My interns and residents had been talking for weeks about how bad a code situation is, and so when the patient was found unresponsive in his hospital bed today, I figured it’d be neat to go watch. Neat being my Hollywood, glam and glitz, heroic understanding of a code; terrifying would probably fit better. Yes. I figured it’d be terrifying to go watch.

I was amazed at the scene when I arrived, watching from outside the door. I got there only 10 seconds after the Code 66 had calmly been announced overhead ( Code Blue scares patients, I guess), and already 25 people were in the room, with supplies, the crash cart, and it was loud . About 8 people were actively around the patient, with others supporting the 8, while some other people were trying to move the patient in the next bed out of the room. I did my best to stay at the periphery, out of the way, and help out when I could. People were quietly talking about how the patient was found, that he was supposed to be discharged today–and who knows where the rumor mill went from there.

A small woman was doing CPR on the gigantic patient (and luckily soon switched with a much larger male nurse), while others were checking pulses or trying to configure the defibrillator. Interns and residents were trying to start femoral lines, palpating weak pulses that trickled by with each chest compression. Two people were bagging the patient with oxygen. The ICU fellow was calling for meds and thinking aloud (I would soon learn the 5 H’s and 5 T’s ), while the intern responsible for the patient was announcing the patient’s morning labs and vital signs (“K was 3.6 this morning! Blood pressure was 110/65!”), all of which were stable and within normal limits. The pharmacist was doling out medications from her kit as fast as they were being called for.

Toward the end, the senior resident responsible for the patient was in tears, and the room grew more quiet, with fewer audible voices drowning out the sounds of the code equipment and the oomph of each chest compression. There were fewer looks at the patient, and more at the clock. The pharmacist announced the passing time. “Four minutes since arrest” became “nine minutes” became “fourteen minutes” became finally “twenty minutes,” and the patient was pronounced dead.

“The key is to stay calm,” my resident told me. I told her I didn’t think I’d ever be calm in a situation like that, and she shared her secret: “I just assume the patient is already dead, and anything I do can only help them.” I think she may be right.

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Valentine’s Day Grand Rounds are up!

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The hospital I’m at has been on divert status multiple times this month ( this is not uncommon ). That basically means that the ED is full, and can’t accept any more patients. For us, it’s also worked out to mean that our entire hospital is full, including the ICU. There are no open spots. Anywhere.

This prevents surgeries from happening (because there’s no place to put the patients for monitoring after the surgery), and it prevents truly sick people that walk into the ED from getting hospitalized, too. Our schedulers and case workers and discharge planners knock on our doors daily, desperately seeking patients who might be going home. And with our aging population , I really can’t see this getting any better. Nursing shortages make this worse, because of staffing, especially on the weekend, open beds can’t always be turned into patient beds, because of nurse to patient ratios.

This obviously brings up something of an ethical dilemma, where the lofty goals and aspirations of perfect medicine hit the limited resources pavement. There are several people in the ICU who have been there for as much as 8 months or even a year–in comas, on respirators–with little hope of improvement. Yet their living wills insist that they remain on a ventilator, or their family members insist–even despite the patient’s own declared wishes. And so they remain. Then there are others who come back time after time with the same serious problem, sometimes self-induced.

I could easily argue this point either way, and where you stand probably boils down to where you sit on issues of individual or group mentality. Should we do what’s best for any one individual, at the possible cost to the group, or should we sacrifice an individual for the good of the group? (I myself am a total hypocrite, preferring the group mentality in theory, but the individual mentality when it comes to my own health.)

I guess I mainly worry that this problem won’t just go away, and that whatever solution we come to will be one decided either at the last minute, or will be decided based on the most unethical of deciding factors: money. There’s of course an alternative I haven’t discussed here: just build more hospitals, more nursing homes, more clinics, and try to squeeze everyone in, but that will probably just lead to worse nursing and doctor shortages, and lead us deeper into the red.

Any of my answers turn my stomach, so I guess it’s up to choosing between the lesser of two evils.

1. First-come first-serve doesn’t really seem appropriate; just because you got sick when there was an available hospital bed shouldn’t decide whether you get care.
2. There’s a “he who contributes most deserves most” idea, but it’s rotten, too–just because subjectively one person “contributes” more to society than another shouldn’t necessarily buy them more or better care than someone else.
3. You can also go by age alone–that children should get more extensive and intensive care than the elderly, because in someone’s words, “children haven’t been able to live their lives yet,” but some elderly folks may still have better prognoses than some very sick children.
4. There’s a functional cutoff–if you’re “high-functioning” and you get sick, you should get extensive treatment, but if you’re low-functioning (again, the definition is a problem), you’re out of luck.
5. Or how about an formula based on your chances of recovery, partial recovery, or no recovery, based on all the data we have available?

I don’t particuarly like any of these for many reasons. You can’t arbitrarily sign a death sentence for a person, and you can’t take away a person’s hope so quickly. I don’t know what’s going to happen, but it really, really frightens me.

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The bf’s interpretation of me, with scrubs, white coat, and stubble after coming home post-call.

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Flawed and unethical, but I bet it would work:

1. Alert the media that for the coming week, everyone will be DNR/DNI until proven otherwise, instead of full code.
2. Miraculously watch as everyone rapidly develops a living will, durable power of attorney, and talks about their wishes with their loved ones.

You would’ve thought the Terry Schaivo thing would’ve done this already, but I seem to get all the patients who have no idea what they want. Just last night, an elderly Hispanic man was admitted for possible heart failure and possible heart attack, and after a lengthy discussion about code status, he tried to give me this innocent little indecisive giggle-shrug-smirk, as if I asked him what type of food he wanted to eat for dinner and just wanted to be agreeable. This ain’t one of those types of questions. You need an answer.

On a more ethical but medically ethical topic, some people propose making the organ donor system an opt-out system, where one would automatically be consenting to donate their organs unless they specifically said they didn’t want to.

*A person’s code status tells the health care system what he or she would like done if their heart stops or lungs stop working–would they like everything done (full code) at one extreme, or would they like no measures taken (DNR, DNI – do not resuscitate, do not intubate). You can pick any level of code status, and have specific parameters as well.

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Set to the tune “Ho” by Ludacris (which I totally loathe, but hey, I’m on call tonight).

Who’s full code?
Who’s full code?
Who’s full code?
I said that you’re full code.

Rinse and repeat.

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