Quotes of the Day
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.
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.
Displeasure showed on her face. I had been pushed out of the way by senior residents within a minute. They had her well-ventilated with the mask and "lined up" (all the IV's inserted, fluid pouring into her circulation to increase her dangerously low blood pressure). Same for the old man on whom she had passed-out.
The concentration of activity was incredible; two full codes going on in the same smallish room. The medical people had squeezed in; there was a knot of them around each patient, hands on chins or EKG strips. We were working away but could only get their pressures up a little. They were both doing well lung-wise. The old man was completely out and intubated now; the nurse was breathing and reacted weakly when needles were inserted ,but that's all. There was a moment of stability and everyone seemed to look up at everyone else — the surgeons looked at the medical guys, the medical guys looked back. What the hell was going on? What do we do next?
I was an intern; I looked for the oldest nurse.
"What was this girl doing in here?" I asked.
"Well, I just sent her in to check his vital signs and put him to sleep."
"Any meds given? Did she call out?"
"No."
"Any idea why she would have rolled him to prone (put him face down)?"
"Well, maybe to give him a backrub before going to sleep." (Hospitals were nicer back then).
With that last comment I saw the medical senior resident's eyes shoot over to the bedside table. Mine followed his, but he got it first: "Get towels and rubbing alcohol — and we have to roll the man back on his face."
On the bedside table was a familiar yellow and red tube and it was almost empty. Nitropaste is a transcutaneous cardiac nitrate — a form of the more familiar 'nitroglycerin' that heart patients put under the tongue to relieve anginal chest pains. They both work by opening up certain blood vessels. Because it is well absorbed through the skin, it's given by squeezing a little out — like a half-inch long squeeze of toothpaste — onto a piece of paper or plastic and sticking it onto the patient's skin. Patients usually can do this for themselves — that's why it was left at his bedside. Nitropaste is pretty potent, too; a smear of it the size of a quarter can bring down blood pressure enough to cause a headache.
The riddle the smart medical resident solved was this: the student nurse had come in to say goodnight to her patient. She then gave him a backrub. And what did she use for the backrub? The cream on the bedside table — Nitropaste. The huge surface area of his back gave the patient a walloping dose. Even the surface area of the nurse's hands was enough to knock her out. Smiles went all around. Though the two weren't awake yet, we all knew that they were safe — a good thing about Nitropaste is you can "turn it off," rapidly stopping its effects by simply wiping it off the skin. Within 15 minutes of getting the stuff off, both patients were awake and alert.
We also knew that we had been through the oddest of codes, and that few ever ended this happily. I went back to finish evening rounds and fell asleep thinking — about an old Avengers' episode in which Diana Rigg's black leather gloves keep her from being affected by a transcutaneous hallucinogen that bad guys have put on children's toys. And how lucky I was to be sleeping that night, in this great, big hospital.
- DR. SCOTT HAIG
- Even surgical residents used to the heady rush of "codes" occasionally encounter emergencies that throw them for a total loop