OK, so apologies to Dickens. All three are the worst of times, if you are the patient, even if they turned out OK.
First code I ever went to. I was a third-year student, told that whenever and wherever a code was broadcast, I was to drop everything and go, right away. Sure enough, in a day or two, the overhead page announced a code in the Coronary Care Unit, not more than a minute away. I went quickly, and arrived to find a very old man on his back not breathing, and a doc at his head with an endotracheal scope in hand and a ventilator tube ready to insert. He looked, and then put the tube down, reached for a ring forceps, a sort of doctor pliers to grab things, reached way down the man’s open mouth, and pulled out a very long piece of meat. The man started breathing and coughing. On his cross-the-bed table that had been pushed aside was his lunch tray. A tiny amount of detective work showed that he was trying to eat his Swiss steak but without his dentures could not chew it, and it wouldn’t separate into bites, and he had tried to swallow more than his throat could handle and had almost choked to death on it. My first experience of systemic malpractice! How could an intensive care unit have allowed this? Also, the whole experience was scary to me, rather than exciting. I was not cut out for cardiology or ER duty.
Second memorable code. I’m several years into practice in one of my two exam rooms, when my nurse raps very sharply and insistently on the door calling my name. The patient in the next room has gone unconscious! I walked next door and found Mrs. Smith, someone I knew a bit, not well, in her late 70’s. She was sitting, unconscious, and then stopped breathing also. You know, if someone stops breathing first, and THEN their heart stops, that’s NOT a cardiac arrest, but if they first go unconscious and then stop breathing, the heart went out first! Well, I told you, I’m not great with emergencies, but I did realize what was happening. I told the nurse to call 911. Fortunately, the average response time for them at my suburban office was 3-4 minutes. I bodily lifted my patient onto the exam table (I know, I should have put her on the floor, but I was in fight or flight mode!). Then I started CPR. I heard multiple ribs break on the first push, but I kept going. The medics showed up, put on the defibrillator leads, and found her in ventricular fibrillation, shocked her, and her heart started up! Wow! So, the CPR was effective, and brief. They took her to the hospital where she was placed in the CCU and on a ventilator. She awakened pretty quickly, but had to stay on the vent for a while because she had too many broken ribs. She made a full recovery. A great save? Not ideal, but not awful, considering the good outcome. Oh, and the reason for the arrest? Well, her treating physician, my partner, had not been monitoring for adverse effects of her diuretics, so the origin was her low potassium level. Malpractice?
Third one. I had a fishing trip planned in the summer with my friend. I was to drive 30 minutes and meet him at 0430. Days are long in summer, and we wanted to be on the water before dawn. However, the day before, Saturday, I got a text from him: “D is not coming fishing tomorrow, he is in the CCU at the hospital”
Wow! So, some kind of heart event. I decided to go see him after church the next day. I went up to the CCU, where I was known, and checked his chart. Then I went into his room.
“Hey, you cancelled our fishing trip!”
“I’m sorry! I had to, I was on the treadmill at the gym yesterday and my heart stopped. I fell off, and they called 911. It took them 4 minutes to get there, but they shocked me back and brought me here. They took me to the cath lab and found coronary disease in an artery, opened it and put in a stent. They say I don’t have any heart damage, but my memory is pretty foggy, ‘cause I was out for a long time.”
“I know,” I admitted. After all, I read his chart first. “I was just kidding. But why did they wait for the medics? Don’t they even have a defibrillator in that gym?
“Yeah, they do, but I guess nobody knew how to use it.”
Right.
Why tell this part of the story? Because the AEDs are now idiot proof, that’s why! Take a look at one at your school, church, office, gym. Open it up. Directions are printed, and also in graphics, like the safety card in the airliner. Oh, and when you turn it on it gives YOU verbal directions on what to do and how to do it. Literally a tutorial, walking you through the process. Anyone can use it. This means YOU!
How do you know when? ABCs of CPR. So, you determine the patient (no longer a consumer!!!) is not breathing, cannot be aroused, and has no pulse. Less than half a minute. Start CPR, call 911 for help, get the AED. Then open it and use the directions. CPR cannot restart a heart in ventricular fibrillation, and many heart attacks do not begin with chest pain, but with a heart rhythm disturbance that results in ventricular fibrillation. 4+ minutes with no pulse, no circulation, and no CPR, no defibrillation means death. Call 911, CPR first, defibrillation ASAP.
My friend would surely have benefitted from earlier defibrillation if one of the many bystanders had thought to use the AED. He had some memory damage from waiting too long.
On the other hand, his wife let him retire so now he can fish more, so there’s a silver lining!