
They finally sent us students away. I wanted to stay and see what happened, but I also did not want him to die on my watch. I finally decided to just go. The PA student on my team and I left and debriefed together.
My residents complimented us on being part of the crazy code, and we all spoke about how helpful it was to have just done a simulated rapid response that day.
The PA student and I talked about what we did and what we could have done better. She was worried because she got bumped off chest compressions quickly. I told her how impressed I was with how she had anticipated needs for blood draws and lines. I wish I hadn't blow the jugular line out when I started chest compressions the second time. I think I would also have taken more time attempting the arterial blood draw rather than looking for a more experienced resident to do it for me.
I was also amazed at the sheer difficulty of each of the individual steps involved in the code - getting venous and arterial lines, blood draws, compressions, decisions about medications, diagnosis on the fly - all happening rapidly in the controlled chaos of a code. I had no idea that not having tubing or maybe accidentally squirting half the medication across the room could mess things up during a code. Life or death lay in those messy details. And it was messy - blood all over the sheets, opened wrappers for needles and blood draw supplies lying everywhere. Leadership and clear communication plus initiative were everything. We were a team - and outside of war, few people grapple with life and death on a daily basis except for healthcare providers. I suddenly understood why veterans felt so bonded with other people whom they had gone to war with. I felt very connected to everyone in the team who had shared in the code. I wished that we could have debriefed with the rest of the team, but at least we debriefed with eacvh other.
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