The radio call came in from the ambulance: 4-month old male with "active CPR," had been sleeping on mom's lap, woke up, sat up, took a big breath and slumped over.
("Sat up" should've been our first clue that something was wrong with the report.)
We prepped our code room, set up the backboard for support for compressions, readied cardiac meds based on a typical weight (5-6 kilograms) for a 4 month old, tested the ambu bags and oxygen, and I got the job of watching the clock and marking off two- and three-minute intervals, first for rhythm checks (by the defibrillator) and second for epinephrine boluses. The attending ER physician prepared to "run" the code (that is, give the orders, designate roles, observe for changes). A few strong residents and nurses stood by for airway control, and compression rotations. The primary nurse is in charge of IV set up and pushes. There are a few other nurses, and of course, one designated as "documentation nurse," who is the person I stood next to. The PICU and NICU charge nurses joined us, in fact, and took over for some of the ER nursing staff.
We'd been told fifteen minutes out from the call -- it was more like twenty or twenty-five, and I'm not sure how long in the field the cardiac arrest had been occurring anyway.
Finally, the ambulance arrived and the medics wheeled in the patient.
Well, he wasn't 4 months old. He was 16 months old. So now we had to adjust all our weight-based medications (though that was largely the only effect, aside from the psychological shift). This is, however, a bit interesting because it's pretty unusual for a 16 month old to suddenly collapse. Tentatively, you could explain a 4-month old by "undiagnosed heart trouble" or "underlying metabolic disorder." Sixteen months is past a fairly pivotal window of time where things can look innocuously fine.
Regardless, we began at exactly 18:30. I called out time intervals. We pushed epinephrine, then eventually sodium bicarbonate (given in pediatric patients if cardiac arrest persists longer than 10 minutes), inserted an intraosseous line, and delivered shocks. Mom watched on, bawling and nearly hysterical.
At 19:00, the attending terminated the resuscitation effort. Mom collapsed to the floor.
We cleaned up what we could do, and wrapped him in a warm blanket, so she could hold him and grieve. A short debriefing session was held afterwards for staff to discuss how we felt the code was conducted and just to release emotions. It was revealed that the patient had had a very low thready pulse when the medics arrived at the home. The attending (who is several months pregnant) also expressed her fear that her future child would be one of these unlucky children. In response, I mentioned that working in a hospital, we often forget that our patients are the minority, while daycares and schools host so many kids who have never had a serious problem. We forget that what we see everyday is not normal.
This had been a fairly clear case to me. The patient, for some unclear reason, had suffered cardiac arrest, away from our facility, with a fairly low chance of survival, with prolonged lack of spontaneous circulation. I was prepared he would not survive, and though saddened for the loss of him and the grief of his mother, I accepted his death and the existence of it.
I'm not quite so sure I would have emotionally handled it quite as efficiently if, for example, I had known the patient on a more personal level (although I have experienced several terminal patients during my time, both pediatric [as young as a few days and as old as young adulthood] and adult), or if the patient had been previously stable in-facility and then suddenly collapsed.
Ultimately, as a future MD-to-be (please, please, please!), I am most intrigued by the fact that the patient was in cardiac arrest. Someone made fun of me the other day for "liking" code blues. I replied, "I don't wish a code blue on anyone, and I admit to being an adrenaline junkie. However, code blues in pediatrics, at least, are very rarely fatal." (He wasn't quite comforted by my answer, alas...)
This is primarily due to two reasons: (1) the resiliency of children, both physically and psychologically, and (2) the fact that almost all codes are due to respiratory distress/arrest, not cardiac, implying that once we manage the airway and lungs (intubations, relieving pressure, removing secretions, managing pressure on the lungs/trachea), the patient is very able to survive with minimal impact, if reached within a specific window of time. This is absolutely key.
I'm sure I'll get to see a few more of these full codes, and hopefully a successful cardiac resuscitation as well, hopefully not incredibly soon. I thoroughly enjoyed the experience on many levels, but it's no less potentially traumatizing for anyone else. Regardless, every time I experience one of these, it garners so much incredible content for introspection.
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