The day-to-day experience of a physician-in-training is difficult to understand and digest for outsiders. After years in medicine, I have found it on occasion quite hard to describe life as a resident or fellow to those in other occupations. (Admittedly, this is not a one-way phenomenon: those in other career paths will often have a hard time getting me to grasp what they go through.)
There are particular defining moments along this long and winding journey that --- for better or for worse --- stick with you, occasionally bubbling up to front of mind involuntarily on the walk home from work. Sometimes these memories come up with no particular trigger or for no apparent reason. Sometimes, they are positive, like warm feelings of comraderie among teammates, or the satisfaction of a job well done on a long overnight call. But sometimes, like the one I am about to describe, they are memories of those moments in the hospital marked by powerlessness and the guilt and shame of not being able to help the person in front of you. And I believe these moments, accumulated over years, amount to some form of trauma unique to a career in medicine.
Internal medicine residency is a whirlwind. You start out as an intern, pulling 28 hour calls on general medicine admitting patients with a mix of run-of-the-mill emphysema or heart failure, sprinkled in with the occasional exciting zebra case --- perhaps some rare infection (monkeypox?) or immune dysregulation. As you rise in seniority, you quickly move into a team-leadership role as a junior, caring for dozens of patients at a time and managing residents and students. At MGH, senior residents adopt even higher-level roles, overseeing hospital operations by directing admissions from the emergency room and guiding transfers to the intensive care unit. One role of the senior resident is to carry the Code Pager, a beeper that squawks whenever someone in the hospital acutely declines (via a rapid response) or experiences a cardiac arrest (Code Blue).
"Running a code" --- leading a team through a cardiac arrest --- felt like one of those crowning experiences for senior residents, a sign that you've made it as a real doctor. But it was not something I looked forward to. Throughout all of residency, as I grew comfortable making decisions and leading teams, I still viewed leading a Code as something out of reach, something terrifying and difficult, something I'd never be ready for, regardless of the countless times I practiced in the sim lab. The Code Pager was a hot potato, and my anxiety spiked every time it came around to me when I became a senior. Some of my co-residents told me that it was not unusual for some residents to graduate without ever having the Code Pager go off on their shift. Secretly, I hoped that would be the case for me.
But one night at 3am the Code found me while I was on call. The trill of the beeper shook me from the patient note I was writing, and my heart sank as I read the dim text: "Code Blue, Lunder Building". The other residents in the call suite stood up. We were on our way.
Like many other hospitals, MGH is an odd amalgamation of old and new buildings glued together. To get from one end of the hospital to the other could take 5 minutes or more, especially after accounting for the elevator ride. During the entire 5-minute jog from our call room to the Lunder building I found myself wishing to get paged again, "Code Cancelled, false alarm", as sometimes happens. But it did not. When my troupe arrived huffing and puffing at the bedside, I found myself facing a young 20-something-year old man, unconscious in bed, nurses panicking. He had lost his pulse.
I remember that moment very clearly. I stood at the side of his bed in a panic for what felt to be an eternity but probably was only 5 seconds, until my co-resident said "Hey, do you want to start some meds?". That kicked me into gear, and I assumed my position at the foot of the bed. I pulled out my phone and started the ACLS app, barked orders to start compressions, and the chaos of the Code Blue began.
A Code is not something easily described, and not often portrayed accurately on medical shows. It's what I would call "organized chaos" most of the time. The patient's room is swarmed by nurses, interns/residents, respiratory therapy, among many others. One of the first things I learned to do is to clear the room, so I yelled for everyone who didn't need to be there to please leave. During a code, we run through the ABC's of cardiac arrest, ensuring prompt initiation of compressions and assessing the airway. The senior stands at the foot of the bed, makes sure that someone's doing adequate compressions, someone's starting access, and that meds are given at the appropriate intervals. Despite the initial chaos of getting everyone set up, perhaps what's most unnerving is the quiet that typically follows. 5 minutes into a Code, after compressions are started and meds are given, and after everyone starts to try to figure out what the hell's going on and why this kid is arresting, there is an awkward period of not being able to do anything until the couple minutes are up for the next pulse check and the next round of epi.
Such was the case here. 15 minutes in, after several rounds of me announcing "Pause compressions, pulse check. No pulse, resume compressions" I was running out of options. We had given multiple rounds of ACLS meds and continuously given high-quality CPR. I looked around and asked if anybody had any other thoughts. We placed several calls to ECMO to consider life-support, but because of this patient's medical history he was declined. Occasionally, one of the other residents would yell into the room the results of some labs, or some additional piece of medical history that they managed to dig up in the patient's charts. Nothing changed. After 10 more minutes, I started grasping at straws. Should we give this kid tPA? Could this have been a PE? No, said another resident. He's had a stroke before, tPA is contraindicated.
At one point, during a pulse check while I was assessing the rhythm, I thought I saw a few beats of ventricular tachycardia, a shockable rhythm. I remember frantically asking a co-resident, "Hey, is that VT? Should we shock him?" He said "I can't really tell, maybe we should try." But as soon as he said that, the rhythm degenerated into asystole, and we continued with ACLS as we were doing.
There comes a time in every Code that lasts this long, maybe 20-30 minutes into chest compressions, when nurses and residents start giving each other "the look". This is the look of futility. It's the look that quietly says, "I don't think we're going to save this patient, this has been going on for a while." Half an hour into this Code, I could tell people were starting to give each other knowing glances. I ignored them. This guy was only 20 years old. We had to save him.
But minutes later, nothing changed. His labs were getting worse. The attending, who had been standing by me observing the event, finally said "Hey, maybe we should wrap things up." That's when I knew: my first --- and only --- Code Blue was going to end with the patient dying. I announced to the room, "Let's do 2 more rounds of good compressions. If anybody has any thoughts on other things to try, please let me know, otherwise we will discontinue CPR after 2 more rounds." The room remained silent, with only the sounds of compressions (by this point, the LUCAS device was delivering the compressions mechanically), and my occasional commands to "Pause compressions for a pulse check. No pulse, still asystole, resume compressions."
In the end, the inevitable happened. This young patient, whose name I didn't even know, did not regain a pulse. So quietly, we discontinued CPR. A moment of silence, and the room cleared.
The night went on. My shift did not end until 8am. In that period, I held a debrief session with the nurses and physicians involved in the Code. Some were familiar with the patient and shared a few memories. Some cried. Many expressed gratitude for our tremendous efforts in the end. Sometimes, cardiac arrests are not unexpected, especially if the patient is old, sick, with known cardiac disease, and had been declining. It was not the case here. This was a young man, who had been improving after a lengthy hospital admission. Nobody knew why his heart stopped that night. His passing was a surprise to everyone.
The rest of the night was a whirlwind. I returned to the on call suite, where I continued to take overnight medicine consults and review new admissions with interns. The hospital doesn't stop after a Code Blue.
When I stepped out into the brisk morning air at 8am, I felt something had changed. Despite usually being exhausted after a shift, I could not sleep. I stayed outside and went for an hour long walk.
In the weeks that followed, I had nightmares about the Code. I dreamed of the Code Pager going off. Sometimes in my dreams, the patient would survive. Whenever this happened I would wake with the crushing realization that no, I did not save the patient. He did not live.
I have since replayed that night in my head more times than I can count. I sought more debriefing sessions with my colleagues and my attendings after that event. Should I have pushed for tPA? Was it VT that I saw in those brief seconds during the pulse check? Was there something I missed that could have led his heart to start pumping again?
The debriefs always go something like this. He did not die because of anything you did or didn't do. When a patient's heart stops, he is already dead. Your job then is to simply give the heart the slimmest chance of being resuscitated. No, you could not have done anything more for him. It was a well-run code. You did everything right and stuck with the algorithm.
It's now been over three years since that fateful night. Moments like this one stick with me. Partly it's because of the sense of responsibility physicians have over their patients. We invariably want to do right by our patients and to improve outcomes, and in cases like these, poor outcomes trigger our natural tendency to look back and see what we did wrong. Partly it's because of the feeling of frustration and helplessness, of not being able to change the trajectory of a heart stopping, of still not knowing precisely what happened in all that chaos.
Sometimes, on days like today, when the winter cold is letting up into the springtime sun, I take a walk in the nearby park. Sometimes, like today, these memories resurface out of the blue. I spiral a little, imagining how things might have been different if I got to the room a minute sooner, or tried shocking his heart, or had the pharmacy prep the tPA. It takes me a while to run through the debrief sessions I had afterward, for me to settle down again and take a deep breath knowing I did all I could with what I knew in that chaotic half hour.
There's a growing graveyard of other memories. Patients not getting better despite best efforts. Patients dying for reasons outside of our control. And this graveyard will grow over the course of a lifelong career. It's no wonder that physicians become desensitized to this stuff; we have to, in order to move on and continue to deliver good care.
There's an irony in the privilege to be a physician, that the elation of making a positive difference must come with the burden of death and loss. But in medicine, you don't get to keep the privilege without also bearing the weight. The job is to learn to carry both.