Code 45

I work as a paramedic. On average, I respond to between five and eight calls in a 24 hour shift. There are days when I sit and wait for the pager tones to go off, but nothing comes in. Other days, I can’t finish one report before getting called to a new scene. Shortness of breath calls, chest pains, falls, weak and dizzy, diabetics, unintentional and intentional overdoses. Day fades into night, the patients faces’ blur, the details get fuzzy. Then I hear the pager go off with words that snap me awake:
“One-nine, call in code 45.”

A ‘code 45’is a full arrest. All spontaneous breath has stopped, the person is completely nonresponsive, and there is no pulse. Clinically, the person is dead, and the clock is ticking.
Racing to get my boots on, I flew out the door and into my truck, thanking God once again that I live so close to the station. For nights that I’m on call, it’s a life saver. Literally. I’m at the station and jumping into the rig with my call partner within four minutes. We tear off towards the neighboring town to assist the duty crew that’s already en route. Radioing the hospital that we have a suspected full arrest, my partner guns the turbo diesel and maneuvers it through the evening traffic. Being the day after Thanksgiving, it was heavier than usual, but in my hometown of less than ten thousand, it’s never really that bad. Once out of town and heading for the scene, he’s got us doing ninety plus, lights and sirens all the way. We listen over the mayhem for radio transmissions on patient status updates. Five minutes into our sprint, we hear the first crew call in to dispatch that they’re on scene, with the local first responders already there and performing CPR. The radio goes silent. All we hear is the wail and scream.
Taking a fast left onto a gravel road, we kill the siren and start reading fire call numbers. Luckily, we didn’t have to search for long. Cresting a hill, we saw the valley to our right lit up like a landing zone and knew we had the right place.
Inside, every light was on. There were three first responders, one county sheriff, and the two members of the primary crew. The patient’s husband was sitting in a wheelchair, surprisingly calm. He gestured almost imperceptibly to the bathroom in front of him. Turning the corner, I saw our patient.
She was a tiny woman, maybe 5’4” and a buck-fifty soaking wet with boots on. Now, she was dead weight. No pun intended. The first responders were using a bag valve mask to force air into her lungs, and her shirt had been cut open down both arms and up the front for access. (For the modest: there is no modesty when you’re in this situation. Sorry.) One of my fellow medics was thumping away, performing chest compressions and looking dog-tired. I quickly stepped over everyone and relieved her.
The bag valve mask, a.k.a. BVM, wasn’t doing too well at getting her air. Instead, which is common in BVM use without a tube in place in the patient’s trachea, it seemed to be inflating her stomach. We needed to intubate.
Not wasting any more time, I started asking for the equipment. “I need the ET kit. Now. And suction.” Moving around to her head, I checked out her airway. As I opened her mouth and tilted her head back, I was greeted with a flow of vomit that quickly covered any visual of her vocal cords. “Crap! Where’s the suction?”
“Here!” one of my partners shoved the grey bag containing our portable unit into my hands. I ripped off the sterile package over the rigid suction tip and cleared her mouth and upper airway. Switching tips to a wide, soft, flexible catheter, I opened her airway again and took another look. This time I saw her vocal cords. “Okay, I got a visual. Let’s bag one more time and then I’ll go in.” I prepped my equipment, feeling the thrill I always do when I intubate. I sat with the scope in my left hand, tube ready in my right, looking like a praying mantis, frozen, waiting to strike.
The EMT that was ventilating the patient gave two breaths and backed up. I dove in, slid the blade in to the spot just behind the woman’s tongue and lifted up. The epiglottis flapped up and out of the way, exposing vocal chords that had been bathed in bile. “She’s aspirated. I can get the tube, but we’ll need to suction right away.” I slid the tube down the blade, through the vocal chord opening, and advanced it another inch or so. Inflating the balloon at the end to seal it against her windpipe, I ripped the mask off of the bag and attached it to the end of the tube. Listen…listen…listen… “We’re in.”
The brief moment of elation at a successful intubation was lost as the ventilator stated that it was hard to get the appropriate amount of air in. She had aspirated, I knew that. Now I was about to find out how much. Grabbing the catheter, I eyed up the distance and started feeding it down the tube. Almost immediately upon turning it on, I felt resistance. She hadn’t just aspirated, she had drowned herself in her own vomit. “Shit! She’s full. Let’s get vitals and prep her to transport.”
The easiest way to move anyone who is unconscious is on a long board, which also doubles as a solid surface to continue with chest compressions. We picked up her body and slid the board underneath, sliding her more into the hallway at the same time. A couple of us worked on strapping her to the board while the others kept ventilating and compressing. You never realize how much help even one more set of hands is in a code until you look back and wonder how it all got done. As we loaded her in the rig, I leapt up into the jump seat and continued bagging, rechecking the location of the tube. It was still in the right place, even after all the movement. I checked her carotid artery on her neck and tried to detect a pulse.
“She’s got a pulse!” I almost shouted.
“She does?”
I looked up at the duty crew chief and nodded, hardly breathing as I counted the weak, but still present, beats. “It’s only at about 39 beats a minute, but it’s there.”
“Is she breathing on her own?”
I shook my head and grabbed the suction in the rig, as more vomit had to be removed that our portable unit could not manage. Suctioning the tube again, we bounced down the gravel road towards the highway. Before we turned onto it, we stopped again and checked vitals and her heart rhythm. “Agonal, at 29,” the crew chief said.
We continued breathing for her, and recapped our drug administrations. While I had been busy securing the patient’s airway, the crew chief and one of the responders had given three milligrams of epinephrine and two of atropine. We called the hospital to let the emergency room know what we knew. Overhead, the lights illuminated the road in reds and whites and the siren echoed in the woods on either side of the highway. I wiped my forehead, finally getting a really good look at the patient.
She was probably around eighty years old. She had dentures. Her eyes were blue, but cataracts had ruined the pupils. Now, her eyes were open and staring blankly at the overhead lights, pupils fixed. The actual surface of her eyes had dried to the point of resembling gelatin. She had an implanted pacemaker, and what is sometimes known as a ‘zipper’ scar on her chest from a previous heart surgery. She had a rather large, twisting vein that the scar seemed to terminate on, and it was a deep blue color. Her mouth and nose had once been bluish purple, but with more effective ventilation had turned more towards a pinkish hue. I blinked and realized I didn’t even know her name…
They were ready and waiting in the ER. The red metal crash cart was placed near the bed that we quickly transferred the patient to from our cot. I spoke loudly, over the din of so many medical people rushing to get things done. I explained what I knew, what had been done, and what had come of our interventions. I stepped back and took in the scene. There were at least a dozen people from the hospital alone, plus three of the on scene personnel, including myself. There was a steady flurry of activity, but at that moment, I knew my job was done. I had done what I could, and it was in the capable hands of the staff in the ER now. I wiped my forehead again, and turned away.

I’ve had quite a few codes now, and though each one is different, they are so alike. My first code is still clear in my memory. It was a ninety-one year old woman. I was still a student, and working a clinical shift in the ER when the paramedics from the service I now work with brought her in, CPR in progress. We worked her for another twenty minutes before the doctor called it. I can still remember her eyes, staring blankly up at the ceiling as I pushed repeatedly into her chest, willing the life back into her, even if only for a moment. I was green; I still wanted to believe I could save lives. I wondered as I pumped, ‘Can she see me? What does she know of what is going on?’ I’ve often wondered that. What is the patient aware of? Are they screaming inside those clouded eyes, trying to tell us to work harder because they aren’t ready to die yet? Are they wanting us to stop and let them go? If I could express just one thing to each one, it would be the same: I know that if it is their time to go, that it’s out of my hands. But if it’s not…I’m going to everything I possibly can to make sure they come back. I will push every amp of epi I have. I will get that tube in and breathe for them. I will perform compressions until I have no strength left. I will exhaust every single option I have to bring them through. The way I see it, God has put me there, on that scene, in that patient’s most helpless moments, to be the one to bring them back. He knows the outcome of every call I respond to before I even get paged. So if He sends me, I will go.

This patient is still alive, though I don’t know if it’s worth it or for long. She’s in ICU, somehow managing to maintain the basal functions of breathing and beating, but she remains unresponsive. These can be the hardest ones to deal with. You wonder why they are still here. Maybe it was one that I should’ve let go? You ask yourself so many questions. Did I do the right thing? What could I have done differently? Will this patient ever come back to the way they were before that moment when their body failed them? Eventually, every one of us in the medical field come to terms with the fact that a good number of people we come in contact with will die within six months of meeting us. I joke that I don’t take it personally anymore when someone dies shortly after meeting me, but there’s always the truth in the joke. You aren’t born with the ability to separate yourself from the human experience. It’s something you have to learn, and no class exists that can teach you this skill. When I say that I separate myself, I am not saying that I have no compassion. I care very much for even the most unruly of patients. But I try to stand outside the immediate circle of the experience in order to maintain some autonomy.
You can’t do that on codes. You are in it, and in that person’s circle as far as you can go. You are the last thread of this life that they can grab onto. So many calls have faded from my memory already. So many patients have been lost in the passage of time. But codes stay. They whisper over your shoulder, telling you to try harder. They reverberate in your heart every time the pager goes off...
“One-nine, call in code forty-five…”