Thursday, February 28, 2008

Code Snippets

I've run three cardiac arrests in the past two days. It is a staggering number for a newbie medic over such a short period, and the experiences have far from left my consciousness. These three were the first codes I have ever worked as the sole ALS provider on-scene, and there were a few moments during these calls that I would like to write down and remember. Perhaps these notes are more for myself, to read back on some day in the future. I am aware that my perspectives will change though time, but sometimes it is hard to tell which ones. Hopefully this will help:

1. The man being held in a seated position by his franticly hopeful family, aunts and uncles who were completely oblivious as to the gravity of the situation. He had a dead look about him, a point that became more clear to everyone when you asked the family to lay him down and he smacked hollowly to the tile floor. They had no clue. Asystole.

2. Pupils fixed and dilated. Flat lines. Twenty minutes of ACLS on a kitchen floor with firefighters groaning and sweating through the work. You rolled your sleeves up because the effort and proximity of the room made everything seem stuffy and hot, but it was a message too: let's get to work, I'm ready.

3. Thirty-nine years old, the family said, and they thought she was alive this morning but they couldn't be sure. Someone thought they heard her get up and make coffee. "The lady deserves a chance at that age," the doctor said over the radio after refusing your request to discontinue resuscitation. "Bring her on in."

4. Frozen to the ground with the weather in the teens. No idea how long she has been laying there but it has been a while because all her clothes have become solid and crinkly around her iced-up flesh. A reluctant jaw and a lucky tube, an 18 gauge in the wrist. Protocol says we can't give drugs without orders?

5. The words coming out of your own mouth to a family not expecting any such thing: "Ma'am, his heart has stopped and we are doing everything we can to get it going again." Never having thought of practicing this phrase, considering ahead of time how to deal with these words. I hope it didn't sound too hurried or callous, too revealing of the situation's hopelessness.

6. How did the wires get this tangled? Do we have all the sharps? Knotted end-tidal CO2 lines and and the top of the ET tube coming off with the BVM. Feeling like the equipment needs to be reigned in as much as the patient. How do you keep this organized?

7. Delegation gone right. Partner getting a great line as the tube slides in. CPR from the firefighter, all in sync. The way it's supposed to be. Now what?

8. A sigh of relief when it's done. Fisties from the rest of the team. Thank you's, good job's, and you-did-all-you-could's

9. The knowledge that there will be many more to come, and that I will have the benefit of these to reflect upon.


Ambulance Driver said...

"...the top of the ET tube coming off with the BVM... How do you keep this organized?"

Next time that happens, take an alcohol prep and wipe the BVM connector where it fits into the ET tube. Stick it in there and twist firmly.

When the alcohol evaporates, you'll find that the connector should stick in the tube much more reliably.

Anonymous said...

Erm.... is there more to the story about the frozen one? That seems like it's asking for an "Incompatible With Life" declaration.

Otherwise, good job.

fiznat said...

Thanks for your comments Anonymous. It was a combination of things that suggested we should work the patient: her (young) age was one, the unknown downtime another, and the fact that this was a "hypothermic arrest" which - by my understanding - research has shown has more potential for ROSC than any other type of arrest, was a third.

It wasn't that clear in the snippet, but the "frozen" body had everything to do with the cold and nothing to do with rigor, as we later found out as the patient was warmed in the ambulance and ED.

Never got her back, still, but we thought it was worth a shot.

Anonymous said...

Excellent point.... doom on me for not thinking of it.

Medix311 said...

In my experience as both a BLS and now an ALS provider, codes go one of two ways: good or bad, regardless of patient outcome. It seems that everything will either fall into place--you get your IVs first try, the tube slides right in, maybe they're even in a schockable rhythm and you get a few ACLS rounds in. Otherwise, it's all wrong--you can't get an IV to save a life, the tube is nothing more than a vomit dispersal device, and it's asystole all the way. I've never run a code in the middle ground.

Of course, if the patient makes it, it's always a great code.

Keep up the good work.

- Medix311