First Code Blue

A few weeks ago, on a night shift, Mrs. M wasn’t doing so well. She was trached and ventilated. With her respiratory status compromised, it was unfortunate that shortly after, her heart did too. I remember my colleagues stepping into the room after multiple alarms on the monitor went off. She was breathing fast, her oxygen saturation was decreasing and the patient was visibly in distress. She was known to be very anxious. At some point during her hospitalization, when she did not have a tube down her throat, she would express her fear of dying. In this case, her fear had quickly became her reality. While in the room, all colleagues saw her heart skyrocketing from the 120s to 160s. The alarms were erratic, and so was her cardiac rhythm. At that point in time, the nurse in-charge looked at me wide-eyed as I was standing outside of the room and stated: “She’s gonna code, bring the crash cart”. Right there and then, her heart rate went down to the 70s, 60s, 50s, 30s, 0. I did not participate in this code blue as there were 7 other patients that needed to be supervised while most of the team dealt with the emergency. But, witnessing such event brought back memories to my first Code Blue (respiratory/cardiac arrest).

I remember it like it was just yesterday. In fact, I remember it solely because it was the first and only Code Blue I actively participated in, despite being an ICU nurse for nearly three years. It all happened during my final year in nursing school on an exchange program to Malawi. At the time, I was nineteen and had been in the "Warm Heart of Africa" for six weeks. It was our last clinical day at Kamuzu Central Hospital (KCH). What made an abroad internship unique was the ability to experience different wards/units on a daily basis. In the last four weeks of our rotation at KCH, I had been placed on the men's general medicine ward, the burns unit, the medical short stay, the medical step down unit and the intensive care unit. With one of my classmates, our teacher had assigned us to work at the emergency room. Given that it was our final day, our nursing instructor had informed us that if not much was going on, we would have a half-day.

With minor emergencies happening in the morning, it appeared that our day would indeed end at noon. As 12 o'clock was soon approaching, my colleague and I suddenly heard yelling from the ER entrance. In came four Malawian men wheeling down a stretcher with a lifeless middle-aged heavy-weighted Caucasian man. Upon settling the patient in a big room filled with other patients (no curtains were available), the blue hue on his face quickly hinted that he was in a cardiac arrest. No pulse was felt, no rise of the chest was seen. I remember quickly starting chest compressions while my teacher came in at that exact moment. “Is there a doctor in here?”, she yells out. She was met by the gazing eyes of the other patients and their family members that are in the room. With no time to waste, my instructor asks for epinephrine ("epi"), a medication we give in attempts to get the heart back to beating. My instructor also demanded that someone get an oxygen machine and a defibrillator. After doing my set of compressions, I search around for an oxygen machine. Unfortunately, the only one available was broken. After a few minutes, the ICU doctor (a native Malawian man) joined us and started leading. As we were performing CPR (cardiopulmonary resuscitation), his wife, his daughter, a foreign passerby who had witnessed his collapse and another colleague of ours entered the room. Every two minutes, whomever was capable would rotate between chest compressions and bagging him (giving him breaths through a Ambu-bag). I remember the chaos all happening at once. The search for the necessary equipment being confusing and nerve-wracking. Where are the IV catheters? Where is the epi? Where is the defibrillator? Where is everything?

In a Code Blue, seconds mattered. Without proper treatment, it is said that after eight minutes, the heart and brain suffer irreversible and fatal damage. No one knew how long this man was pulseless. Everyone's focus was on trying to bring him back to life. The most vivid memory I had from this day included the physical and mental fatigue it took to compress on this man's chest. I remember during one of my rounds of CPR on him, looking at him straight in the eye. I remember the smell of vomit from his mouth caused by us repeatedly pressing down on his chest. I remember yelling the question out loud "What is his name?" during compressions. "MARK!", I heard a voice. I remember muttering under my breath, with sweat dripping down my forehead and every muscle fiber of my upper body aching, talking to Mark: "Come on Mark, come back. Your family is here, come back for them!". Then joined in my colleagues also saying his name out loud, talking and asking for him to come back. I remember once my turn was up, taking off my hands off his sternum and seeing the skin underneath peeling off from the repeated friction of everyone's gloves onto his skin. I don't remember how much time had passed by until the defibrillator finally came. I remember the struggle to get the pads on his chest as only a tiny razor blade was provided in the kit, and his skin was cool and clammy. I don't remember how much epi vials we ended up administering to him. I just remember everyone's efforts.

Once the pads were on his chest and abdomen, we paused to see what kind of cardiac rhythm he had. PEA. Pulseless electrical activity. This was a non-shockable rhythm that required the resumption of chest compressions. The decision was made by the ICU doctor to transfer the patient to ICU. Mark was wheeled via stretcher throughout the hospital walls with one of my colleagues doing CPR during transport. Once arrived in ICU, the same routine was continued. Chest compressions. Giving breaths. Monitoring the rhythm. Checking his pulse. After forty minutes of chest compressions, Mark still did not come back. "Stop," said the ICU physician, "Time of death 12:37."

What quickly followed those words were silence, heads looking down and a bittersweet feeling. With his wife and daughter waiting in a more private area, Mark's face was cleaned and his chest was covered to make him more presentable to his loved ones. Once the tragic news were delivered to them, they entered the room, shedding tears that felt heavy as they streamed down their cheeks. They embraced him with hugs and kisses that made me feel guilty for not being able to revive him. I remember looking away from them with tears falling down my face as well. Before we left, my two other colleagues and my instructor gave our condolences to his wife and daughter. "We did our best", said one of us. "We know you guys did, thank you ..."

My nineteen-year-old self took several months to process what happened. It was my first time seeing a deceased individual right in front of me. The event raised questions in me not only about death itself, but the many constraints experienced in such a devastating time. Despite the limiting factors, I just told myself that, at the very least, this man, Mark, was given some form of dignity through his passing.

His name is Mark.

Rest in Peace Mark.