Code 99

I've been on CCU for two weeks so far, and I can easily say it's the most stressful rotation I've had so far. Even more so now that I'm the resident and am expected to know how to read EKGs, assess patients for heart failure vs ACS, and (ideally) run a code. I had only been in one code so far as a resident (this patient ended up coming to the CCU after going into PEA), and at that time there were so many people in the room I didn't play an active role in the code. Even still, I dreaded the day when I would be the first responder in the room and would have to run a code.

My most recent call (which took place on a Saturday) was fairly uneventful until around 3 pm, when the dreaded code pager went off. My intern and I went to see what was going on and I went to grab the patient's information. When I saw the name on the sheet, my heart froze. The patient was a 35 year old woman I had seen just 3 weeks ago while I was on the heme-onc consult service. She had been admitted for abdominal pain and found to have a pelvic DVT, and I had been working her up for a hypercoagulable condition. There had been a MICU eval called on her at that time b/c she'd been persistently SOB and tachycardic, but when a CT angio ruled out a PE, the MICU team decided she could remain on the floor. I remembered she was a very sweet person, apologizing for not having shaved her legs in days and often speaking of her son and daughter (both in elementary school), always hoping she could get better and go home soon to be with them. The last time I saw her, I was under the impression that once her INR was therapeutic she could go home. I had no idea that she was still here, and when I realized that she was the patient coding in the room, my first thought was, "Did she have a PE?"

By the time I got into the room, there was a cardiology fellow standing at the foot of the bed giving orders while the MICU resident and the heart failure resident were already assessing the patient and getting in line for chest compressions if need be. BP 80s/30s and HR 56; it wasn't long before she went into PEA and I took turns with the other residents doing compressions while the nurses pushed epi, vasopressin, amiodarone, and fluids. Compared to the last code I was in, everything in this code was done in a very orderly fashion. The heart failure resident got an ABG with help of chest compressions; needless to say it came back extremely acidotic (pH 6.8, CO2 80s). At one point I roped my intern in to help with compressions while I called the patient's primary team resident to fill him in on what was happening. He later told me that his attending was in the process of getting the patient transferred to the PCU or MICU because of her persistent tachycardia, and that the patient's family had just been at the hospital to visit her a mere hour before this happened. Several residents tried to call the patient's family, but all the phone numbers (much to our dismay) were invalid.

At one point the cardiology fellow asked if anyone objected to his calling the time of death. Someone suggested he check the pulses one more time, and the patient was found to have a carotid pulse on Dopplers. Then I felt a pulse in her foot. We'd finally succeeded in getting a pulse, and the patient was now in V-tach. One of the nurses warned, however, that this could be the drugs working, and once they wore off, she'd go back into PEA. The defibrillator declared that the patient was not shockable, despite the rhythm looking as though she was in V-tach/sinus tachy, and so we resumed chest compressions. Then we had to pace her heart because her HR fell. Things were not looking good. The entire code lasted over an hour; I think the reason we worked so hard was b/c she was so young. My intern and I ended up leaving before the code ended in case anything happened in the CCU.

Later I ran into the resident who'd cared for this patient and he told me that he'd found prescription bottles for Indocet and Ambien in the patient's purse. The team had not been giving her narcotics, and apparently she had her family bring her some from home. So cause of death COULD have been due to overdose or drug interactions, but I doubt we'll know unless there's an autopsy. *sigh* Her poor family.