Devotions Upon Emergent Occasions
No man is an island,
Entire of itself.
Each is a piece of the continent,
A part of the main.
If a clod be washed away by the sea,
Europe is the less.
As well as if a promontory were.
As well as if a manner of thine own
Or of thine friend’s were.
Each man’s death diminishes me,
For I am involved in mankind.
Therefore, send not to know
For whom the bell tolls,
It tolls for thee.
-John Donne, fulltext via Project Gutenberg
Late entry note, written 1 1/2 weeks after the fact:
Every emergent overhead page at University Hospital begins with a characteristic double chirp that usually stops all conversation dead. Usually, as the brief adrenaline buzz subsides, all that remains is a reminder that someone, somewhere was toiling to save a life, and you go on with your business. But on my floor, no one even listened.
“Code OB, Labor and Delivery, Level 8, OR #4 … Code OB, Labor and Delivery, Level 8, OR #4 … Code OB, Labor and Delivery, Level 8, OR #4.”
…More after the jump …
Her section was going poorly, two units of red blood cells were already in the room, and she was typed and crossed for eight more, meaning that we were already prepared to replace her entire blood volume. We all knew it was coming. Hell, the resident standing next to me called it in. Even still, there is a unique chill that runs down your spine and back up again when your brain computes that, yes, that code on the overhead page was called for your team, your floor, your room, your patient. The social worker on my other case – an urgent section that kept getting bumped back and bumped back – looked up at me with eyes as wide as dinner plates. I nodded at her and then turned back to the nurse who was printing out blood bank forms. At this point I was out of the OR – no room at that table for a medical student – running back and forth to the blood bank with fresh frozen plasma and packed red cells as fast as Anaesthesia could transfuse them.
This was my first code – the first code for one of my patients – the first time I knew for whom the bell tolls.
Don’t think for a second that I was any kind of hero in this situation – most life-or-death situations which depend on medical students end in the latter outcome, not the former. At our institution, a “Code OB” is a life-threatening hemorrhage which is anticipated to require massive transfusions – it’s a signal to assemble the entire OB staff, every OB anesthesiologist, and every L&D nurse to save a single person’s life (and to cover the floor so that nothing else slips by or gets missed). I didn’t cut a hole in someone’s windpipe with a ballpoint pen or make a lifesaving diagnosis that everyone else missed. At best, I did work that a fleet-footed sixth grader could have done. But I did no harm – I stepped back, stayed out of the way of more qualified folks, didn’t clog the operating room – and I did whatever limited tasks I was assigned to the best of my limited ability.
As I write, the outcome of this lady’s procedure has not yet been determined. She was typed and crossed for 6 units, then 8, then 10, then 12, and then more. At the end of my shift her blood volume had been replaced twice over, but she was alive in the operating room with a great team working on her. She delivered a baby whose neurologic outcome will not be known for some time, but who is receiving the best care we can provide.
And, out of this near-tragedy came something beautiful. My other patient, a very very very sick young lady who we wanted to take to the operating room because we feared for her baby’s life, watched her husband cry as he gently rocked their newborn daughter in his arms. Her labor had arrested and she had made no progress for almost eight hours, during which time her longstanding disease was causing terrifying swings in her blood pressure and we were concerned that we would be unable to manage her appropriately due to her underlying disease. We had been unable to take her to the operating room because of the emergency case’s demands on the staff, and we were watching, waiting, and pushing drugs to try to keep her out of the stroke range.
All of a sudden she decided to take matters into her own hands and give birth. Although we tried to counsel her against it, pregnant women have a way of making their own decisions, and all we could do was observe her birth (she went from incompletely dilated to fully dilated and crowning in the five minutes I was in the back eating lunch, she already had good pain control and didn’t want or need anything else from us). As she held her daughter and gave her eskimo kisses, I couldn’t help be thankful that we didn’t take her to the operating room.
Today was a tough day, and a bad day for me. I had a lot of personal stuff going on, I felt like I wasn’t really there for one of my patients, I did a crap exam on a patient everyone else had written off as not needing to be on the floor (I HATE when I skip and save time on patients because other people don’t take their stories seriously … usually I am able to ignore them and take the time to do the best job I can, but today was not one of those days). I missed a couple key parts of the exam which is ultimately not a great thing for me. The patient was checked by two other people and was fine and I didn’t miss anything because there wasn’t anything to miss- but that won’t always be the case. I dropped the ball because of how the day had gone and didn’t do my best work. I missed my patient’s delivery because it was 1445 and I hadn’t eaten since 0600 and I was hungry and just wanted to grab a bite and was only in the back for ten minutes – but those were the most important ten minutes of the day. I didn’t deserve to participate in that delivery, no matter how many times I checked on this mom. And I let down my other patient because I let the knowledge that other people were taking care of her allow me to feel better about not taking care of her. Ultimately that is not okay.
We have a nice weekend off now, and I’ll be catching up on some sleep. I have a lot that I need to learn, and a lot that I need to do better on, but I am learning and I am trying my level best every day for every patient. I don’t always succeed. But I do get up just one more time, every day, after something knocks me down.
So, what was the experience of my first code?
Mostly, it reminded me of where I want to be. I want to be on the other side of this experience. I want to be in life threatening, urgent and emergent cases. I want to have the skills to be able to make a difference, not just in a thousand small ways, but sometimes in one big way. I don’t want to be powerless (does that mean I want to be powerful?) when one of my patients starts to turn the corner. Eventually, someday, I want to be the person who comes running.