Friday, September 10, 2010

Code Blue

Internship, shift 12.

"Medic 12, please respond code 3 to [hotel] for respiratory arrest."

It was 4 in the afternoon, so before the dispatcher could even finish her sentence, we were running out the door and into the rig.
"The patient is not breathing. The patient has foam coming from her mouth." Tracy read off of the dispatch page. "Yup, she's coded. Ready?" She said, looking back to me. I nodded and slipped my gloves on, then flipped my protocol book open to the cardiac arrest algorithm. As we pulled up, a slew of curse words erupted from Tracy as she saw one of our other crews running into the hotel.
"God DAMNIT! She KNOWS I have an intern WHY is she jumping this call?! OH HELL NO! Get in there, she shouldn't be here. Let's go!"
As we pulled out our equipment and trotted over to the appropriate room, a crowd of people stood hovering near the door. Police officers, firefighters, other guests of the hotel. I pushed my way past them and into the small hotel room to see a mess of more people. A young woman was draped across the floor, a firefighter was pumping at her chest furiously as we tried to step around and over them. I grabbed the intubation kit and tediously stepped over everyone to her head. Tracy settled in near the woman's right side with the IV kit.
"Just get your tube, okay? I'll run a line and drugs until you get an airway. Concentrate on your tube."
I nodded again as I pulled the laryngyscope out and snapped it open. As I assembled my supplies in a neat line next to me, a voice interrupted my thoughts.
"Hey kid. You ready for your tube?" The fire-medic who had been ventilating her looked up and grinned.
"Oh hey! It's you!" I said, recognizing Don. He had been on most of the shifts with us, and he was awesome. Always helpful, always with positive comments towards me. He had also been the one with us on the bad trauma call last week.
"Whenever you're ready, alright?" He said.
"I'm good here. Let's go. Hyperventilate her and pull the OPA [basic airway] out please."
He nodded, following the order and moving aside. I slipped the scope in and pulled up, leaning in to get a better view of her vocal chords.
"Nothing," I said to Don, "Suction please."
The suction tubing was in my hand immediately and as I snaked it into her mouth, vomit bubbled up. I leaned to the side to avoid being spewed on, but kept suctioning. When the vomit stopped, I leaned in again, pushing the scope deeper and pulling up harder. Nothing still.
"I can't see anything. Keep bagging her." I said, pulling the scope out and backing up slightly.
"I'll hyperventilate her again for a few, then come back in here and look again. I'll give you crich pressure if you need it." He replied. I nodded solemnly, and gazed at her face for a few seconds. This was not the face of a woman who would live. She was dead, she probably had been dead for quite some time. I don't think I would have even attempted to work her up if it had been me who was there first, but since everyone had already started before we got here, we didn't have a choice. Chaos was erupting all around me, but I hadn't noticed since I had been up at her head with Don. As he ventilated her for another few seconds, I looked up and saw the entire scene. Wrappers and packaging everywhere, tubing and wires snaked all across the floor. Blood leaking slowly from each arm as Tracy and the first arriving crew stuck her numerous times for IV access. It was a mess.
Don backed up again and motioned for me to try again. I guided the scope in and pulled up, leaning as far down as I could for a better view. I shook my head, I still couldn't see a damn thing. Don wrapped his hand around the scope's handle above mine and pulled up more.
"Here, I'll hold it. Look again, I think you'll see them."
I bent down, my chest and abdomen against the floor now, and looked. There they were, like a light at the end of the tunnel.
"Got it, I'm going in." I said, sliding the tube delicately down her throat. As soon as the tube passed her teeth, it blocked my view of her chords. I slid it in regardless, and hoped I had made it. As I removed the guide wire from the tube and hooked up the BVM, the firefighter doing chest compressions turned to me.
"I think it's in, I felt it slide down. I felt it go in, you're in."
As Don attempted to ventilate, vomit suddenly filled the tube and leaked from around the seal of the BVM.
"I'm not in, pull it."
Tracy looked up from her IV attempt. "What happened?"
"It's in her esophagus, I'm doing a King airway, I can't get the tube."
The medic that had gotten there first from the other crew stood and stepped over the woman's body.
"Let me look, okay? Get another tube ready."
I backed away and assembled another tube. She grabbed the scope from my hands and looked again.
"Screw it, hand me a King." She withdrew the scope and jammed the King airway in. Immediately vomit filled the tube again, but this time it shot out of the BVM like a volcano, covering her and Don with brown liquid.
"Just try to BVM her, maybe we're still in."
Don squeezed the bag, but it only made the vomit spew more.
"Damnit, okay. I'm gonna have to try for a tube."
Again, she slid the scope in and immediately reached her hand back to me.
"I see it, tube, NOW!" She yelled. I shoved the tube into her hand and she passed it through the chords.
"Okay, it's in. Ventilate."
Don squeezed the bag again and the woman's chest rose slowly. With that problem solved, I finally looked up and let the chaos sink in.

"We can't get an IV, get me the IO.."

"Still asystolic, why aren't the compressions showing on the monitor?"

"IO is in, no infiltration. I think it's running."

"Epi and Atropine, please!"

"Keep checking the pads. When we touch the wires it shows on the monitor, but the compressions just aren't registering."

"Epi and Atropine in, record it!"

"Are you getting good compliance with the bag?"

"She's vomiting again, suction!"

The more everyone talked, the more I sunk into my corner of the room. PD hovered anxiously outside the door, further back I could see curious bystanders struggling to get a look inside the room. I looked at the woman's face again and shook my head.
There's no way. She's been dead for hours.

As everyone shuffled around, I took the BVM from Don and ventilated so he could stand for a few seconds. I listened intently to the metronome.
"Click, click, click, click, click, click, click, click, VENTILATE! VENTILATE!" The robotic voice demanded.
Tracy stood from her spot near the door and walked outside, phone pressed to her ear. I heard a few seconds of her report before she walked beyond earshot. She returned a few seconds later and stood in the doorway.
"Okay everyone, stop. We're calling it. Time of death, 1535. Let's clean up."
Everyone stopped, sat back on their heels, and began breaking everything down. I yanked at the BVM but couldn't detach it from the tube. I struggled, grunting and straining, before Don's hand reached down and held the tube while I yanked one final time, breaking it free. I looked up and smiled tiredly, he grinned back at me and grabbed the airway kit.
Sarah grabbed a blanket and draped it carefully over the woman. She looked up at me and pointed outside.
"There's kids running around outside. I just... It's not something I would want my kids to see."
I nodded and pointed at the woman. "Leave everything on her, right?"
"Yup, just like it is. Everything stays with her."
"Okay."
We quietly tip-toed around each other as we gathered all of our supplies and trash. I glanced one final time down at the outline of the woman, now just a lump under a thin blanket, and turned and walked out.
Back at the station, I sat down next to Tracy as she filled out the paperwork on the laptop.
"I'd just rather have you watch me do this one, it's a lot of information to try to do yourself and I want you to see it done before you have to do it next time." I nodded quietly and folded my hands in my lap.
"How do you think that went?" She asked.
"I mean.. She was a difficult airway. I really just... Couldn't see anything. But I really was trying."
I looked up at her and she stared blankly at the computer screen.
"As a code though, it went horribly." I finished.
"Yeah. There was just too many people trying to do too much." She said quietly, before resuming her typing.

That night, I had a dream about the code. I was at her head, scope in hand, and leaned in closely to look at the chords again. As I leaned in to get a better view, the woman's eyes shot open.
I sat straight up into bed, gasping. Tracy poked her head through the door.
"We have a call."
"Ok, I'm right behind you."

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