CODE Blue..ER show style

We have had several code blues (cardiopulmonary arrests) here in Fiji but this is the one of the first ones that I ran essentially by myself and finally called it by myself.

I don't think I have mentioned this before but there are no attendings here. For those that do not know what that means. In the US, I work while another more seniored doctor and one with more years of clinical expertise oversees what I do. If I have a question on a patient or if someone is truly an emergency, they are most often within earshot and can respond quickly. Also if I was managing a patient that the attendings think could be better served another way or possibly offer a differential I did not immediately think of, then we manage the patient accordingly. You have responsibility but the ultimate liability and accountability if anything goes wrong lies on someone elses' shoulders.

Here in Fiji. You are on your own.

The other residents here can help you but in a busy ED and other critical patients, no one is there to hold your hand. If you did not do a proper work up on a patient and you sent them home and they die, it is on you. Inner monologue: Ok, that's frightening. For those of you keeping tabs, I am about a 1 1/2 from that point since I am still finishing up my residency. I find myself reading more often when I get home because I leave shift thinking if I have done the right thing. I have sent home some questionable patients with potential acute medical problems (more on that later) simply because there is no space for them. Say what?! That doesn't seem right.

Case: 45 y/o Fijian M with sudden onset collapse, questionable history of c/o chest pain earlier in the day. Pt had downtime of >10 minute with no bystander CPR. When the patient arrived in the ED, I was told his initial rhythm on the monitor was Vfib. He got defibrillated x1 (btw it was actually done with the manual external defibrillator (shock paddles style in the ER show fashion.) Most machines are automated external defibrillators now...pretty neat).

Pt's rhythm went from:

Vfib --> PEA--> asystole

We intubated the patient. He got several rounds of CPR and epinephrine and finally when we coded him in asystole for some time, decided to end the code since further measure would be futile. Unfortunately, he died. What seemed like his whole village came and mourned.  The code came and passed and then we commence with our day.

The problem is you still have all these patients in the ED and the curtains are not sound proof.

Definitely not the case

They have heard everything that you have done in the previous pt "room"/area and now you turn around to handle their not so acute situation (minor forehead laceration and viral hepatitis in this case). It is an interesting dynamic. I have always wondered how the other families and patients feel when hearing this whole scenario play out in front of them. Even then, you put on a fresh face and smile because you still try to give the best care to your new patient, no matter what just happened minutes ago.

Growing up..one patient at a time...