A code in the cath lab that was unlike anything I had ever seen

An excerpt from The Other Side of the Bed: What Patients Go Through and What Doctors Can Learn.

As soon as I’d opened my mouth, I regretted it. In the hospital, it’s bad luck to say “It looks quiet,” or anything to that effect. At the sound of those words, alarms begin to ring. In the hospital, crises always seem to come in waves. There are spurts of relative calm, followed by the utter chaos of simultaneous codes.It was a Thursday afternoon, around 2:30 p.m. I was a second-year internal-medicine resident working in the coronary care unit. The emergency room was relatively quiet and we had finished afternoon rounds. I had already assigned all the admissions for the afternoon. Casually, I said to myself, “I might get out of here early.”

Moments later, over the intercom, I heard an announcement: a code in the cardiac catheterization (cath) lab. Codes differ in their severity. A code might be an early warning, a call for additional hands, or an alarm for someone who’s lost his heartbeat — a patient who’s literally dead. I knew right away that a code in the cardiac cath lab meant real trouble. There had to be at least one cardiologist on-site, as well as skilled nurses trained in cardiac resuscitation. If they couldn’t handle the situation, it was serious.

When I arrived in the room, I noticed an overwhelming silence. The only voice I heard was the cardiologist’s, calling the shots as he pumped the patient’s chest. The patient was in real trouble. For one reason or another, a large bolus of air had been injected into the bloodstream. It was going straight to the heart and brain, and it would likely lead to a terminal event.

There I was, right in the middle of the crisis, standing next to the cath lab table where the lifeless patient lay, right in the middle of the crisis. There were plenty of other people who had recognized the severity of the call and responded to the code. The cardiologist singled out the most senior physicians, residents, and nurses, sending everyone else aside. I was one of the residents he told to stay in the action. I’d been involved in plenty of codes; I work well in the middle of things, doing the hands-on work required to bring patients back from the brink. It’s an adrenaline rush. Of course, I would never want to be the patient or his family in that moment, but I’ve always gotten a thrill out of doing the split-second work that can save a life.

This code in the cath lab was like nothing I had ever seen before. We knew that we had to think outside of the box. The cardiologist suggested that we place a needle directly into the patient’s heart and drain out the air. It was like I’d been dropped into a TV medical drama, but with a real patient in front of me. I saw the needle pierce the skin and go right to where the heart is, then saw the syringe pull back air. It was outrageous!

Despite the cardiologist’s impressive work, the patient was still in trouble. I could see what needed to happen next. I told one person to get a cardiac surgeon and another to get a chest saw. We needed to pump the heart muscle manually, as shocking alone would not do the trick at this time. The cardiologist, who could have yelled at me for issuing orders out of turn, expressed his approval with a quick nod. It was surprising that I knew what was needed: I had never been in this situation before. I wouldn’t know what the chest saw looked like if someone had sent me to get it, but I could envision what had to happen. We continued to siphon the air from the heart chamber, repeatedly stabbing the patient with the large needle. Then, the cardiac surgeon rushed in. With a calm tone and a few words, he took charge.

He grabbed a bottle of iodine cleaning solution and poured it over the patient’s chest. This was nothing like the pre-op prep work I’d seen and done before. In medical school, getting to prep patients for surgery was like a carrot for me. If I stayed late post-call, completed all my notes, and sucked up to the attending, the senior physician in charge, and the chief resident, I would be allowed to prep the patient’s skin before surgery. In the operating room, I would do the painstaking work of sterilizing the patient’s skin before cutting. I was taught to carefully spread the iodine cleaning solution and meticulously clean from the inside outward in a slow, systematic approach. In the cath lab code situation, there was no time for a ten-minute sterilization process.

Just at the last moment, a nurse came rushing through the door with the chest saw. The cardiac surgeon grabbed it and cracked the patient’s chest open in less than ten seconds. Upon gaining access to the heart cavity, we found this precious organ lying still. It wasn’t beating.

The surgeon began squeezing the heart, and when he needed to do something else, he told me to grab the patient’s heart and start pumping. It felt like I was in a MASH unit in a combat zone. I did as he said; the feeling was indescribable. I had dissected a heart in anatomy lab, but it felt nothing like this heart which, just minutes before, was beating on its own. Now, the heart was in the palm of my hand. The surgeon grabbed the paddles, called “Clear!” and tried to shock the heart back into rhythm, without success. Then, his voice still calm and clear, the surgeon told me to start pumping again. We moved the patient to the stretcher and the surgeon climbed onto the bed, straddled the patient, and began pumping the heart himself. With the assistance of a security officer, the other staff cleared the way for a direct path to the elevator and into the operating room.

My job was done.

Daniel Mishkin is the author of The Other Side of the Bed: What Patients Go Through and What Doctors Can Learn.

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