Death packet

Brenda Nuyen, MS4 at UCSD SOM

Code blue, the intercom serenely pronounced. Always said in such a matter-of-fact tone. It is an orderly packaging of un-orderly words, attempting to regain control of an uncontrollable situation. That day was my last one on this rotation, a beautiful altogether matter-of-fact Sunday. Who could have known that despite all, the day was heading towards uncontrollable.

My intern and I were seeing another patient that morning when we heard the announcement. Per the usual, we perked up our ears; per the unusual, our eyes widened when we realized the patient could be ours. The intern ran out of the room to hear the intercom better, and heard some nurses mention the patient’s name. From that moment of realization was a blur of actions. Ripping off my gloves. Sprinting down the hallway. Jamming the elevator button. A whole lot of movement, not a whole lot of thought. I could not process the fact that this was our patient who basically had been announced on the brink of death. It was my first code, and I did not have the benefit of observing one with less emotional connection – there was no “easing into it,” if this situation could possibly even be “eased” into at all. Running down the hallway to where the patient was, I was amazed that the nurses and RT’s pointing us in the right direction were so calm, so controlled. They, unlike I, did not personally know the patient. They, unlike I, had seen this before. Security officers were standing outside the room with their arms crossed in front of them, just like they were presiding over some concert in the park and were keeping tabs on it. Keeping calm, keeping control.

The room was full with people and quiet concentration. If despairing anxiety was at all present, it was well masked. An ER attending led the code with expertise, and the code team shocked, pushed meds, bagged. I got in line to do chest compressions, all the while frantically reviewing in my head what I had practiced on a dummy in the Price Center ballroom just months before. Before I knew it, I had to climb a step stool and fling my knee onto the hard surface where the patient lay, in order to get into position. What hit me first was that the human chest is not unlike the dummy chest. It was springy, and responded jauntily to each up and down, up and down. The body jerked with every compression, every shock, every attempt to intubate. Some blood trickled out of the patient’s mouth with each time the tube was jammed into it. All these signs of life – the flowing blood, the dancing movements of limbs and head – were so discordant with the realization that the patient was slipping away. 22 minutes went by, and with the fourth shock, the ER attending announced asystole on the monitor. As I was wrapping my mind around that declaration, he – never wavering the tone of his voice throughout – asked for any objections. I felt the futility of the moment rise from the bottom of my stomach. I wanted to say something. I didn’t want to hear that it was the end. No one moved; no one spoke. The attending said, in the same tone in which you would order a coffee and pastry, OK – time of death is 9:09am.

I could barely hear someone murmur that the clock in the room was 5 minutes slow, and I hardly registered that the attending corrected himself and announced 9:14am. The room still continued in calm motion, but now in the packing up of equipment, the grabbing of stethoscopes and white coats, the heading towards the exit. Except I just stood there awkwardly, thinking what now? My team huddled in the corner around me. I had never seen my attending and residents so crestfallen. In a way this dejection reassured me, that what I was feeling was normal, and that we were allowed even just a mere moment outside of the bubble of calm unfeeling precision that is the protocol of a code.

We headed upstairs to talk to the young granddaughter of the patient, who did not know what had happened. Neither did anyone else we passed in the hallways. Riding the elevator back up and walking through the floors, I saw everyone go about their business. Nurses were charting, patients were ambulating, visitors were carrying balloons and small children. It really was another day. I felt that I was walking in a glass box, that there were walls shielding me from the normalcy of this beautiful Sunday and shielding others from the tragedy we had just experienced downstairs. We were all occupying the same physical space of the hospital, just not the same emotive space.

My attending made the necessary phone calls, and the discussion with the family unfolded in a private room with a social worker. I watched as these people I had never met express emotions and thoughts that strangers rarely see or hear. The team sat in acceptance of the grieving process and the sobs and the silence. When we left the room, I was thinking that although I likely would never see them again, I was tied to this family in some way, a connection more profound than what I share with even some people I see day in and day out. This experience would be an indelible thumbprint in their lives, and even if not as deep and wide, in mine as well.

At the nursing station, my intern dug out a manila envelope. On the front was a big sticker, displaying tall composed capital letters – “DEATH PACKET.” In it was a stack of papers to fill out, with numerical steps and bullet points and signature lines and fine print. This clean orderliness reframed the sense of calm manufactured by the operation of the code. Here we were again, trying to regain control of something that fell out of our control. The rest of the day, the team continued to round on patients, put in orders, and type up our notes. But there was no way we could pretend it was just another day. Sitting amongst ourselves, we fought with our doubts settling in our minds and in our stomachs. We knew that there was absolutely no way that we could have predicted that what had happened would have happened that morning in that way. We would reassure each other, but then soon enough we would be back revisiting those doubts.

When I left the hospital that day, this last day of the rotation, I walked to the parking structure, and instead of driving off to enjoy the gorgeous afternoon, I sat in my car and cried. I had to step outside of that bubble of unruffled precision and confront the un-calm and the un-control. I did appreciate the methodicalness – without it, how could the hospital continue to function? How could other lives be cared for and bettered and saved? But it was taking me some time to process the event and come to terms with the fact that for the first time, I fully realized that I for a lifetime will be standing on the cusp of life and death and will have to stare into both.

I continued to reflect on the events and emotions of that day, and for some time, the bruises on my knee that had climbed onto the CPR surface board reminded me that I had reached a milestone in my training. I am sure that with each future code I am a part of, I will be more able to envelop myself in the calm and control with which the neat lettering of DEATH PACKET was imbued, the precision that allows us to confront death time and time again. But I also hope to never lose that human edge of un-calm and un-control, that keeps us present and connected with life.

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