By Ali Haider

It was about 12am during my Saturday overnight call--the worst night to be on-call. Despite the obvious loss of the weekend, it was also the “night float” interns’ night off, which means four of us held down the fort for the other interns’ patients, while we admitted new ones. I had six patients I was already caring for, some of their problems were clear cut and being treated, others I was clueless about. I had one 40 year old patient in fulminant liver failure. Liver cancer? Infection? Some autoimmune or inflammatory disease? The etiology remained unknown, but fluid was accumulating in his abdomen (ascites) and lungs (pulmonary edema), and now his kidneys were beginning to fail. He was in severe respiratory distress on the brink of being intubated, and all we could do is cross our fingers and await the biopsy while we pumped him full of antibiotics to cover any sort of infection.

My second sick patient was an IV drug abuser with sepsis, who likely had endocarditis--bacteria growing his blood and seeding into the valves of his heart--causing symptoms of a failing heart. His vital signs were barely stable as we tried to control his infection with broad spectrum antibiotics and intravenous fluid support. I had four other patients with everything from an HIV patient with a fungal pneumonia, to an 80 year old man who thought it was 1975 and swore he talked to dead people last night. Such was the scene on a busy night during my first month on the medicine wards as an intern.

Sleep deprived, and overwhelmed with the workload, I felt like I would never sit down, never eat, and my pager would never stop beeping. Despite having two or three senior residents there to back me up, it was a daunting thought that the overnight care of some 30 odd patients was solely in my hands (and the same went for my 3 other co-interns). I called the shots. If someone was crashing, I had to decide what meds to give, what scan to get, which consult to call. It was intimidating, yet exciting all at once. Just as my thoughts continued to ramble, I heard the announcement on the overhead page: "C.A.C, Klau 5! C.A.C, Klau 5!" Shit. Klau 5 was the floor right below me. And C.A.C meant there was a code blue--which means I had to haul ass.

Code blue, (and all its various synonyms), means a patient is pulseless or breathless--"crapping out", or “crashing” as we say, and requires immediate cardiopulmonary resuscitation. That means if you are on the "code team", you better drop what you are doing and be there five minutes ago. I ran down the hall towards the stairwell, passing half-gowned patients with their IV poles, the sounds of old demented men moaning sweet nothings, and the odors of disease that would nauseate any normal person. As I dashed out of the stairwell, I could spot the room in question down the hall by the surrounding commotion. My heart briefly pounded, wondering if I would actually remember anything from my Advanced Cardiac Life Support (ACLS) training, especially if I were to be the first M.D. on the scene (highly probably given the time of night and my proximity to the scene).

As I arrived, I saw the lifeless body of a 70 year old man half-naked on the bed, and the "crash cart" had just been wheeled to the door. I was the first one there, with a fellow intern not far behind. "Patient was found unresponsive, and not breathing", the nurse reported. I felt for the carotid pulse, and my co-intern felt for the femoral. Nothing. I began CPR. The first four or five compressions were difficult, met with resistance, but as I felt and heard the ribs crack, it became easy, and I could almost feel the chest wall compressing the heart. The respiratory therapist arrived and began "bagging" the patient to provide artificial breaths, and the defibrillator was rolled in. We applied the electrical leads to the chest to check the rhythm. We waited. There was no rhythm, just random electrical activity: Ventricular Fibrillation. Bad. A quivering, non-functioning heart, providing no circulation of blood to the brain or body. Immediate cardioversion was the treatment. The paddles were applied to the chest, "200 Joules charging! Clear!" The body jerked with the jolt of the current. We check the monitor, still V-Fib. "Clear!" Another shock, 300 Joules. We check the monitor. Asystole. Flat line. Shit. "One of Epi!" I heard a familiar voice scream. I realized at some point amidst the chaos, the senior medical resident had arrived, and I heard her start calling the shots. I was somewhat relieved. My co-intern took over the compressions, as I pushed the epinephrine, and then some atropine. More compressions. We glance at the monitor again, back to V-Fib. Another shock of 300 Joules, and then, a rhythm: V-tach. Ventricular Tachycardia. Still no pulse. Unstable. The clock continued to tick.

I began to think in my head the patient was reaching the point of brain injury now. "Clear!" We continued the cardiac arrest protocol. The patient went in and out of V-tach and V-Fib, but never gained a stable rhythm. After ten minutes you begin to lose hope, and after fifteen it is basically game over. Even if we could revive him, he would probably have brain damage, and would code again later in the night. A few more rounds of medications and shocks, and that was it. Time had run out. Persistent asystole. I called the time of death: 1:44am. I was not covering for the patient, so someone else would have to call the family to break the news. I am thankful, I hate that part. The late night call to the family of a patient you don’t know, and a family you have never spoken to before. Luckily it was not on me this time. Unfortunate as it is, death is usually the result when someone codes on any medicine ward, and if it happens to be your patient it’s always a little rough. But it is something you just learn to deal with. I de-gloved, washed my hands, and returned to my work.

Afterwards, I glanced at my 5 unanswered pages, and reluctantly starting calling back. I learnt that my IV drug abuser was spiking fevers to 103 degrees with chills and rigors, and his pressure dangerously low. That meant drawing blood cultures, consulting the critical care fellow, starting vasopressors to support blood pressure, and potentially transferring him to the ICU. I then got called about an old demented man that was just found on the floor and likely hit his head, and would need a CAT scan to check for an intracranial bleed. There was also a sickle cell patient in a pain crisis who was screaming in pain and wanted more morphine, and then a diabetic whose sugar had dropped to 50 and she became unresponsive. I had 2 new admissions waiting for me in the ER to evaluate, and I just realized the late night coffee shop had just closed. Damn. Needless to say it was going to be a long night ...

Images Courtesy Corbis