My first code was brutal. The man was rushed in to the emergency room in asystole, his cardiac tracing a flatline, eyes glazed, tongue lolling out of the side of his mouth, his body strapped to a backboard as the paramedic compressed his chest with one hand and blew oxygen into his mouth with the other. It was the most terrible thing I had ever seen. But everything moved so fast, and before long I couldn’t even see the patient’s face. Two doctors were over his head, intubating him. His face was covered with an oxygen mask, his clothes stripped off before he was even on the table. And then the chest compressions began. Compressions that shook the bed. I hadn’t realized until that moment how much force it requires to push the human chest down, hadn’t realized the speed and the intensity we have to exert in order to mimic the movements of the human heart. Within seconds, the tech compressing was sweating, breathing heavily, hinging his entire body over the chest like a pendulum.
I heard medication orders shouted. Labs were ordered. Fluids were hung. Three nurses bent over his arms and legs, trying to get more IVs in. The defibrillator was brought in, but he never had a rhythm to shock.
Meanwhile, I stood back in the corner, nausea rising, watching the lifeless body flop on the bed, fighting off a terrible memory. Six months before, my own father had passed out in our house. For an excruciating 30 seconds, his eyes had been glazed, his expression as completely lifeless as that of this patient. With each chest compression, my stomach clenched into knots, imagining my father on that board, imagining this man’s family, either not knowing what was happening to him or just receiving the call that he was in the ER.
The announcement had come over the radio minutes before his arrival: Middle-aged man found down in vehicle, smelling of alcohol, toxic ingestions unknown. Asystole on EMS arrival. The nurses and physicians looked unsurprised, their shrugs an expressive, “here we go. Friday night in Baltimore.”
They pronounced him dead after 22 minutes of CPR. The senior resident looked deflated. ‘Anyone have any other ideas guys? Anything else?’ The room was silent, except for the occasional beeping of the monitor. Time of death 3:22 a.m.
I wanted to flee the room. The finality of death was there, now, as it had not been before. The other medical student on call that night had been performing chest compressions. He came down from the step stool, and over to me, sweating. He looked gray. ‘I felt his ribs crack,’ he said. ‘I think I’m going to be sick.’ It had been his first code too.
Since that night, I have spoken with other medical students about it. The first code seems to be a universally horrifying experience. No one ever forgets their first patient. And not a single person does not jump to the vision of a loved one – one that died or one that has been ill, one whom they imagine on that table, undergoing these extraordinary measures.
A friend called me near dawn one day, upset and almost tearful. One of her patients had coded on the medicine floor. She had been very ill but had opted to have an operation that morning, despite the risks involved. She went into ventricular fibrillation a few hours after she returned to the ward. My friend had grown close to both the patient and her family, so she was asked to explain what was happening to the family. She had also recently lost a close relative, and couldn’t help but think of her while the code was in progress. She said that she began crying almost as soon as she walked into the family room. She did not know how to describe the code, what was being done, and why. It all felt futile and brutal.
Codes are barbaric, this friend said to me as we spent hours talking about it. When we started medical school, no one really explained their purpose. We launched into CPR training with life-saving glee; we pounded on plastic dummies and intubated baby manikins. Chest compressions were performed nostalgically, rhythmically, to “Stayin Alive.” Then we started in the hospital. My emergency medicine attending told me, with quiet seriousness, that if there was one thing I should remember, it was that a code is not to keep someone alive. It is to bring someone who is dead back to life.
That Friday, the senior took me with him to speak with the family. For a medical student, that meant standing in the corner of the room. His sister and brother were in a small room that smelled of bleach, a disused gurney in the corner. The resident sat down, and told them. The sister didn’t seem surprised; a twitch in the corner of her mouth betrayed her. The brother put his face in his hands; a terrible quietness. I’m so sorry, said the resident. I stood telegraphing sympathy, but in truth I had absolutely no idea. It was unrelatable. And every possible phrase in those circumstances is hollow. The resident left the room before me; “I am so sorry”, I said hollowly, turning back to the sister. My son, my mother, and now my brother have died in this hospital, she said. I shook my head. I am so sorry. Her shrug was like the shrug of the nurses when they heard of the code. She shook her head.