First Chapter

Code Blue to Coronary Care Unit’. ‘Code Blue to Coronary Care Unit’. ‘Code Blue to Coronary Care Unit’. The words ‘Drill’ were missing. This was the real thing again. This was the third time today and it was only 11am. The rapid response team mobilized and responders funneled to the second floor of University Hospital. The frenzy of movement resembled Piranha attacking an unsuspecting prey that stumbled into the Amazon. Focus with tested skill described the members of the code team. This was their chance to make a difference today. Elevators were abandoned for stairs, lunch was left in the cafeteria to cool down and non-emergent activities briefly set aside.

The speed and well-rehearsed steps all took in the next few minutes could make the difference. Either a life would be resuscitated to a productive existence or a vegetative state left only to consume ever more costly healthcare resources. Too often, with no explicable reason, no matter how prompt and well-orchestrated the efforts, the victim was doomed to occupy a dank, dark hole six feet under a neatly manicured lawn visited by lonely family and friends less often as the years and more urgent matters rolled on.

Personnel donning blue smocks worn in cardiac intensive care units, respiratory therapy wearing their mauve smocks, and white outfitted nursing staff assigned to today’s code teams raced toward the patient. Those arguably more fortunate to avoid the call looked up from their duties to see who may be the saviors or bearers of bad news today. As though lights and sirens draped these cardiac warriors, aisles widened and subordinate traffic came to a standstill. Stairwells resounded from all varieties of pounding footwear. Neck draped stethoscopes and swinging name badges barely clung to their owners.

The ICU activity level soared as code team members arrived and hustled into room 217. They quickly surrounded the patient’s bed deciding exercising the duties they had been trained for. ICU nurses had already moved the crash cart to the left side of the bed, sharing space in a room already full of IV poles holding multicolored solutions. The patient’s ventilator had been moved aside allowing anesthesia to better control the airway. What at first appeared chaotic now looked like a well-rehearsed battle field.

Dr Tate assumed command and the ICU nurses moved aside to allow the code team to work their magic. Anesthesia was assisted by respiratory therapy. As additional large bore IV was placed by the code nurse in the patient’s right femoral vein. This line would allow unrestricted administration of any volume or type of medication with little concern about medication incompatibilities. A cardiac pacemaker wire could be passed through this line if needed. Another nurse moved the defibrillator into position if needed. A charting nurse managed the clerical duties, recording those in attendance, actions taken and medications administered.
Patient Babcock was a 47 year old white male recovering from a massive left ventricular myocardial infarction that caused his sudden collapse at the dinner table just 48 hours earlier. Earlier the intern had updated the ward team, indicating Babcock was on the mend. Cardiac enzymes had returned to normal, no symptoms were experienced during the night, and he showed signs of steady improvement. The miracles of modern medicine had saved another hapless victim who despite knowing better ate whatever he wanted and whose practice of exercise was little more than pushing away from the TV lounge chair to refill his bowl of Fritos and retrieve another beer from the fridge.

This was Babcock’s third arrest this morning. Not a good start to write home about. This was another of those unexplainable conundrums that so fascinated John Tate and was largely responsible for his attraction with medicine. Patients seldom followed a textbook course, or as was so often parroted by attendings during patient rounds, ‘patients don’t read the textbook'. How could a resident be expected to learn the full variety of signs and symptoms of a disease, learn the nuances of presentation, or master the recommended therapeutic maneuvers, if the patient didn't cooperate? The rules were always changing. Dr Tate loved the challenge.

A sense of structure began to permeate and evaporate the tension as Dr Tate tookover. The nurse recording the play by play action, codifying the medication administration, electrical shocks, and rhythmic chest compressions, stepped back against the wall to make room to stay out of the way and have a clear view of all events as they happened. John stood between the struggling patient and the cardiac monitor. Though any resident or attending could run the code, as chief medical resident he assumed these critical responsibilities. He was well trained and confident. Beyond this he felt a strong sense of fidelity to his patients and pride that he was trained to meet their needs. After all they placed their most prized possession in his hands and he gladly accepted the responsibility.

"Give me an update of what's happened”. He needed a brief history of this event so he knew better how to manage the arrest. This was not the first code he had managed. He had attended and/or managed hundreds of similar situations. This was his fourth year of Internal Medicine Residency. On top of that, he distinction of being called the Chief Resident. This designation signified a level of academic achievement, management skills and political savvy.

“What was going on during the past 15 minutes”, he asked? Often described as the mystical seat of emotions and love, the heart was anything but dependable. Unexpected rhythm disturbances, transient but lethal vascular events, and quirks of behavior that even the most diligent forensic pathologist could not explain, were forever causing this 450 gram mass of muscle to misbehave. What had started off as a challenge and quest for knowledge had turned into John’s nemesis; a perpetual bewilderment of nature that did not cease to amaze him.

The recording nurse stepped forward from the wall to summarize the details up to this point. Dr Tate had high expectations during these codes and his team did not disappoint. He appreciated this about the group. Punctuality, precision, and reliability were necessary ingredients he insisted upon for the code team. He had spent too much of his limited training time fine tuning this group to expect anything less. He didn’t manage his life that way and he wouldn’t be part of a professional team that couldn’t perform this way.

"He arrested 5 minutes ago. His nurse was in the room first when the monitor showed V fib. The precordial thump did nothing so a code was called. He has received epi twice, the last dose 2 minutes ago. No bicarb because we have been ventilating him since the arrest. He has been shocked three times with 400 joules without response. Cardio version was followed with a lidocaine bolus and he is on a 2mg drip. "

Sylvia moved away from the bed, back against the wall, assuming her attentive monitoring of events. The room, though adequate for patient care, was barely navigable when occupied by three code team nurses, respiratory therapy, a clerk, a phlebotomist, an EKG tech, the managing physician, and the patient. In addition, a visitor’s chair, bedside table, and bed tray all competed for precious space. And now with the code in full progress, two additional intravenous poles decorated with IV pumps and cords, an EKG machine, respiratory therapy equipment, and laboratory supplies cluttered the 10 by 12 space; unfortunately, all of it necessary.

"Any electrolytes yet?"

"They have been drawn and sent, but no results yet," she said. John was always impressed with Sylvia. After working with her on several codes in the early days of his residency, appreciating her attention to detail, he requested she be placed on the code team as its recorder. She was an early 30s, very attractive blond nurse, who exercised daily, wore crisp uniforms that accentuated her gorgeous hips, and had the most fragrant perfume John had ever smelt. At times he had a hard time focusing on important matters when she was around. Add that fantastic perfume and he became spellbound. Now that he was ending his four year residency at the University of Minnesota, he wondered if his vow to avoid her advances was all that smart. After all she wasn’t a patient or employee of his so he wasn’t sure why he had placed such a stupid restriction on his life. Besides with his busy residency, it had been several years since he last dated and questions were stirring about his preferences.

"Someone call for those results, and if lab says there will be a delay, hand me the phone," he commanded. He hated waiting for lab results, or any other pieces of medical information he needed, especially during a code. He did not understand what took so God awful long in the lab anyway. Lab instruments were finely tuned computers that he was told could process thousands of samples daily with the precision of a NASA mission. There was always an ample cadre of relaxed lab techs moving about automated platforms when he went looking for patient results. He placed the most blame on the pathologists cloistered in their private offices who had nothing better to do than to think about clinical issues. He recalled hearing something about‘Internists know everything, but do nothing; surgeons do everything but know nothing, and pathologists know everything but are always too late’.

This was Mr. Babcock’s first hospitalization, which was surprising given his sloppy dietary and exercise habits. He was massively overweight, had nicotine stains over the left side of his bushy mustache, many left handed patients did, and sported some of the highest, blood glucose values John had ever seen. His blood pressure had been elevated for years and despite his doctor’s pleading, the advice fell on deaf ears. Little surprise he was the center of attention for this code team. Yet he was a patient that deserved the benefit of the doubt, and John would make sure he survived another day so he could inhale at least one more double bacon cheeseburger.

"Rebolus the lidocaine, and give him an amp of bicarb. Even though Rob’s got a good airway, this guy has a lot of fat to perfuse with these chest compressions.” Dr Robert Calder was a remarkable anesthesiology resident. John was fortunate to have convinced Rob’s attendings that he was needed on this team.

A cardiac arrest dramatically alters the normal human physiology. During a code, John dug into his anatomy and physiology memory banks so he would not overlook a critical process. The body wisely set aside unnecessary functions during an arrest. Gastrointestinal organs ceased to function. Skeletal muscles, a large consumer of blood and blood products, rested. The brain went into hibernation as the patient lost consciousness. John spent four grueling years with innumerable sleepless nights and incessant attending rounds learning these details.

As the minutes dragged on, he became impatient with Babcock’s response. He taught ACLS courses every spring to other residents, nursing and attending staff. Students are taught during those classes that if you follow the algorithms, the patient will resuscitate. He always followed the steps he taught. However, he went through this scenario enough times to realize that not every arrest victim survived. This day would be no exception. Babcock would survive this event if he had any say in the matter. God would not take this victory away from him today.

His impatience mounting, he pushed aside the nurse doing chest compressions and began the rhythmic up and down motions himself. Having seen this happen before, several team members furtively sharing glances, aware of Dr Tate’s mounting anxiety. Beads of sweat began to appear on his brow. He became testy, sensing he was losing this man. Babcock had a family and a life that depended on John to save him from this disaster. This was why he went into medicine; to make a difference and to help those in need. This mission had brought him to this bed, at this time, and he could not let it slip out of his control.

Sylvia’s jaw dropped as she looked just outside Babcock’s room. "Oh no, there's Mrs. Babcock," she said. Babcock's wife was rounding the corner of the nursing station on the way to her husband's room. Nursing staff had been unsuccessful trying to contact her this morning since Babcock’s first arrest. They would learn later she had been in church all morning thanking the Lord for her husband’s improvement since his massive heart attack just 48 hours ago. She was a faithful Baptist who did not subscribe to her husband’s careless lifestyle. She regularly prayed asking God to change his heart. She would not be prepared to accept what she was about to witness. Babcock had one foot loosely tethered to earth and the other reaching for eternity.

All eyes turned toward the approaching Baptist. She was confused eyeing so much activity in the room. She checked the number on the doorpost. Susie, the charge nurse, left the bedside and rushed toward the door, hoping to intercept Mrs. Babcock before she realized what was going on. She was too late. Judith Babcock, a trim and smartly coiffured companion of incredible, living faith, seeing the commotion in the room and recognizing the photos at the bedside of their children kneeling next to their golden retriever on their well-manicured grass Babcock had just mown three days earlier, knew this was her husband they were working on. The site of his lifeless torso being pounded and forced to breathe through a plastic tube caused her to emit a guttural whimper of disbelief. She fell against the wall of windows and collapsed bumping her head first on the wall and then the floor. She collapsed, the sickening sound of her flesh smacking onto the floor, her head striking shortly thereafter with that distinctive hollow whoop, brought swift attention from the ICU. A swarm of nurses and one doctor at the nurses’ station rushed to her aid.

Dr Tate reacted with rage at the collapse of Mrs and the zero response from Mr Babcock. "Who in the hell let her in the unit? Why wasn't somebody watching for her?” His eyes were aflame as he pushed harder on the cracking ribs trying to will the sick heart to life. Sweat drenched his scrubs and dripped from his brow. "Is she alright?"

The unexpected appearance of Mrs. Babcock had disrupted the methodical cadence, setting everyone back on edge, a precipice they were relieved to have left behind with Dr Tate’s arrival and management. Just his presence on the ward, in the unit, and at codes, provided an atmosphere of control, an air of assurance that everyone appreciated. Having him upset, both from the failure of their resuscitative efforts and now with the arrival of Mrs. Babcock, marred the security that his presence provided.

"Susie will take care of her Dr. Tate. Dr. Jones was at the nurse’s desk and he's checking her out," Sylvia spoke. A short glance her way and the quick reply that all was taken care of settled John's agitation for now and allowed him to focus on the code. He was glad Sylvia was here today.

“Give me the paddles.” The nurse to his left reached for the paddles from the cardioverter, smeared conductive jell on the electrode side, and gave them to John. Placing the paddles on Babcock’s chest he announced, “Clear”. The dial was turned to 400 and the charge button was depressed. “Clear”, he thundered, and all stood back making sure not to be in contact with Babcock. John depressed the red buttons on the paddles and Babcock’s body stiffened and arched briefly off the bed. The monitor continued to show a flat line. “Charge again”. The paddles were placed again on the chest and electricity surged through the lifeless body once more throwing over 300 pounds nearly off the sweaty sheets. However the cardiac rhythm remained unchanged. John’s jaw clenched as his agitation grew. He shoved the greasy paddles back to the nurse and resumed compressing Babcock’s chest.

"Sylvia check on those lab results," he demanded. All in the room, except John, recognized the inevitable. They were ready to concede defeat and terminate the code. All that remained was for the managing physician to cancel any further efforts. Stop all further lifesaving attempts. The irony was that they just raced to this man‘s bedside to give all they could to save his dying heart. How could they contemplate stopping. For years, systems had been put in place, processes scientifically studied and compared with other processes all in attempts to keep patients like Babcock alive. The protocols demanded certain drugs at certain times, as well as chest compressions of certain intensity, ventilation frequencies meant to simulate normal respiration, and electrical shocks placed at specific sites and with prescribed intensities. Millions of patients had been saved over the years following these steps. Even victims of sudden collapse from cardiac arrest in the community, in shopping malls, in school gymnasiums, on the street, had been saved by these procedures. The very bed that Babcock lay unconscious in and fighting for his life had seen numerous successful attempts of cardiac resuscitation.

But this would not to be the case today. Today, on John's watch, a tried and proven system that had been refined to perfection, was going to fail its Babcock. This lifeless body would soon be placed upon a cold and well used gurney, with a single thin white bed sheet placed courteously over his cooling massiveness, and he was going to spend the next several hours of his hospitalization in a dark, silent refrigerator, located in the morgue, near the cavernous, undecorated, back entrance of the University of Minnesota Affiliated Hospitals. All waited now for the order from Dr Tate, the chief resident of internal medicine, a title he had earned after four years of exemplary accomplishments in all aspects of patient management, to quit doing what he had been trained so repeatedly and methodically to do. He just needed to say, 'let's call the code'.

Dr Tate had a hard time uttering those last, terminal words today, and every other day when the coded patient on his watch was not responding like they were supposed to. Why was Babcock not converting to normal sinus rhythm. The code team was following the management of this code by the book, using every drug and mechanical maneuver that literature said to use. John taught ACLS. He knew what steps to follow. He had been teaching for the past three years. And even though he knew that not every patient would survive even though correct protocol was followed, why did it have to be his patient, this day? How could he go through four years of training, be at the end of his residency program and eligible to begin private practice in a few short days, and still lose a patient? He was not trained to lose patients. He was trained to save patients.

As the futile efforts to save Babcock droned on for nearly an hour, all in the room, except John, realized that death was inevitable. John realized it too, but giving up, as he knew all in the room thought they should do, was a bitter pill to swallow. It took Dr. Jones, after he finished caring for Mrs. Babcock's collapse, to enter the room and suggest, in that courteous, self-deprecating style doctors use with each other, that Babcock did not appear to be destined to overcome this unfortunate turn of events. Having a senior staff member say the unutterable, coaxed John back to reality and he realized he had done all there was to do.

John pushed himself to say the words - "Lets call the code."

Everyone was relieved, including Sylvia. However, it still took John several minutes to extricate himself from the bed, from his position as team leader. He stood back from his failure, away from everyone else and leaned against the wall for several minutes. He stared lost in thought as the cleanup efforts began; removing IV lines from Babcock and IV pumps from the room, wheeling the cardioverter and laboratory equipment out into the hall, and pulling the endotracheal tube from Babcock’s throat. The bed sheets and blanket were neatly arranged over the cooling corpse, the hair was combed the way Mrs. Babcock liked it, and in minutes the room looked tidy enough to film for a marketing spot on a local television station. The only problem was the lifeless body that lay in the bed; lifeless because John had failed to make a difference.

After all had left the room, he moved away from the wall and stood at Babcock’s feet. He stared at the bloated and dusky blue face that less than two days ago had probably been filled with a greasy chicken dinner plate drenched by plenty of gravy smothering mashed potatoes and dressing. He thought careless and unthinking patients deserved what they got, but why today, on his watch.

He forced himself from the room and stood at the nursing desk. No one directly looked into his face, but all knew what his expression showed and all heard his thoughts though they never crossed his lips. He signed the code work sheets that Sylvia had left for him. With slouching shoulders and shuffling gait, in failure he pushed himself down the corridor, and into the counseling room to face Mrs. Babcock. This scenario had played out many times before, but it was never easy, not like it was when he made a remarkably astute diagnosis, or saved a patient from sure death with the appropriate prescription of antibiotic. It was all part of life as an Internal Medicine Resident, a life to be exercised, and tested very soon as he entered private practice. He hoped those days would be better than today.