Cardiac Arrest

I had the distinct "honor" of experiencing my first cardiac arrest patient and full code this past Sunday.

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.

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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. 

University of Washington

Decision: rejected, no placement on the alternate list.

Apparent rationale: lack of understanding of patient-physician relationship, encouraged more physician shadowing.

Personal response: disappointed, angry.

To elaborate: I feel the recommendation is unclear. I shadowed two physicians, interviewed another, and I've worked 3000+ hours in clinical care, at least half of those alongside physicians. While their rationale may be true, there are suspicions otherwise.

And 2009 Brings...

I had no idea it'd been so long since an update, but it's been busy and I do have substance for you! First things first.

Mom: She is doing quite well, though still lacks energy day-to-day. She is currently planning to return to work in March. One of the interesting new issues is that her workplace is now in a new location in a new facility, and the radiology department has been "downgraded" to a cubicle structure format, rather than the former private reading rooms. This increases the chance the circulating air is infectious and/or irritating, so the administration will need to address this issue before she returns. Supposedly there are arrangements already being made. She is quite excited to return to work in some ways, as it'll give her something to do and of course financially.

Her hair is a few inches long now, and her energy more consistent. She never really lost much weight, so fortunately there hasn't been much issue there. Before treatment, because her spleen was so enlarged causing her to feel bloated and always full, she couldn't eat much, and she is treasuring her normal appetite and ability to eat now.

There really isn't much to say except that the progress is good, and this is great news! It means there are no complications or no scary or emotional stories to share. As much as I'd love to blog about those, I don't want to have to tell them about my mother...

Job: I am now working nearly full-time in the Emergency Department, still in the role of a CNA. I absolutely love it, although it's not a position I'd want to pursue long-term. I am able to do a few new duties, such as more transport, irrigations of lacerations, clean rooms (totally fun), and assist with lumbar punctures, suturing, and other MD/RN-procedures. I like the turnover, the variability, and the staff. It's been wonderful so far, and a good change for me from the Medical Unit. My last day there was fittingly December 31st.

Application Process: Supposedly interview invitations are wrapping up now; I've received three, and I'm hoping to receive more but not anticipating a large number. I have not been accepted anywhere yet, but I anticipate hearing back from all three schools within the next 4-6 weeks. I am trying to figure out whether to anxiously begin preparing for this ugly cycle again, or whether the nervous comments I am hearing are just feeding into each other.

Interviews:

1. The interview at the University of Pittsburgh was a bit startling; you interview first with a medical student, who was surprisingly a first year student, and then secondly with a faculty member. I couldn't form a connection with the MS1, but I felt like the faculty interview went quite well. I'm not anticipating being accepted, due to the shaky first interview, but who knows -- I will receive news hopefully by the end of January.

2. I have also now completed my interview at the University of Washington, over the winter break. Supposedly they meet today to discuss outcomes, although I'm not certain my application will be considered. I could potentially hear back by the end of this week or next week. This was a stressful interview, because the structure involved a three-person panel with one interviewee. They were also much more pointed in their questions than U Pitt, and more future-oriented. U Pitt focused more on how students came to the point they wanted to practice medicine, than on how they envisioned healthcare developing. I am hoping for an acceptance, but I would be pleased with a waitlist at the least.


3. I am scheduled for an interview at Creighton University next week, in Omaha, NE. It is a Jesuit institution, and I am told they often interview students from Jesuit (or Catholic) undergraduate schools (and Seattle Univeristy is one). This is a less research-oriented school, which I like since I am more clinically-oriented, but aside from that, I have yet to read deeper into its goals. I have heard all good things nonetheless, and I like their focus on social justice and outreach medical care.

So that is where things lie presently; very hopefully I will have great news to share by the end of the month, but it is highly possible I may have only more suspense to endure (with waitlisting or even rejections from these schools). I can't help but feel very stressed out!