When Mister Q requested banana pudding for breakfast yesterday morning, slightly cranky from being NPO after I had operated on him 4 days earlier, I had no idea that 12 hours later I would be standing at his bedside racking my brain as nurses pounded on his chest and pushed ampules of medications through his central venous line. Time ticked by nearly audibly. His EKG tracing bounded with every rib that cracked. Stop: analyze rhythm. Stand clear! Shock. Asystole. Continue compressions.
One of the first patients I saw on my most recent rotation on Trauma Surgery was Mister Q. He was pleasant, sitting up in bed at 6 am, ready to be discharged. He had been in a motor vehicle accident and suffered a traumatic duodenal perforation that was managed non-operatively. He tolerated a diet and went home. A couple weeks later he returned with a duodenal bleed that was initially managed endoscopically. His family begged for surgery, stating that he lived an active lifestyle and attended every high school football game in the area. They could not fathom the idea of taking him home to bleed again and die. He went for laparotomy.
His postoperative course was incredible. He tolerated tube feeds via a transnasal feeding tube into his small intestine immediately following surgery. His bowels began working as evidenced by the passage of gas. He even walked into the hallway several times. I was thrilled.
On the morning of his event, he dropped his oxygen saturation and his breath sounds became coarse on one side. Possibly a brewing pneumonia, but the white blood cell count was still normal. He was peppy and ready to eat, but we weren't quite ready: he still had to heal his gastric anastomosis so that the food would empty. That afternoon he became tachycardic with a heart rate in the 150s, with an irregular rhythm. A sign that the heart was being stressed, possibly from fluid shifts after surgery. By the time the medicine team was called to evaluate their patient, he was falling out of bed, losing his pulse, and a code was called.
"Code blue, room 726" I heard over the emergency department loudspeaker. I was taking care of new trauma admissions after car wrecks but looked down at my list and realized it was Mister Q. I sprinted for the elevator. Several medicine residents nonchalantly called for me to hold the elevator and stuck a hand in. They are trying to figure out where the code is. They don't know Mister Q supports high school football or likes banana pudding. "Well hurry!" I am worried. A code blue is an unfortunate circumstance at best, a nightmare when it is your favorite patient and he is 7 floors away.
He is being ventilated with a mask and with every breath squeezed on the bag he spits up more dark vomitus onto his face and the bed. Suction! Anesthesia is at the head, I stand at the side and open the laryngoscope which the anesthetist places and intubates with some difficulty. Chest compressions continue and with an effective crunch, vomit spews from the endotracheal tube. I place a oral tube into his stomach carefully, remembering my sutures in the stomach and wondering what difference it will make now. Epinephrine. Epinephrine. Vasopressin. Amiodarone. Magnesium. Calcium. Epinephrine.
Hold compressions... V fib. All clear! Shock.
After 30 minutes the code is called. He has no pulse and further attempts would be futile. He is disconnected from the ventilator and the room, previously full of people with overflow into the hall, empties.
We stand and discuss what we think happened. Did he have a cardiac event? A pulmonary event? A bleed? No, not a bleed. Was he bleeding from his gastric tube? No, come look, it is not fresh blood, it is normal postoperative blood. We walk back into the room.
The vomitus is dark, we note. Then Mister Q heaves a gasp. He is breathing. My hand goes to his groin. He has a pulse. I grab the bag and reconnect it to his endotracheal tube. His heart is beating on its own.
Call the code team back! We cheer. We roll the bed out of the room to take him to intensive care immediately. He is pushed into the elevator. He loses a pulse in the elevator. Once out of the elevator, he is undergoing chest compressions again as he rolls into the unit. It is family visiting hours. We call out for family members to step back as the bed comes careening down the hall.
I place a new central line, we complete 30 minutes or so of compressions and medications, and he regains a pulse! We decide to induce hypothermia, a protocol designed to protect from ischemic brain damage in cardiac arrest. I place new lines and we begin transfusion of massive amounts of blood products. He is teetering on ridiculous doses of IV drips that cause his peripheral blood vessels to constrict so that he will have enough pressure to perfuse his brain and organs. His labs show that his liver is already hypo-perfused and his clotting factors are not functioning, therefore he bleeds from everywhere, even his abdominal staples from 4 days ago.
A code blue is called yet again. This time the family wishes to be present. They call off CPR, no more compressions on his poor flailing chest. But Mister Q is still not ready to give up. He comes back again with a pulse. Decision is made to terminally extubate considering his brain perfusion has been inadequate for hours.
I go in to pronounce him. I listen carefully to his heart. It is not beating quickly now the way it was when he watched football, hoping that the underdog would come back for a big win. I looked at his eyes, fixed, dilated. His skin is already cold from the hypothermia protocol, despite his heart beating until a few moments ago.
Sometimes in football you play teams that you beat once in a blue moon. A field goal, a sack, a moment's encouragement that your team is playing well, that you might just win. Then the opponent drives for a touchdown. They intercept, and touchdown again. That sinking feeling that you lied to yourself. That we all believed we could bring him back and that is why we worked so tirelessly. Good fight, good effort.
Rest in peace, Mister Q.
