Oh too soon I will forget that for the past several weeks I’ve enjoyed the tropical heat and the views and sounds of the Atlantic Ocean beating the Ghanaian shore. Too soon I will attend to the many calls from the Emergency Room for yet another “chest pain rule out MI”. Yes, because this is the season. Old people, and those not so old, who should delegate the snow-shovelling to someone else – come in through the emergency room with their angina and heart attacks as if a prize is to be won for the best (or worst?) MI (myocardial infarction) presentation. Yes, when Ghana celebrates its 50th anniversary of independence from the British in a couple of weeks, I will be on call in the cardiac intensive care unit probably managing someone on an intra-aortic balloon pump here, another with bradycardia in need of a pacemaker there, another in florid heart failure, and yet another who has barely survived sudden cardiac death. Oy vey! I’m already depressed thinking about my next clinical assignment.
Code Blue Bells Going Off in My Head
Today, as if I do not have enough reminders that my time here is soon up I heard the code blue bells go off. Those bells that always give me my own mini MI especially when I’m the resident on call or the ICU resident on duty. Those bells that infiltrate my dreams and turn them into nightmares. Hearing them today jolted me back to reality and reminded me that I’ve truly been away.
What are code bells? Hospital Emergencies! There are so many emergencies for which the code bells go off. And although each hospital has its own jingle for a code, it uses that same jingle for almost every code, which can be quite annoying and very stressful for someone like me. Most hospitals use colour names. Here is a variety of reasons that alarms, codes, are sent through the overhead intercom.
Code Blue: medical emergency – someone somewhere has stopped breathing or his/her heart has stopped beating and is in need of life-saving measures.
Code Red: Fire! Typically it is just a fire drill.
Code Yellow: security officers needed. Dr. Green is another term for this, which works perfect until there is an actual Dr. Green on staff.
Code Pink: child abduction.
Code Brown: someone (usually a patient) has suffered from severe faecal incontinence and now everyone on the ward is suffering from the stench! Okay, so this is not a true code announced over-head but come on, wouldn’t you want to know which wing of a nursing station to avoid temporarily?
Anyway as I was saying, code bells bring angst to me. They shouldn’t but they do. In my hospital, the medical residents are the doctors responsible for showing up for all Code Blue alerts. We are responsible for administering whatever life saving measures are needed using ACLS protocol. So as not to have the whole department show up only the team on call that day needs respond. Of course if you are not the code team but you are nearby the right thing to do is to show up.
Code Blue Bells Disrupt My On Call Day
So this is me on a typical call day. Tra la la la la. Admitting a new patient here. Admitting a new patient there. Seeing old (already-known-to-me) patients with the team and coming up with management plans for the day. Avoiding the stashes of chocolate at the nursing station. Fielding pages from my interns or medical students. Thinking about what to have for lunch or dinner and then DONG DONG DONG and my heart skips a beat and is about to go into palpitations as I wait for the rest of it. Code Blue, Code Blue, Room 345 and now my heart has sunk but my feet are already running, running, running to save a life.
As an intern early in the year you pray you’re not the closest person to the location of the Code Blue because truthfully you have no idea what you are going to do when you get there. When you know there’s a good chance you might be there first, you may decide your papers need arranging (you don’t want all the hard work you’ve done admitting a patient to get lost after all) or that your shoelaces need to be tied (so you don’t hurt yourself on the way to the Code, duh). Please know that I jest.
But as Murphy’s Law dictates usually the Code Blue is the furthest place from you, like on totally the other side of campus, like a 15 minute walk away, like where you just trekked back from. Invariably it is on a surgical floor where you do not already have a rapport with the nurses. Eh! So rather than trying to arrange your affairs, you sprint while praying for endurance and reciting the ACLS protocols in your head.
As the resident, you know you can’t just rest a minute when you arrive because who else is going to run the code?! So 9 times out of 10, you reach there, all out of breath, wheezing and puffing, wishing you too could get oxygen via face mask or a few puffs of albuterol, while trying to figure out what made the patient stop breathing, lose consciousness, or what made their heart stop beating so that you can direct the nurses and other doctors in the room about what to do to try to save the patient’s life. Often it is too late, but sometimes there are miracle codes where the patient survives and goes to the intensive care unit and eventually makes it out of the hospital. On those occasions you forget that you too almost saw the pearly gates on your sprint to the code. Hmmmm!
Sometimes codes are false. You get there and the patient is fine. Maybe they slipped off the commode. Maybe they are just heavy sleepers. Other times, you’re in the middle of your 5 minute sprint, when you hear DONG DONG DONG, Cancel Code Blue, Cancel Code Blue and as you come to a screeching halt you feel like just murdering the person who called that code. These are the codes that occur in the waiting room or the main lobby – usually someone just fainted – briefly!
There are times you just can’t help but be the first to the code. Maybe you were in the room with the patient when they decided to stop breathing. Or maybe you heard commotion down the hall and you were on the way to check things out as the code is being announced overheard. I will admit though that being the first is not too scary. You just have to be composed. The worst though is back-to-back codes. Especially when they occur at night. During the day, at least there are other residents around. So if the code bells go off for another patient soon after one has been called, other medical residents (those not on call) will show up to both just in case. But at night, there’s a skeleton crew. Just one team. Just you. Now that’s the absolute worst. That is hell.
But back to sunny Ghana.
What made me hear the Code Blue Bells today of all days?
Today was a clinic day. It was already proving to be an abnormal one. The patients were sick! One was dead even before being taken out of the car they had come to their appointment in.
There was a new patient, a young woman who was referred from an outside hospital. She was found to be HIV positive a week earlier after presenting with 7 days of palpitations. Blood work showed anaemia which prompted the HIV testing. So this woman walked into the consulting room with her sister and spoke to us in clear language. She was not cachectic like some others I’ve seen. Actually she was overweight. She looked uncomfortable as she explained that she was still having palpitations and that her chest was really hurting. So off she walked again to get admitted to the Fevers Unit inpatient service.
I didn’t think she was going to die but maybe that frightened look in her eye was her realization that she was going to die. Just a couple of hours later, I walked over to the inpatient side to socialize with the doctors there. I was met by a very anxious junior house officer who said he was having difficulty admitting our patient. So I went to see her.
She was apneic, already cold, already far gone. It was her agonal breathing that set off the CODE BLUE bells in my head. I saw the imaginary bustle of nurses and doctors rushing to her side to administer oxygen, to bag her, to do chest compressions, to place a central line, to push atropine or epinephrine, to hang a litre saline bag WIDE OPEN. I saw her imaginary ECG strip, the imaginary defibrillator poised to deliver a shock as needed, and the imaginary X-ray technician waiting outside ready to take a chest x-ray. Then I heard the imaginary flat-line beeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeep as she took her last breath.
I imagined all of this of course because she was all by herself dying alone. How do you run a code if you do not have an oxygen tank, an ECG machine, a mechanical ventilator, emergency medications, central access or for that matter any sort of access? How do you run a code when all you have is human power? Chest compressions and mouth-to-mouth I had been told were already partly administered and stopped when it was clear care was futile.
So depressing.
Thus I am rudely awakened from my tropical slumber. Soon those code blue bells will be real. I will have the chance to intubate a patient and know that there will be a mechanical ventilator available to use, to have an ECG to interpret, to call for epinephrine and know that it will be available and will be administered in seconds and to have a central line kit or two to place. I realize now my privilege of having these resources available to me to help me help others. For this I am very grateful.
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