October 12th, 2008

Nescafe rabbit

All Alone

Sunday day shift in $ER.

I walk in at 0700 and the night doc says "Boy, am I glad to see you."  Never words you want to hear.  "Full arrest 15 minutes out.  I was going to tell you there was nobody to see, but..."  He grins, claps me on the shoulder, and heads for the door.  A wise man.  He's gone before the Code call goes out overhead.

Found down in bed in the early morning.  Late 40's, chronic medical problems, a hundred-ten pounds at the outside.  Scars and stigma of medical interventions now rendered futile.  CPR is going.  Two rounds of code drugs, bicarb, all given by EMS.  The ET tube is in, and I confirm position with a stethoscope and a chest X-ray without interrupting the flow of the resuscitation, wheeling her in. 
Stop CPR.  She has a rhythm.  A pulse.  Is she breathing?  No. Keep bagging.

They know what to do - I'm just the overseer.  Lab arrives, looks down.  I know her.  Her name is Laura.  Shall I call her family?  I nod.  There's not much happening now - lab draws, watching the monitor, the steady hiss of suction and the fft-ahh of the bag being squeezed.  Holding pattern.  Stably unstable.
And her family arrives, confirms what Lab had thought - No Code Blue.  We call her doctor in $city.  No Code Blue.

And all the time the crash cart monitor is ticking a steady hundred-and-five a minute, and I can feel it flutter in her wrists, and the biox probe is reading 100%.

It's an old joke among ER nurses, and they're half-serious when they say it.  "I'm going to tattoo No Code Blue on my chest."  Because this happens, O Best Beloved.  And now what do you do?  Because the emotional distance between withholding and withdrawing support is a chasm.
I call the brother in, explain the situation.  Her arterial gas has a pH of 6.8, she's making no effort to breathe, there's a helicopter on standby right now to take her to $major_hospital for ICU care, if we're going to continue.  "She wouldn't want that," he says, reflexively.  Automatically.  "She wanted us to let her go."  And his words catch up with his mind, and he shakes his head.  She's not breathing on her own.  If we stop breathing for her, she'll die.  I can't make that decision for you, but her chances of her brain returning to normal, ever, are slim.
"I have to call my brother." Life sometimes gives you a phone-a-friend.  Fifteen minutes later, he comes back.  "No more." 

They look at me.  Stop bagging her.  No more CPR.  No code.

We take the tube out of her throat, wash her face, wrap her hair in a towel.  It takes half an hour for her to reach asystole, and the last ten minutes are the worst, an agonal rhythm at 10 beats a minute that won't stop.  I explain to the family about the way heart muscle cells work, the tiny automata without direction from the cerebral cortex.  Lab reminisces about her fried chicken.  And then I count out seconds as the flatline sweeps across the screen, three, four, five times, and doesn't waver. 
She's gone.  Everyone looks at me again.  It's over.  Oh-eight-seventeen.

We disconnect everything at last.  Within minutes her skin is the cool ashen color of death.

"Look at it this way, Doc," the EMT says as we walk out of the room.  "At least your day can only go up from here."  And me - I know better, but I say it anyway.  Don't know how it can get any worse.