The Mystery of the Double Cardiac Arrest

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Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.

"Code" is medical resident lingo for emergency resuscitation team response. Different hospitals use different names; some use numbers, some colors, but they are all ways of instantly telling the people who work there, without scaring patients and visitors, that there's an emergency. Code red is typically a fire in the hospital; code blue is cardiac arrest. I was three weeks out of medical school, a brand new surgical intern (that is, a first-year resident) at the Brigham and Women's Hospital in Boston, when my days and nights began to be punctuated by the heady rush of codes.

A page operator's voice, clearer than usual, would repeat "code blue, Six West" through the enormous hospital complex. The code team residents would drop everything — being in the middle of an operation the single exception — and run at full speed to the floor location. Chief residents had keys that could instantly hijack big elevators jammed full of people; younger residents galloped up or down the stairs.

Codes were why I always wore rubber-soled shoes in those days. Dodging and weaving, we sprinted through the corridors, running as fast as was safe — and sometimes a little faster. We ran as if lives depended on us — and sometimes they did. Running just as fast through our heads were new-doctor's thoughts: "stopped heart, brain damage worse by the minute, airway, breathing, circulation — run fast."

We blew into the patient's room eager not to show how we panted. A 10-sec. synopsis of the patient's situation would come from a nurse or medical resident while we took our places. I was amazed how natural this behavior seemed, unrehearsed, undirected but seamlessly coordinated: Somebody pumping the chest; somebody bagging (holding a mask over the patient's face and squeezing the bag that forced air into the lungs); somebody reading the continuous EKG strip and calling out meds; the nurses getting, giving and recording the drugs; the medical students and younger residents drawing bloods from veins and arteries, labeling, packaging and running them to the labs.

As an intern you want experience and responsibility — you are trying to become a surgeon, so you want to do what's hard. At the code you hope to intubate, or to put in the huge IVs we use in the big veins of the neck or chest. If the chief wasn't there yet we were the ones who had to start giving directions to the nurses and medical people who filled the room. A smart intern in this situation always watched the face of the oldest nurse and changed course when it told him to.

The rule at the Brigham was that we, the Surgical team, ran the code. Medical teams' advice was suspect — they never gave enough fluid or bicarbonate, didn't use big enough IV's or strong enough electrical shocks. They were not "procedurally oriented"; no "hands." "Doctors who can't operate" was the typically arrogant Brigham surgeons' term for the medical residents.

For surgeons such as myself, wrapped in our Harvard mantles and so full of ourselves, only the remove of years would eventually reveal the manipulative secret of the program; pumping up the egos was a way to get us to work incredibly hard. In the midst of it we felt openly superior to nearly everyone, especially the medical people, whose carefully formed opinions on subtler issues were, admittedly, not always very helpful in the emergency of a code.

Here pumping the chest, inflating the lungs, filling the blood vessels and starting the heart were the immediate and technically demanding needs. It was only when the medicine was unknown to us or very complex — renal failure cases, rare diseases or cancer patients on weird experimental chemo — that we looked to the medical residents for help.

We were, nevertheless, in particular need of them one night when we responded to a code during the early part of my first year.

"A second code five, six west" was on the overhead as we ran onto the floor. Two codes at the same time on the same floor? "They're both in here," called a very distressed female voice from a patient room on the far side of the floor. We charged in to find this scene: A nurse's aide was pushing and tugging at an unconscious woman, dressed in white like a nurse, lying face-down, unconscious, on top of an old, fat, naked man, also unconscious in his hospital bed. The man was in for some urologic problem. The nurse was a student from the nursing school.

The first thing to do was sort out the bodies. The other bed in the room was empty, so we picked up the nurse and put her on her back on a back-board (a flat piece of plywood that makes chest compressions more effective than they are on a soft bed). She had no palpable pulse and the nurses couldn't get a blood pressure, but she was still weakly responsive to noxious stimuli. This is the medical term for stuff that bothers you.

Being plopped onto a piece of plywood, having your clothes ripped off, a two hundred pound man driving the heels of his hands into the center of your chest while others poke needles into your limbs and groin, another squeezes a rubber mask over your face and another prepares to send four hundred watt-seconds of electricity across your body is a noxious stimulus, however you slice it.

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