The Code

I woke up that morning to loud quacking, the sound of my alarm clock. It was 5:30AM on a Saturday and I needed to be at the hospital at 8:00AM to shadow my Service Chief. The Department of Medicine was divided into services based on the disease subtype, which the attendings specialized in. The Chief was the head of his or her Service. I’d gone to bed near midnight the night before, having stayed out with some of my colleagues from the clinical trials department, to unwind after a long week. I’d found out my research study was going to be audited. A standard review, the sponsor – a pharmaceutical giant – had said, to prep for an expected audit from the FDA. Very standard, they’d said. I was still stressed out. But I couldn’t think about that this morning.

I rolled out of bed, taking my phone with me. Through squinting eyes, I dialed the number of the girl I was going to be shadowing with that day. She’s pre-med, too. I’d agreed to call her to make sure we both made it to the hospital on time. She sounded as groggy as I felt, and muttered her thanks. She’d arranged with her Service Chief for us to shadow him the next week. Next week she would be the one making this early morning call. Quid pro quo.

I got ready on auto-pilot, pausing once when I remembered the dream I’d had where I’d received a grant to research Circulating Tumor Cells. I usually recalled my dreams, but this was specific enough to warrant further consideration. I’d also been thinking a lot about what to do for my first summer after beginning medical school. But I couldn’t think about that this morning either.

I speed-walked to the train station, knowing that there were only two trains every hour into the city. The station was empty and quiet, but it was a nice quiet. Peaceful. I guessed everyone else was still in bed. My parents hadn’t even been awake when I left the house. I was glad; I’d gotten tired of explaining what drew me to the hospital on my days off, on weekends, in the hours after I was supposed to be done with work. I didn’t think I could get enough. There was always something happening, something new, something to learn. The week before, one of the attending physicians showed me how to identify the spleen, pancreas, liver and gall bladder on a CT scan. Another day, I learned what nephroureterolithiasis was. (Kidney stones.) I wouldn’t forget that. The draw wasn’t something I could adequately convey with words alone.

I got to the hospital earlier than my friend, and felt a small hint of pleasure at getting in before her. Hey, I admit it, I’m competitive. She made it in before the Chief though, so it was all right anyway. An hour later, we’d reviewed all the patients before starting out for Rounds.

One of the morning’s patients was young. Really young. And his wife looked even younger. We were on the transfusion floor, so we had masks on. It felt overwhelming being in the room at the time. They had a translator, who was doing her best to follow the wife speaking. The attending was asking questions and the nurse practitioner was talking to someone from Pain Management who had joined us in the room. As they spoke, the patient sat with his eyes partly closed, his breathing labored, and his skin pale. I knew his case was bad from the review we’d seen, but it did nothing to prepare me for seeing it firsthand. He was dying. And there was nothing we could do to stop it. I blinked rapidly, thankful for the mask. I couldn’t cry in front of a patient.

I took in a gasp of air once we left the room, and hastily flicked the moisture from my eyes. I should be able to handle this, I told myself sternly. I cleared my throat. I didn’t look at the other pre-med, knowing instinctively that she had borne the visit better than I. We were moving to another floor. Another patient.

My colleague had several questions for the nurse practitioners and the attending, and I felt somewhat inadequate, not having anything to ask and sadness at not having any solutions to offer. In the outpatient clinic, where I spent most of my working days, we had solutions for everyday problems. Technical difficulties in blood test orders, patients needing to reschedule, physician schedules needing to be adjusted. I would often caution trainees against panic. I would tell them most problems have solutions, nothing was the end of the world. But for physicians, sometimes problems had no solutions other than patience and acceptance. It wasn’t a matter of how many hours he could stay behind to work on the problem, it was simply unfixable. It was a daunting realization, a sobering one. But perhaps one I needed to learn.

We usually started rounds on the lowest floor and worked our way up. We were on 17, having started on 6, when the page came in to one of the nurse practitioners.

“Dr. W, I’m going, he’s coding.” She said, giving the room number before bolting.

“Who did she say was coding!?” He asked us both, before turning rapidly to follow her. We ran down the stairs, each flight a blur, before we burst onto the floor where the code had been called.

We didn’t need any directions; there was a crowd. People in scrubs everywhere, in a whirl around the room. We got in, and there he was. Someone had started chest compressions. Someone else called out instructions and requests for epinephrine. An ICU nurse was telling people to clear out if they were not doing anything for the patient. She nodded to our attending, and acknowledged us with a look that said, “Just don’t get in the way.”

“Is someone with his wife?” someone called out.

“Can someone start a counter, I need a two minute count,” said another voice.

“Starting the timer now.”

The exchanges were rapid, the movements efficient.

I felt frozen. The terrifying knowledge swept through me: that this man, this man who had a wife, who we had just seen, who we had just spoken to, could die. Right now. In front of me.

“Alright, we’re going to shock. I’ll tell you when,” someone said. It was absolutely nothing like any television show, any movie. There were no enormous paddles, nothing dramatic, only tautness in everyone that filled the room. Later, I realized they were waiting for a shock-able rhythm, at the time the silence seemed like the pause before a verdict. It was all too real.

“Clear!”

“Clear!” The chorus of people, who had been working to save him, responded, moving back from his body before the shock was administered.
I watched him move, and then realized someone was saying they had a pulse. I let out a breath I hadn’t known I was holding. I knew more was happening, but I could only think of that pulse. A pulse. A pulse was the evidence of life.