A cardiac arrest, a career altered
Every DAY, in the course of medical training, we are exposed to situations that influence the way we turn out as doctors. One profound interaction with a patient, family or doctor can be life-changing. This is the story of one such experience that made me a better doctor. It begins with a cardiac arrest:
As senior medicine resident on call for the night, I was responsible for two interns, new admissions and all cardiac arrests. The interns and I each carried a little red pager that went off with a sound of screeching tires when a “code” was called. There was no mistaking that sound.
It was 11 o’clock when the beeper went off. I had been examining a man on 4-South whose kidneys had shut down. It had been a busy night, and many patients were still waiting to be seen by the interns.
I looked at the extension on the pager: 6-North. Surgery floor. Some medical screw-up by the surgeons, I thought at first. I ran down the long corridor to the north stairwell and up two flights.
A cardinal rule when running to a “code” is: Slow down and walk the final 50 yards, catch your breath, clear your head. As I passed the nurses’ station, the unit secretary pointed to the patient’s room. I asked about the patient’s code status -- whether she had “do not resuscitate” instructions in the event of a cardiac arrest. None was listed.
I entered the room to see a very old and frail-looking woman sprawled unconscious on the bed, a nurse squeezing an air bag over her mouth, and one of the two interns performing external cardiac massage.
The head nurse from 6-North pushed a rattling “crash cart” into the room and started attaching EKG leads.
The other intern had joined us and was reviewing the chart:
Mrs. Cheever (not her real name), 89, leg cellulitis (a skin infection), admitted two days ago, on IV antibiotics, laboratory tests from admission OK, except hemoglobin a bit low.
Underlying illnesses: None stated.
The surgery admit note was basically two lines: cellulitis; IV cefazolin (the antibiotic).
A young nurse spoke up. She had been giving the patient a sleeping pill when the patient said she felt dizzy and fell back on the bed, unresponsive. The nurse initially thought she had fainted but then couldn’t find a pulse. Fortunate timing for the patient, I thought, before reconsidering how unfortunate it might turn out to be.
Without a “code status,” we would be going the whole way -- a “full code.” I leaned over the EKG machine.
“Looks like V-fib,” said the nurse -- the patient’s heart contractions were disordered and ineffectual.
“It is V-fib,” I said. I ordered drugs for ventricular fibrillation and requested that electrical paddles be readied. I asked the second intern if he would like to try to intubate the patient. The nurse handed him the laryngoscope with which to visualize the vocal cords before inserting the breathing tube into the lungs.
“Stand back,” the nurse said, after the drugs were pushed into the intravenous line and the paddles placed on the patient’s right chest and left side.
The lifeless patient jumped from the electrical jolt of the defibrillator.
No rhythm yet. The first intern stepped back to the bed and continued CPR.
The second intern was having trouble with the intubation. The laryngoscope clicked against the patient’s teeth: Her neck was not adequately extended. He said he couldn’t get her tongue out of the way. The interns switched places.
I ordered a second dose of drugs. The nurses applied the paddles. The patient jumped again. “Still in V-fib,” I said.
I put on gloves and went behind the head of the bed where the other itnern, too, was having difficulty with the intubation. The 89-year-old patient lay motionless: pale and dead except for the rhythmic CPR on her chest. There was blood on the laryngoscope, common in difficult intubations.
This poor woman, I thought. This is the last thing I’d like to have done to me when I’m her age.
I leaned over her face, placed my right hand behind her neck to extend it and with my left, inserted the scope into her mouth, pressed her tongue down flat, then lifted her throat with the tip of the blade, exposing her vocal cords. Holding that position, I held out my right hand for the tube and slipped it past the vocal cords into the trachea. A nurse filled the balloon to secure the tube and gave three quick squeezes on the air bag.
The head nurse reported that the patient had converted to normal heart rhythm. I looked at the EKG. “Looks like she had an M.I.” -- a heart attack. I ordered one last dose of drug cocktail and put a call in for transfer to the cardiac care unit.
Mrs. Cheever remained stable; we transferred her and returned to our new patients. I walked back to my kidney patient on 4-South, thinking that it had been a tragedy to resuscitate Mrs. Cheever. Cracked ribs, broken teeth, electrical skin burns -- all on a frail old lady at the end of her life. We had kept her alive, but for what? Aren’t we supposed to “First, do no harm”?
A few days later, I decided to check on her status. The operator said she was back on 6-North. Surprised that she had survived, I went to see her.
I entered her room. In the bed, propped up reading a hefty book, was an attractive elderly woman. She looked up at me with a tilt of her head and a smile. I informed her of my involvement in her case and asked how she was feeling. She said that she would be going home soon, that her leg infection was better and that she was doing fine, except for the pain in her ribs when she took a deep breath.
She mentioned that she was looking forward to seeing her great-grandchildren and proudly displayed the photograph of them she used as a bookmark.
I was flabbergasted. When I first encountered Mrs. Cheever, she was near death, unconscious, gray skin, gray hair, gray eyes. I had considered it cruel to be resuscitating this 89-year-old. Seeing her now, conversing and alert, with hopes for the future, was a lesson more powerful than any I could ever have found in a book or lecture.
From that point on, I no longer considered a patient’s age as a determinant of the care they should receive. Instead, my newly acquired reverence for elderly patients became a steady source of joy and pride that has lasted throughout my career.
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James Channing Shaw is a dermatologist at the University of Toronto. He can be contacted at jc.shaw@utoronto.ca.
