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Sounds of a Code

      Yesterday I was jeopardized to take call in the pediatric intensive care unit (PICU). Two words I will never forget. Jeopardy. PICU. Yuck. I've been there before, but this call was different, thus the need to put it down in writing as I sit at my computer on the floor of my living room.
      I hate the dinging sounds in my head that last through my shower, through my nap, and into my evening on postcall days from the PICU. I've got a lot of them going on right now. They are far worse than the monitors in the neonatal ICU, where alarms are gentle and tended to with a quiet, brisk walk and a little gentle stimulation for the preemie with apnea. No, in the PICU it is a whole different class of alarms. The “red alarm” means something really bad is happening. Mostly with cardiac surgical kids. The “lite alarm” just tries to get your attention about some concerning vital sign. There's another alarm that goes off in the call room and means a patient is not where they're supposed to be (as in, a baby is missing, hopefully not stolen). The most annoying, though, is the O2 sat alarm that is musically and metronomically set to change with every point change in oxygen saturation. Every one of our PICU patients has one. De de dee deeee de de do do doo doooo. I can hear them all right now.
      This morning there was a code. For a little girl I met yesterday sitting on her dad's lap, crying and in mild respiratory distress. Only minutes before that she had been leading the cardiology fellow in a game of “you can't get me,” where she kicked and screamed and clawed and was generally just a funny, naughty toddler who didn't want her heart listened to. Somehow, in seconds, she went from that girl to a gasping, choking, chubby little intubation nightmare. Luckily, anesthesia happened to be standing right at her feet, and that was one hurdle crossed. I escorted the parents out to the waiting room at that point. The mother could barely walk. She had no idea how much worse it was going to get. The early resuscitation—for what we think was a viral myocarditis-induced dilated cardiomyopathy—went pretty well to my limited eye. She needed dopamine, a little epinephrine, but she didn't falter during the hours we spent putting in arterial and central venous lines to get information that could save her life. She pulled a fast one on us with labs that showed a coagulopathy. We couldn't figure out why. It was my idea to give her fresh frozen plasma, or so the attending intensivist let me think. We gave it. The nurse was getting ready to give intravenous immunoglobulin (IVIG)—our big gun against myocarditis. We were there, ready to watch it work. The cardiology fellow and I stood there and watched her pressure dip, dip, dip, and then her heart just stopped. And ours, too.
      There are so many things that go with a code. People yell. And run. And sweat. Especially when they do chest compressions, because if the patient's heart isn't going to pump, the compressor's starts working overtime. It's hard, and if you give wimpy compressions, people push you out of the way. Time is surreal, slow and fast together. You can see people straining their brains. I swear my attending wanted to give rescue breaths just so he could stop thinking for a few minutes. I was giving compressions when we decided to see if all that we had done had helped. I took my sweaty hands off of her, sank off my tiptoes, and the 20 or so of us in the room got very quiet to listen to the monitor. “Beepbeepbeep beep beep beep beep beep beep beep beep beep beep beep beep beep beep beep,” and back to compressions. And all the sounds of a code again. It sort of worked. That's what kept us going; we could try harder, maybe she could try harder, and if we all tried our hardest together, we could go back to when she was that naughty little patient. Except her heart was so broken. I was assigned the task of calling the extracorporeal membrane oxygenation (ECMO) people. Including the surgeon. At 4 am. Pretty scary for a tender-hearted, second-year resident. I got the people we needed there, though. Unfortunately, it wasn't fast enough. Our patient had been coded for almost 2 hours before she was placed on ECMO.
      As the surgeons were taking off their gloves, the cardiac fellow said, “There was that point this morning when she started to smell like death.” I thought at first he was talking metaphorically. Then I realized he wasn't. And I knew exactly what smell he meant and when exactly it happened. I had even smelled it before. The third week of my third year of medical school when I was just going to see “my” surgical patient that I'd been taking care of for weeks. She coded right when I walked down the hall. I did chest compressions on her, too. But I know exactly when I smelled it then and today. Like metal and blood and sweat and something else very specific, but not something you can even name.
      And just like that, my little patient was hooked up to ECMO. Two giant hoses in her neck and going down into her heart to carry all the blood away to a mechanical oxygenator and pump it back again. A desperate last resort, but of course her family just thinks it's another treatment that we do quite often. (Because, unfortunately, here, we do.) They can't understand why we're putting ice packs on her head and face. Or why her tummy is so distended. Or why she has to lie on her back, naked, exposed, back arched, hands limp, like she is already dead. Maybe she already is. The mom and dad stand there and hold her warm, little hands. One of the attendings I called in from home whispers to me that there are always miracles. I look into her face for a glimmer of hope, and then she adds that this kid is not going to be one of them. I realize that morning has come and there is lots of other activity going on around the unit. I can't look away from my patient, though. It kind of hurts to look at her—it's raw and powerful and you really want to look away. Yet, it makes you feel very alive to see her like that—which is sick yet true—and then you're all confused. In the end, it's just sort of this gut-wrenching feeling. And all of a sudden I'm postcall. I go to the stairwell to gather my heart out of my stomach, and then I am okay to sign out to the day team.
      I'm still caught standing outside her door. I've just spent my entire night with this girl and am not sure when is an appropriate time for her, me, the staff, her family, or anyone really, to leave the playing field. This place is all I've known for the last 30 hours. I've had to pee for the past 5. And I'm just not sure how to break away. How do I make my exit significant? Walking out of that hospital is something I do every day—smelling the Starbucks, trying to remember where the hell I parked my car because I always forget postcall and have to check 7 floors before I find the right one. I think it should feel different today because I just left such a life-changing event. Life changing for a lot of people, not just her family, but even those of us who were there trying to help. Doctors are a funny breed of people. Who would volunteer to deal with these impossible situations: deliver bad news and get your hands covered in blood and go without sleep and water and toilets, all for these kids? Who we probably can't even save. How are you supposed to leave with all these thoughts in your sleep-deprived mind that's a little bit crazy? And you do it—you walk out of the PICU and past the line for coffee and out into the cold, quiet December morning air. And you take a big deep breath and realize that your life has changed. Even though hers might be over and she's only 16 months old. She affected a lot of people today. Enough to get me to sit down and do this computer diary, Doogie Houser sort of thing. Enough to leave images in my mind that probably won't ever leave. Oh, my brain hurts, and my bladder really hurts, and so do my chapped lips, and my stupid sore runner's hip, but mostly just my heart.
      Usually I fall into sleep so easily. Today, I'm not even tired. I can hear those monitors beeping and the sound the respirator bag makes during CPR. And I'm hungry and nauseated at the same time, and I can't quite get that picture of her out of my head. But it doesn't feel the same as it did while I was there, so I think eventually I'll heal like everyone else there today will have to do, in their own way and time. But there's no way people can step away from a situation like that unchanged. At least I can't. And in a little while I'll go back to the PICU for more. But this is the end of this job—for me—for today.