Spinning Plates

When I was much younger, I had a fascination for juggling. I learned how to juggle on my own. I could juggle 3 tennis balls, or toy blocks, or even plastic bowling pins. Though I did not and would not try juggling chainsaws.

Juggling is an art. The more dangerous and challenging the feat, the more captivating it is.

Have you seen an act of spinning plates, where the juggler spins several plates on sticks? He goes from plate to plate to keep them spinning or else the plates drop to the floor and break.

plates

Three weeks ago I had one crazy weekend duty. I think it would fall as one of my busiest calls in the ICU in my recent memory. It was so busy that my Friday to Sunday, kind of blended to one very long day with only a few hours of sleep in between.

In one particular stretch of that call, hell broke loose.

I worked on a very sick young man in his 30’s, who was admitted to ICU room 5. I intubated him, placed him on ventilator, placed a large neck catheter for IV access, and started several medication drips on him, all in one rapid succession. I was in the midst of trying to stabilize him when another patient, a lady in room 18, went into cardiac arrest. “Code Blue”* was called.

I have to drop what I was doing on the first patient and ran to room 18. When I got there, the ICU resident was already running the code. After 10 or 15 minutes of CPR and fast paced intervention, we were able to resucitate her back. With her heart rhythm semi-stable, I ran back to room 5, and continued what I was doing.

Not too long after, the patient in room 18 went into cardiac arrest again. I ran back to that room once more. This time I beat my resident to the room and took charge of the Code Blue. My resident who eventually arrived told me that she got hung up in ICU room 16 who was also crashing. I saw another resident who responded to the the Code Blue, but I sent him to room 5, to continue on what I was working there.

After more than 10 minutes of CPR we got our patient in bed 18 going again. It was heartbreaking to see that while the CPR efforts were in progress, the family was just outside the room crying and wailing as we work furiously on their loved one.

After we got the patient’s heart beating again, I gathered her family to a nearby consultation room and discussed with them the dire situation. I told them that there was no guarantee that her heart would not stop again. But given of how sick she was, especially after successive cardiac arrest already, I knew her chances of walking out of the hospital was close to nil, and continuing to do the CPR would be an exercise of futility.

I was talking to the family, when I was called emergently to see room 16 who they were about to call Code Blue. This was the one my resident told me about earlier. We got the patient intubated and hooked to ventilator, started several IV medications and got him stabilized, at least for the time being.

After getting out of room 16, the family of room 18 approached me and told me that they have decided that if her heart stop again, to let her go peacefully.

Less than 30 minutes later, she died.

The patient in room 16 that we attended to also continued to circle down the drain. And despite our efforts, he also succumbed several hours later.

I finally was able to concentrate on room 5 when there was a lull in the chaos we were in. I decided to place him on extracorporeal life support, also known as ECLS** (see previous post about ECLS here), as he would not survive without it. The ECLS team was mobilized, and around 2 o’clock in the morning, the patient was off and running on ECLS.

I have not even mentioned the other 17 ICU patients under my care, but were not actively crashing during that time, nor the other 3 new ICU admissions that came during that span of 4 hours of absolute craziness. I even accepted another patient from an outlying hospital during that period, for whom I ordered our flight crew to fetch. Though the patient did not make it to our hospital, as he was so unstable and our helicopter crew was reluctant to fly him unless they stabilize him more for the flight. I heard he died shortly then.

Spinning plates? Seems like it, right? Sometimes I wonder if I could  keep up with this pace or would I like to continue doing this. Don’t get me wrong I do like my job. But I don’t like the awful stress and the awful reality that comes with it. For it is not just plates that are falling and breaking.

About the patient in room 5? He improved after we placed him on ECLS. He eventually was weaned off ECLS and ventilator after almost 2 weeks in the ICU. He went home from the hospital the other day, walking unassisted and off oxygen.

Success stories like him, though few and far between, keeps us going. After all, I believe it is still worth doing this.

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*Code Blue: an emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a ‘code team’) to rush to the specific location and begin immediate resuscitative efforts.

**ECLS: extracorporeal life support (ECLS) is an extracorporeal technique of providing both cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange to sustain life. It is done by siphoning blood out of the body and artificially removing the carbon dioxide and giving oxygen to the blood by running it through a special machine.

Lullaby and Stairway to Heaven

If you are in an airport you would probably hear an announcement like this: “Flight 201 to Manila, now boarding in gate 7.”

If you are in a grocery store it maybe something like this: “Assistance needed for price check in counter 3.”

If you are in a hotel it may be similar to this: “Ms. Nely Ligaw, please meet your party at the lobby.”

Those overhead announcements are clear and you know exactly what they are calling for.

However, if you happen to visit a hospital, you may hear announcements on the public address system that you have no idea what’s going on, like: “Code Blue in room North 357.”

In case you are wondering what they are about, here are some of the announcements in the hospital and what they mean. Different hospital systems though have different codes, but here is what we have in ours.

Code Blue: a call for a patient that needs immediate attention and resuscitation, like in cardiac arrest or respiratory arrest. (From my standpoint this is the most common call I run to.)

Code Red: there is fire

Code Green: a call to help subdue a patient or somebody with aggressive or combative behavior

Code Silver: a call to find a missing patient

Code Black: there is a bomb threat

Code Pink: a call for pediatric emergency or obstetrical emergency

Of course there are also announcements that don’t need to be decoded, like “Dr. Stork, please call Labor and Delivery,” or “Level 1 Trauma in the Emergency Room now.”

Recently, our hospital adopted a practice of playing a song over the public address system that perplexed me, at least in the beginning.

I was making my hospital rounds one morning with the medical residents when a lullaby, the first riff of “Rock-a-bye Baby,” was played on the overhead paging system. Were they trying to lull the patients to sleep? But it was the wrong time of the day! A lullaby can only make me and the other doctors who are already sleep deprived, more sleepy.

The residents then told me, maybe after seeing my confused look, that the lullaby song was a public proclamation that a baby was just born. Now, it make sense. A lullaby to herald a baby into this world. Since then I have been hearing “Rock-a-bye Baby” being played overhead several times.

As we take care of the critically ill patients, especially in the ICU, and we deal more of deaths than births, my residents and I wonder if we should also play something overhead when a patient passed away, like the tolling of the bells.

A child’s birth is a happy occasion, and the hospital can be proud to announce that kind of event. I don’t think you can say the same with a patient dying. I see a reason why a hospital would not like that to be made public. Yet death is a normal occurrence, especially in the hospital, and is a reality of life.

If they would play a song for every death, then what song would it be? Maybe a bugle call like “Taps.” Or perhaps a hymn like “Nearer my God to Thee.” Or maybe a beloved song like “Somewhere Over the Rainbow.”

One medical intern, who is perhaps a student of classic rock, jokingly suggested “Stairway to Heaven.” I smiled at his suggestion and told him that I like his idea.

I don’t mean to disrespect the dead and their memory, nor do I mock Led Zeppelin and classic rock. My point only is that perhaps we can play something in honor of those who depart, just like we play a lullaby to welcome those who enter this world.

But maybe a lullaby can also be played for the departed, as we bid them a final goodnight.

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Here’s Chloe Agnew’s (Celtic Woman) version of Brahms’s Lullaby.

Code Blue

I was back in the ICU today after 1 week hiatus. It was not a vacation though, as I was in a conference and a refresher course the whole week. In fact, I even felt it to be more taxing, intellectually, as it was a very intense review course. All the lectures were crammed in a week, a knowledge you should have learned in 6 years of post-graduate training. It was a real information overload.

This morning I was back to work. The moment I stepped in the ICU, two “code blue” (hospital emergency for cardiopulmonary arrest) were called back to back. There was excitement, adrenaline rush (experienced by the medical staff), adrenaline push (given to the patients), action, and chaos, as efforts were made to aggresively resuscitate the patients. Sadly to say, we lost both them in spite of all the valiant efforts. What a way to start my day and the week ahead. Now, this is not just intellectually taxing, but physically and emotionally as well.

The sobering truth is that, all the training, all the skills, all the knowledge, all the refresher course (or courses) we got, was not enough to save those two lives today. Would I say all our training and what we’re doing are for nought? I certainly hope not. But I also realized that even with all the training and learning in the world, I will never be able to “save” or “add” life. That ability belongs to a higher authority. I am a mere instrument. And I am at peace with that.

I hope tomorrow is a better day than today.