Saturday, June 21, 2008

First Call - to Code or not to Code?

I had my first overnight call as an intern. It wasn't too bad. Pennsylvania Hospital is actually pretty nice to their interns. Typically, interns stop admitting around 1 or 2 am if they're on overnight call. Which means they probably get 3 or 4 hours of sleep, which is great! Of course, I spent about 2 hours with my resident doing a paracentesis (sticking a big needle in somebody's abdomen - you usually do it when fluid is building up abnormally in a patient's abdomen, making it all poofy. Yes that's a medical term. Poofy.) and trying to get IV access and blood drawn from a very difficult patient. So I didn't even start admitting until around midnight, and I felt bad, so I ended up doing 4 admissions, which lasted until about 4:30am. Plus there was a code - which is the thing I actually want to talk about that happened that night. I ended up getting only about an hour of sleep.

So the code was interesting - a resident and I are doing admissions in the ED, and suddenly a code call goes out across the hospital-wide PA system. "CRT... CRT... " and it told us the location. Apparently that means somebody was going through cardiac arrest. I found out later that this patient had been doing fine after his surgery and was being monitored by telemetry. That's where they attached a lot of electrodes to a patient's chest, it monitors their heart, and somebody in a centralized location watches a lot of monitors 24-7 to make sure all those hearts are working properly. This person noticed that at 1am, this patient's heart suddenly stopped working for some unknown reason and called the code. When my resident and I got in there, there were 4-5 people already there working on the patient and giving CPR. It turns out giving CPR (which at its most basic is simply chest compressions and giving breaths) is the most important thing in bringing someone back from the dead and giving them the best chance of survival afterwards. Somebody had already gotten IV access, and he was being pumped full of fluids, they were attaching a monitor to his chest. His heart was in ventricular fibrillation, which is a type of arrhythmia, that if left untreated, usually leads to death. They shocked him, and he immediately went into PEA, or pulseless electrical activity, which means the electrodes were sensing electrical activity by the heart, but it wasn't actually pumping, and the patient was pulseless. At this point, shocking doesn't help anymore, and you basically continue CPR and start giving all these different types of medications meant to jump-start your heart.

The rule of thumb is that you don't continue to code a person past 10 or 15 minutes because (1) the chance of survival is way too low after that period of time and (2) even if you bring them back to life, they've been "dead" for too long, and their functionality is horrible. There's a good chance they'll code and die again before they leave the hospital. However, in reality, codes often go on for 20-40 minutes, especially in patients where it is unexpected. Time goes super fast in a code, and people are reluctant to give up. This code had gone on for about 17 minutes... people were starting to give up, they'd loss IV access (I actually managed to put a new one in on the foot that lasted about 2 seconds). And then all of a sudden, someone says "I've got a pulse." Crazy. This guy was dead for 17-18 minutes, and then all of a sudden his heart starts working again. And the monitor shows that his rhythm, although not idea, is a workable rhythm, and he's "alive" again, and somewhat stable. All this activity starts up again and he eventually gets intubated (a breathing tube shoved down his throat) and transferred to the ICU. I don't know what happened to him after that - I guess if you follow statistics, there was a good chance he coded again and died.

Afterwards, I finally found out the rest of his story. This patient has esophageal cancer, one of the worst cancers to have. The treatment is surgery - they take out your whole esophagus, which is an extremely hard surgery to live through. Then afterwards, many patients have to go through chemotherapy and radiation, which is definitely no joke either. And after all of that, there's a good chance of it coming back anyways! So even if this patient lived and was stabilized, first of all, he would probably have little to no brain function since he got very little oxygen to his brain for 17 minutes. He'd be a zombie, on life support, for the rest of his life. Even if a miracle happened and he woke up, he'd die of his esophageal cancer pretty soon, or have to go through chemotherapy or radiation, which might kill him too.

So my question is... should he really have been coded? If I were the patient, I would not have wanted that. But not many people think of these things when they're going in for surgery anymore. In many countries, they trust the doctors to make these decisions, but in this country, and in the era of litigation, that's just not possible. Because of this, we waste millions of dollars on codes and life support and everything else. But more importantly, it leads to horrible situations that families have to deal with.

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