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Nobody wears a white coat any more...
...a tribute to becoming a doctor.
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.
11 whispers echo . o O ( ... ) O o . whisper a word
jonquil From: jonquil Date: October 12th, 2008 04:30 pm (UTC) (etched in stone)
You write beautifully. Please write a book someday.
clipdude From: clipdude Date: October 12th, 2008 05:21 pm (UTC) (etched in stone)
I agree!
ayradyss From: ayradyss Date: October 12th, 2008 05:29 pm (UTC) (etched in stone)
I thought of a title the other day.
"Relearning compassion".
smallstar From: smallstar Date: October 12th, 2008 06:15 pm (UTC) (etched in stone)
That's brilliant, do it. I'll buy your book. :)
mama0807 From: mama0807 Date: October 12th, 2008 07:50 pm (UTC) (etched in stone)
I'll third this!
fyrfitrmedic From: fyrfitrmedic Date: October 12th, 2008 11:23 pm (UTC) (etched in stone)
Typical mordant street humor from the EMT...

I remember a long-ago partner singing (to the tune of "Camptown Ladies"): Start your day with a DOA, doo-dah, doo-dah...
ayradyss From: ayradyss Date: October 13th, 2008 01:54 am (UTC) (etched in stone)
I <3 my EMT's :)
jillofthejungle From: jillofthejungle Date: October 13th, 2008 01:09 pm (UTC) (etched in stone)
...I don't know what to say...
winktwice From: winktwice Date: October 13th, 2008 10:25 pm (UTC) (etched in stone)
Is it weird that now I want a No Code Blue tattoo?
pwwka From: pwwka Date: October 15th, 2008 06:02 pm (UTC) (etched in stone)
What do you do when you have a violently negative internal reaction to the wishes of a loved one for a patient?
ayradyss From: ayradyss Date: October 16th, 2008 01:57 am (UTC) (etched in stone)
That's a hard one, mostly at times when I perceive the patient's family as being unreasonable regarding "no codes". I'm growing out of the visceral responses, though - I don't know that I've ever had a "violently negative" response. I've seen all ends of the spectrum by now...

I've become quite good at the "nod and leave" approach, where I curtail any response until I get away from the family, and then try to figure out -why- I've had such an emotional reaction.

We respect the wishes of the patient or their nearest surrogate. You go back and try to figure out what's going on, why we disagree. And sometimes you just fume for days.
11 whispers echo . o O ( ... ) O o . whisper a word