Tuesday morning, rounds were interrupted by a soft announcement over head, “Code blue, —– elevator.” We all cocked our heads to make sure it was addressed to us, and then tore out of the conference room. I think we thought it said third floor, which was right where we were. Actually it was first floor, so by the time we got there, the NICU and PICU teams were already there; and they had Med-Peds residents, so everyone was happy to leave it to them, since it seemed to be an adult who had collapsed.

Today, another code was announced in the unit right around the corner. Because it was in a patient’s room, we figured it must be a child, so the peds residents felt more competent; but we had seen our sister team walking that direction a minute before, so most likely they would be there before us. I arrived just about last; the room was too crowded to see anything, but I heard a very calm attending announcing, “This is an 8yrold burn patient. . .” and proceeded to give a nice summary of his medical issues. Turns out it was a mock code. So some of the residents practiced running it, all the support staff (respiratory, iv, pharmacy) got to demonstrate their ability to arrive quickly with their equipment, and the nurses got to discover all the pieces of equipment which were not handy (like cords for the defibrillator, blade for intubation, etc). After the patient had been medicated, intubated, stabilized, and CT and neuro pretend-called (he was having cerebral herniation from increased intracranial pressure), the nurses held a run-down of what objects needed to be put in a better location, and the residents reviewed which meds should be used. It was also clarified that in a real code, forty is too many spectators; but for mock, they wanted all of us there.

Thing is, our team is waiting for a real code – except the patient is “do not intubate,” and is already on full-strength BIPAP, so we can’t do anything except watch her die. She’s a 20yrold girl with end-stage cystic fibrosis. She came to the hospital nearly a month ago for a final “tune-up,” but just never stabilized enough to go home. She and her family seem happier for her to be in the relative safety of the hospital. There are six sisters, and one of the others also has very severe CF. Her parents seem to be in denial, and have been avoiding the hospital – until the pulmonology attending called her father yesterday and gave him a lecture on not abandoning his daughter. He spent the last night in the hospital with her.

Today it became clear that her respiratory status is visibly and irretrievably worsening. The attending kept repeating that he doesn’t expect her to last another 48 hours; that she would already be dead, if not for the bipap machine. The intern in charge of her looked to be on the verge of tears, and finally one of the other interns said bluntly that they would like him to tell them exactly what to expect, and exactly what to do, when it really comes down to it, since they are the ones who will be called first. So he told them: let her have the bipap as long as she wants it, give her morphine if she asks for it, and in the meanwhile do your best to make her family come and say goodbye properly. He said when she starts having agonal breathing hopefully she will become unconscious, and the father and doctors can give her more morphine and let her go. Right now, she’s refusing most pain meds because she’s afraid they alter her mental status, and she doesn’t want to lose control.

The interns look apprehensive enough; I think they haven’t had many of their patients die yet. I can’t imagine what her sisters feel like, especially the one who also has cystic fibrosis – to know she’s going to come to this in a few years at most. I can just barely stretch my imagination to one of my sisters dying; I don’t know which would be worse, to be there with her, or not to be. For this sister, it must be just way too eerie and foreshadowing.

The whole team is silently waiting for the final act of this tragedy. I’m on call Friday night.

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