Code Blue

One of my very sick patients passed away today. It all started on Friday afternoon, when I was notified that I was going to get a transfer from another medicine team. They told me about a 36 year old Hispanic female who was admitted about a week and a half ago for generalized weakness and fevers. She was neutropenic, and apparently her primary care physician in Los Angeles had already worked her up, and she had already had a left cervical lymph node biopsy done that seemed highly suggestive of lymphoma. She was apparently becoming coagulopathic and her liver enzymes were elevated. A coag panel on Friday showed that she was in full-blown DIC (disseminated intravascular coagulopathy), so that is why she was being transferred to the ICU. The oncologist told me that he had done a bone marrow biopsy that day, and he said he highly doubted that the diagnosis was leukemia or lymphoma. He suggested getting infectious disease on board to figure out if there was some infectious etiology for her sudden decompensation.

When I got back into the hospital the following morning (Saturday), I heard word from the on-call team that the night was quite eventful. Her blood pressures were plummeting, so a central line was placed and she was requiring multiple pressors. She went into respiratory failure, so she was intubated. She received many transfusions of packed red blood cells, platelets, fresh frozen plasma. We gave her multiple units of cryoprecipitate and more blood transfusions throughout the day. She was bleeding everywhere – vaginally, from her central line site, from the biopsy site, and from her stomach. Her hemoglobin went from 10 to 4. Nonetheless, she remained alive all through Saturday, and she was still breathing when I went in to work this morning.

Today she was still requiring multiple pressors to keep her pressures up. I ordered more blood for her. She was still on dobutamine, levophed, and neosynephrine drips. I finally got an infectious disease consult, and the experienced physician stated that although sepsis could be a possibility, the DIC was probably not caused by an infection alone. He was convinced that there was some sort of malignancy that was the culprit.

Suddenly, at 2:00 pm, I received a page, and an overhead intercom voice announced “Code Blue, Two South; Code Blue, Two South.” I knew it was my patient. She had become bradycardic, and she was now pulseless. My senior was not present (today was his day off), so my co-intern and I were in charge of running the code. One of the nurses told me to find the patient’s husband, explain the situation, and let him know that at any time he could call off the code. So I left my co-intern to continue running the code as I rushed off to find the husband. I saw him come into the ICU, he looked dumbfounded. I explained what was going on – how we were doing all that we could to sustain her, but that by continuing the code we were prolonging her suffering. I invited him to come into the patient’s room, which was now jam-packed with nurses, respiratory therapists, the on-call medicine team, other residents, and medical students. By this time, one of the senior medical students was doing chest compressions. The husband continued to look on, seeing his wife deteriorate in front of his eyes. After about 5 minutes from the time the husband entered the room until finally spoke – which seemed like an eternity – he threw up his hands in the air and said, “Okay, let’s stop.” Twelve minutes total had passed since the code had begun, and the patient was declared dead. The patient’s husband began weeping, a strange cry that was lacking in physical tears but full of agony, as he held the hand of his beloved, deceased wife.

We allowed the extended family to come visit with the patient. After about 30 minutes, I went back in to speak with the patient’s husband about having an autopsy performed on the patient. I told him that he could accept this free service if he still desired to figure out the cause of his wife’s death. After an extensive conversation, he agreed to have the autopsy performed.

By this time, the husband was calm and collected. His stage of mourning was over, at least for the moment. He proceeded to tell both the nurse and me how much he appreciated what we had done for his wife. He understood that we did everything in our power to keep her alive. He then turned to me, clutched my hand in his, and proceeded to tell me that he appreciated me, what I had done, and that as I grew older I would gain more wisdom and learn how to help people all the more. Tears began to well up in my eyes as he was thanking and building others up during his most difficult time of life. He gave the nurse a hug and thanked her repeatedly for all she had done for his family. It was a very emotional time for us all. It took all of my energy to keep from breaking down in front of him, but somehow I managed to blink the tears away.

I know that this will be a difficult few weeks for the patient’s husband, as well as for the two children that she has left behind. For any of you who may be reading this blog, although you do not know this patient, I ask that you take a second to breath a prayer up to heaven for this family.

Dear Lord,

Strengthen this family. Allow the husband – and especially the children – to cling to you for support during this difficult time. May you be real to them. May they grow in faith. And may the patient rest peacefully in her grave until You come again to receive her unto Yourself.

In Jesus’ Name I Pray,

Amen.