A clipboard staked my claim on the counter nearest the nursing station. I poured myself a cup of coffee, whitened it with a packet of powder, and scanned the to-do list on the top page. Not so bad, I thought. My co-residents hadn’t signed out too much. As the intern on call, the forecast for my night now depended on who got admitted to the hospital, but I expected it to be quiet. Around Lake Erie an advisory of sleet mixed with snow got the streets salted and kept most folks inside and out of the ER. I drew little boxes next to the things that had to get done, intending to fill them in as I went along.
I was immediately interrupted with “Doctor Hart, room 342. Doctor Hart, room 342.” The even, detached tone of the voice belied the emergent nature of the announcement. For us it was a fire alarm, the signal for a scramble of residents, nurses, and respiratory therapists responsible for dealing with life-threatening emergencies.
I snatched my stethoscope, pushed back the chair, and thought of my lab partner from med school. She didn’t keep her mantra a secret. “Never run to a code. Never. You might be the first person there.”
I’d laughed when she said it, but mostly because it was true. As green doctors you didn’t want to be first. Being first meant you had to figure out what was going on—was the man breathing, did he have a pulse, do you start CPR? And if he wasn’t breathing, you had to be ready to squeeze the nostrils and kiss the lips to deliver a hopeful breath, despite the presence of blood or vomit.
I sprinted down the hallway and darted up the stairwell. I followed a group wearing white; somehow I got there before them.
The near bed was empty. On the far side a young nurse fluttered against the window.
“What happened?” I asked.
“I came to get his vital signs. When I got the cuff on his arm, he said he was lightheaded and sweaty. Then he fell back and didn’t move. I pulled the cord and called the code.”
I could still hear the operator overhead as someone pushed the “crash cart” into the room. Looking like a metal tool chest the size of a small refrigerator, it held the defibrillator, endotracheal tubes, and the drugs needed in a crisis.
I took a look around. People were arriving pell-mell: nurses, aides, even a medical student, but no doctor. I pulled at the stethoscope that necklaced my shoulders and went to the head of the bed. I bent into the man’s face and thought I detected a faint breath. I turned his neck to the side and placed my fingers over his carotids, hoping to feel for a pulse. I wasn’t sure there was one.
In the hierarchy of running a code, one person is responsible for calling the shots. A team leader assesses the situation, makes the decisions about drugs and defibrillation, and assigns duties to the other people in the room. I never saw an intern run a code. They only started lines, checked blood gases, and squeezed breaths out of an Ambu bag once patients were intubated. Once in a while they climbed onto the bed to give chest compressions when nurses got tired.
“Has anyone checked for a blood pressure?” I asked.
A nurse they called Woody was tightening the cuff on the right arm and readying herself to listen for the sounds. She looked old-school in her starched whites and support hose. She had twenty years on me, but technically I ranked highest on the totem pole of medical education. I made a mental note of everyone capable of helping. There was Woody taking the blood pressure, another nurse pulling the crash cart to the foot of the bed, the sparrow of a nurse trying to stay out of the way, a medical student, and me. I asked the student to get the EKG machine and made the call to start CPR.
“Does he have a line?” I asked. Giving breaths and chest compression was one thing, but they weren’t any good if he didn’t have fluid in his veins. I asked the young nurse to begin CPR, and I set about putting a tourniquet on his left arm and starting an IV. About that time another intern sped breathlessly into the room.
“What can I do?” he asked.
“Help get the EKG leads on and start a line,” I said. “We still don’t know what kind of rhythm he has.”
Woody yelled, “I don’t have a pulse or a pressure.”
“Continue CPR and someone get a board under him,” I said, and the nurse at the head of the bed squeezed a few breaths between the bluing lips and quickly moved to the chest to pump the sternum below her clasped hands. The EKG leads were placed, and the attempts of the heart to telegraph a rhythm were charted on a strip of pinkish paper that was starting to curl on the floor.
“Stop compressions. Woody,” I ordered, “check for a pulse. Let’s see what’s on the rhythm strip.”
I glanced on the monitor, then the strip. There were spikes indicating some type of electrical activity. Thirty beats a minute. Bradycardia.
“We have a rhythm. Do we have a pulse?”
“Not sure,” Woody responded.
“I guess that means no. Continue CPR. Do we have a line yet?”
“I’ve got a sixteen gauge in his left arm,” the other resident yelled, and I asked the nurse to hang a bag of normal saline. “Let it run in, wide open.”
By now I had expected the room to be brimming with hospital personnel. What the hell is going on here, where is everyone? I thought. The other intern must have understood what I was thinking as he gave a shrug, then wiped his forehead on his sleeve. His eyes darted from me to the nurse at the crash cart and back.
“Uh, by the way, where is the code team?” I asked. I may have passed the test and run a simulation on Resusci-Annie, but shocking a plastic dummy with a red wig and potentially electrocuting a person were two different things.
“Most nurses are ACLS certified,” the instructor had said. “This is a team effort. You won’t be alone.”
Yeah, right, I thought and my mind ran through the scenario for pulseless bradycardia. Think, think, I said to myself. What comes next? I tried to visualize the algorithm on the page.
“Okay,” I said. “This is the same as no pulse, no rhythm. EMD, electromechanical dissociation. Causes are hypovolemia, pulmonary embolism, cardiac tamponade. You’re supposed to continue CPR, give fluids, and check a blood gas.”
The other intern looked at me and mouthed, “Shock him?”
I looked at him, pausing, almost second-guessing my first inclination, then shook my head and said, “Get a blood gas. Send a CBC and lytes. We need to intubate him.”
At that moment the nurse at the head of the bed said, “He’s starting to move.”
Woody called out, “We’ve got a pulse.”
The rhythm strip showed that the heartbeat was dreadfully slow. It was half of what you’d expect in a sleeping man, but it wasn’t a figment of our imagination. He had a blood pressure as well. Low, but it was there.
“Stop CPR,” I said, “and give him one milligram of atropine,” intending to block the nervous system responses that slowed his heart rate. The paper from the rhythm strip continued to document the response from the heart as it sped up to forty-six beats per minute.
“He’s starting to stir,” Woody said. “Sir, sir, can you open your eyes?” she asked as she shook his shoulder.
He gave a groan and rolled his uncomprehending eyes from side to side, trying to accommodate his confused vision to the commotion in the room, and he started to wave his arms.
“Don’t MOVE,” we said in unison while the other intern and the nurse pumping his chest jumped to restrain his arms, hoping to keep the precious IV and EKG leads in place.
The tickertape from the EKG continued to roll, and I looked at it a little more carefully, taking advantage of the lull and the relief that the man was alive and I wasn’t going to have to tube him, shock him, or put needles in his heart.
“Hey,” I motioned to the other intern. “Take a look at this. I think the p waves are marching out independently of the QRS complexes. This might be third-degree heart block. What do you think?”
I hoped for some kind of validation, at the least the support of someone else confirming my suspicions.
“I don’t really know,” he said. “I’m transitional. I’m going into radiology.”
Great, I thought. It’s bad enough he doesn’t know, but he doesn’t give a crap that he doesn’t know.
“He needs to be in a unit,” I heard myself announce to the room. “We need to transfer him.”
He wasn’t out of the woods yet. If he had heart block, it meant that the electricity to his Christmas lights were on, but the juice wasn’t getting to the bulbs in his ventricle. A little shake, the bulbs might flicker, maybe go out.
“Has anyone seen the upper level or chief? They have to approve it.” I was stating the obvious. Everyone knew he couldn’t be transferred without their authority, but I couldn’t wait to hand over the man to someone else.
Woody leaned into my ear. “We have a problem. The charge nurse said that the MICU is full, and there’re two codes going on at the same time…that’s why the upper level didn’t come. The SICU’s full too, and some kind of trauma’s got the ORs busy. All available staff are booked. There just isn’t anybody.”
“You have got to be kidding me,” I said, even angrily. “He can’t stay on the floor. Am I supposed to babysit him?”
“They’ll send somebody as soon as things clear up,” she said and left the room.
In fifteen minutes I’d graduated from being an intern to a chief resident but without the benefit of thirty-six months of training. I parked myself in the blue guest chair that occupied every patient room and resigned myself to being behind in the charting, blood drawing, and x-ray checking I was supposed to do.
The other codes won’t last forever, I thought. Someone’ll show up, but my mind drifted to the morning. What if there was no rescue? How could I explain that the other patients weren’t taken care of? I’ll just tell them what happened, I thought. Surely they’ll understand.
I told Woody that I had to have a nurse with me. The comment was followed by a snort and, “Yeah, we’ll see. We have work to do too. The floor’s got twenty-two beds, and someone’s got to give out meds. We don’t have extra staff either.”
I sank a little deeper into the crinkle of plastic upholstery. “I guess I’m the human monitor for the evening,” I said. “Before you desert me, can you hand me his chart? I’ve got to write a note.”
I flipped through the chart, reviewing the admitting note. In a very vertical and angular blue print, it said that the patient was a 57-year-old black man who had never been in the hospital. He had passed out while shoveling snow in his driveway but didn’t remember anything else. His neighbor called 911 when she saw him collapse. He woke up quickly once he got into the ambulance, even arguing that he didn’t need to go to the hospital because he felt okay, but the paramedics convinced him otherwise. The ER found nothing wrong except a few bruises on his shoulder but admitted him for observation. He’d done a tour in the Korean War, so he was brought to the Veterans’ Administration hospital.
Their physical exam was pretty much normal except for obesity. His blood count, electrolytes, chest x-ray, and EKG were all normal. The ER had ordered a drug screen, probably overkill since it didn’t show any trace of marijuana or narcotics, and from what I read, he was pretty much a straight-shooter, married with a couple of kids, and worked in a machine shop. The presumed diagnosis was syncope, doctor-talk for fainting, perhaps brought on by the combination of overheating with exercise, unrecognized heart disease, or some rhythm abnormality. The plan was to watch him, make sure he didn’t have a heart attack, and get a cardiology consult. Pretty routine, I thought, and began to document the events that had just transpired.
As I wrote the last line of my note, the spikes on the rhythm strip that coiled in my lap went slower and slower. He hadn’t really said anything that made much sense since all the commotion, but now he piped up, “Doc, I don’t feel so good.” After a feeble attempt to sit up, he fell back, out cold. The only way that I could get help was to reach for the cord above the bed to call for a code, again.
It turned out he was arousable. A tough rub of the knuckles to the sternum triggered a moan, “Hey, that hurts,” as he struggled to push my hand off his beefy chest. When Woody and another nurse came back into the room and checked his blood pressure, it was really low.
It was clear that he was unstable and had symptomatic heart block. The electrical impulses between the top and bottom of his heart were not in sync, and the ventricles responsible for the pumping action of the heart were not able to deliver enough of a blood volume to maintain his pressure. I ordered more atropine, thinking that it had worn off, but I knew now that this was only a temporary fix. He needed a pacemaker, a drumbeat of electricity necessary to stimulate the ventricles into systole without relying on the natural conduction system of the heart. And he needed a cardiologist. I didn’t even have an intensive care unit. The medical student had disappeared too, along with the radiology-bound intern. Probably hiding in the call room, I thought and paged the cardiology fellow.
“Listen, it’ll take me forty minutes to get there,” he said. “I think you should put in a transvenous pacer.”
“I’ve never put in a pacer,” I croaked. “I’ve never even seen one done before. That’s why I called you.”
“Well, the guy’s unstable,” emphasizing the uncertain and urgent nature of the problem I already knew existed. “Have you ever put in a central line?” he asked.
“Yes,” I said, trying not to sound overconfident.
“If you’ve put in a central line, then you can put in a pacer. Same concept. Just get it started. Tell your upper level when he shows up and I’ll call my attending,” he said and hung up the phone.
“Woody, I need a pacer kit,” I ordered and did my best to explain that I would be the one using it, but that the fellow would be joining us.
I knew she was hiding her surprise, even concern, when she replied, “Well, that’s a first,” but added, “I’m sure he’ll get here soon. The roads aren’t that bad.”
I was grateful that the man was asleep or unconscious and didn’t have to hear me tell Woody I’d never put one in before and that I wanted to read the instructions before we started. I took some deep breaths. Woody must have noticed because she put a gentle hand on my arm. “You can do it. I wouldn’t let that other guy try, but you can do it.”
We unlocked the brakes and pushed the bed away from the wall so that I could get to the head of the bed. I had them position the EKG machine with the rhythm strip on my right so I could turn my face to see it. Woody was responsible for charting, checking the blood pressure and pulse, and delivering any medications. I looked up at the clock, “Start time, 10:35 p.m.”
I took the pillow under his head and threw it onto the chair. I positioned his head so that he was looking to his left. I took the penlight out of my pocket and shined it at a thirty-degree angle to see the pulsations of the vessels underneath. Noting the carotid artery, the external jugular vein, and then the position of the internal jugular vein, I identified the sternal notch, clavicle, the two heads of the sternocleidomastoid muscle, and my imaginary line to his right nipple. This was my angle of entry.
This is just the same as putting in a central line, I told myself. Put the needle in, withdraw blood. Make sure you don’t hit the carotid, then slide in the wire. Pull out the needle, advance the dilator over the wire. The only thing different is attaching a sheath. Then pass the pacing catheter into the right heart. Bingo. That’s all. Turn it on. I tried not to dwell on all the bad things that could happen, like puncturing the carotid or collapsing a lung.
I took my cue from Woody. If Woody knew how nervous I was, she didn’t let on. She precisely assembled the kit on a table next to the bed and turned on every light in the room with the efficiency and authority of experience. She put on a sterile gown and pointed to mine as if we’d done this together a thousand times before. I pushed my arms through the plasticized blue paper, secured the belt, and slipped on the smooth, faintly powdered, sterile gloves.
“I gave you size six-and-a-half,” she said. “Your hands aren’t that big,” and handed me the plastic packet with the povidone-iodine cleaning swabs.
I took the first swab from her and started to clean the right side of the neck in a circular motion, starting in the center and moving outward. After cleaning it two more times, I asked for the drape. I positioned it so that the center cutout was positioned directly over the brownish-yellow area I’d just cleaned. I patted it into place, noting that the excess iodine had run down the side of his neck in brown rivulets, staining the bed sheet, even dripping onto the tile floor.
I looked into the kit and reached for the ampule containing the lidocaine, broke the glass top into a short stack of gauze, and withdrew five ccs into a syringe. Then I injected the anesthetic. Not so bad, I thought.
“How’s he doing, Woody? Pulse and blood pressure okay?” I asked.
“Still good.”
“Keep checking. Let me know how he’s doing.”
I asked for the syringe. I slid the needle in slowly, aiming in the direction of his sternum and nipple, aspirating the whole time. At a depth of about an inch and a half, I got blood and stopped. The blood was dark red, not pulsatile, so I was sure it wasn’t the carotid artery. I pinched the needle with my right index finger and thumb and removed the syringe. “Hand me the guide wire,” and used my left hand to thread the needle with the wire. Then I withdrew the needle and advanced the introducer into the vein and removed the wire. Hallelujah. Step one done, I said to myself.
Now that I had access to the blood vessel that led to the heart, the next step was to attach the sheath to the introducer and thread the catheter with the pacer wires directly into the right heart. This was the hard part. How was I supposed to know when it was there? It’s not like I could feel my way around or see where the wires were since there was no fluoroscopy.
“Woody, put those instructions on his chest so I can see them. And hold the rhythm strip a little higher next to me so that I can see what’s going on.”
All I could think was, This is stupid, really stupid. I can’t guide myself through this guy’s heart based on some cartoon diagrams I’ve got propped up on his chest. What was I thinking? I don’t know what I’m doing. What happened to “see one, do one, teach one”?
Woody looked up at my face, saying, “I can’t hear you,” as if the involuntary movements of my lips were actually instructions for her. I switched to giving the directions out loud, letting my secure, confident self give instructions to the shaky, sweaty one.
“Okay, the wave form changes based upon the location in the heart. If it’s in the atrium, it looks like a big p wave, and the QRS spike is small and narrow. When you pass the mitral valve into the right ventricle, it starts to get taller and broader,” I announced. I get it, I thought.
But what if I passed the catheter too far into the pulmonary vein and into the lung? I could perforate the vessel. If that happened, instant death, so I decided to keep the negative thoughts to myself. Woody didn’t need to hear that if the catheter tickled the heart, I could precipitate ventricular tachycardia, the anarchy of electricity where the heart would not be able to rest long enough to fill with blood, let alone pump it to any tissues. Even his slow rhythm was better than no rhythm. At least it generated a heartbeat and blood pressure. Of course she probably knew this but kept quiet, doing her best to keep from reminding me what we both already knew.
“Hey, Woody, I hate to ask you this, but could you wipe my forehead? It’s really hot under this gown.”
Once we cleared the hurdle of the atrium to arrive in the ventricle, it was time to hook up the pacing catheter to the pulse generator and apply energy to stimulate a rhythm. Now I had to pick a rate and an amount of energy. Since this was a single chamber ventricular pacemaker, I didn’t have to worry about choosing the setting for the atria. I picked eighty beats per minute. It was a normal rate yet faster than his native rhythm. The instructions said to start at an energy output of fifteen milliamperes and sensitivity between two to five millivolts.
I looked at the doorway. Still no one.
“Well, it’s now or never,” I said. “Turn it on, Woody.” We glued our eyes to the EKG strip.
Nothing.
Nothing happened. We watched it a full minute. His heart rate was still thirty-two. No pacer spikes.
Shit, I thought. “Let me see that box.” Panic. “Bring it a little closer to my face,” as I examined the unit. “Turn it off again. Recheck the connections for the wires on top. Does it have a fresh battery?”
She jiggled the connections at the port for the pacing wires. “They may have been loose. And yes, I put in a fresh battery.”
“Okay, let’s try again.” I took a breath. “Turn it on,” with a wordless Please. God, please. God, let this work.
The rhythm strip now showed widened QRS complexes with a pacer spike preceding each one. The rate was eighty beats per minute. Christmas lights were on.
“Check a pulse, please,” I said, placing my own fingers over his carotid, and I knew the pulse was a strong eighty beats per minute before she said it out loud.
She flashed the first smile of the evening with “One-oh-eight over sixty,” and I sutured the catheter into place. I then listened to his heart and lungs, pleased to note that I hadn’t dropped a lung. He was beginning to move around and ask what happened.
It wasn’t long after that the cardiology fellow rushed in. Puffed up with a ski jacket dusted with snow, he yanked a soggy Browns cap off his head. “Okay, let’s get started,” he barked and motioned to Woody. “We need a pacing kit right now,” somehow missing that we’d already gotten the job done. The senior resident followed. “Sorry, it was really busy,” and then the chief resident showed up. He wrapped up his assessment with a succinct, “Strong work.”
All the people I’d wished for had appeared. The patient was bundled up and transferred to the unit.
I took a look around; it looked like a bomb had gone off. There was debris everywhere. Bloodstained gowns and drapes overflowed from trash cans, and empty angiocath containers, inside-out latex gloves, and EKG curls sprinkled the floor. Oxygen tubing going nowhere dangled from outlets on the wall, and flat surface areas were crammed with the remains of plastic bags of saline and face masks. The open pacer kit, pirated of its contents, stood on the tray with a red sharps containers next to it. Iodine and blood stained the floor near a huge cardboard box with a red biohazard garbage bag replacing the patient and his bed. The wreckage a still life of medical exertion.
I thought of how detectives might interpret the rubbish that filled the room if they hadn’t the luxury to interview the people who were there. They might surmise that something serious, even grave, had occurred, but they could never know that the little piece of paper with slow spikes was the decision that I made to give atropine. They would not discern that the recognition of heart block meant dominating my fear to put in a pacemaker. They could never know that the spikes of a paced rhythm was a lifeline to me as much as the patient, and that the garbage bobbing in the sea of this room was the nexus of decisions that helped make a doctor out of me.
I stepped out into the hallway and found a bathroom where I could wash my face, and I looked at my reflection. Bedraggled, with blood flecks on my scrubs and pupils the size of pennies, I looked like I had been in a fight, but you wouldn’t have known that I was the victor. I’d had a good outcome, but I was too tired to even congratulate myself. I was spent. There was no place to sit, so I sat on the toilet. I put my face in my hands and closed my eyes. I let the muscles in my face go. I let my neck and shoulders relax. I thanked God that the man didn’t die and that I’d maintained my wits to do what I had to do. I washed my face and went back down the stairs, back to my floor’s nursing station.
The coffee was cold. The brown liquid stained the rim of the Styrofoam cup, and the clipboard stood exactly where I’d left it. None of my little squares were filled in, and I’d missed the antibiotic level due at 9 p.m. Two hours and a lifetime had passed since that deadline.
I gathered up the things necessary to draw the blood—alcohol wipes, a red top tube, tourniquet, and butterfly needle—as the medical student on our team came up, pockets bulging with a reflex hammer, tuning fork, ophthalmoscope, ruler, and the Washington Manual of Medical Therapeutics, all the stuff he thought he needed to get through the day.
“Hey, I heard there was a code,” he said. “What’d I miss?”
“Come on,” I said. “Let’s walk and talk. Are you good at drawing blood?” I asked. “We have a lady with a staph infection and we need levels. I could use the help.”
He took strides to match my own as we walked down the hallway. “It’s my first clerkship,” he said. “I’ve only tried on my lab partner.”
We stopped outside the room. I knocked on the door and turned to the student. “Here’s the stuff you need,” and handed him the paraphernalia I’d just collected. “You need to try,” I said. “But I’ll stick around until you get it right.”
Gulchin Ergun is a proud Turkish-American and an Ohio native. Gulchin received her medical degree from Case Western Reserve University School of Medicine in Cleveland, and she pursued a fellowship in gastroenterology at the New York Hospital-Cornell Medical Center. Her work is published or forthcoming in Bayou Magazine, Concho River Review, Existere Journal, Journal, Green Hills Literary Lantern, Jet Fuel Review, Sou’wester, Superstition Review, and WomenArts Quarterly.
