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Code Blues

Pulmonologist Ni-Cheng Liang, MD, recounts her vivid experiences in Code Blues in response to Damar Hamlin's cardiac arrest, and calls upon the need for strong infrastructure to provide time, space, and safety for healthcare professionals to process and prioritize mental health.

The loudspeaker clicked on and like the engrained reactions from Pavlov’s experiments, the healthcare professionals of the hospital collectively held their breath for what followed.   Sure enough, “Code Blue, 5 West, Room 552… Code Blue, 5 West, Room 552… Code Blue, 5 West, Room 552.” The code and the location was always enunciated slowly and clearly three times. Simultaneously the cacophony of different pager sounds going off throughout the whole hospital with different cadence of beeps, buzzing, and a melodic tune that tried too hard to sound pleasant went off everywhere. I was the resident on-call for the ICU.  I was the code leader.  By the time the end of the first pronouncement of someone’s heart or lungs no longer able to sustain life, my heart rate had already shot up and I was running. Even though the three pagers I was carrying, like a holster around my waist, clung to life on the drawstrings of my hospital-issued scrub pants, all vibrating and beeping in desynchrony, screaming in proclamation at the loss of life somewhere in the hospital threatened to weigh me down.  I ran  as if MY life depended on it, except another human being’s life DID depend on it.  I don’t quite remember what happened next.  Whether the patient survived or if a pronouncement of death, despite our best efforts occurred.   I have led and been part of too many to count Code Blues and the chest compressions, emergent intubations, AED firings—my usual script of “I’m clear, you’re clear, everyone’s clear… shock,” and then the saddest one, “Time of death…” followed by the sounds of snaps and ruffles from the removal and discarding of disposable gloves, and the rolling up and crumpling of the blue drapes of the Code team,  the shutting of drawers from the code cart, and the latching up of the toolbox that was the airway kit reverberates in my ears to this day, over 10 years later.

 

I remember some of the codes vividly- like the first one that I ran in the ICU.  It was a heavy boot upon my shoulders waiting to fall, the anxiety hanging in the air for what seemed like eons, until it came crashing down, all too quickly and vividly.  I remember her face and the circumstances too well.  She survived.  There was the nightmare call on the 4th of July when I was an intern, when we had four Code Blues within the span of 2 hours, and we kept going, and running, and going and running.  And then there was the corner room code in the ICU where the patient was in limbo for weeks, when the heart finally said, “I can’t do this anymore.” Or the one on ICU rounds when the team was watching the arterial-line meander into textbook pulsus paradoxus. I ran the code, timing the shocks in between the fellow and attending performing the bedside pericardiocentesis, blood splattering on my co-resident’s scrubs, and attending’s tie.  She was eventually discharged from the hospital.  Or the one where the patient was my age, complications from a genetic condition, who survived, but was still in the ICU when I rotated off service.  She remained in the back of my mind for awhile, with me wondering what happened next.   Then a few months later on rounds, I saw a familiar looking face walk into the ICU.  I’ll always remember her face, as she walked in.  It was her, and the life force emanating from her, bright and pure, and strong, as I remember the feeling of a soul- embracing deep sense of fulfillment then, that she made it.  That she was thriving after dying.

 

This is my reaction to Damar Hamlin’s on-field cardiac arrest, as the remainder of the football game was rightfully postponed, tens of millions of people witnessing the shock and horror of the collapse.  Sports casters, news anchors uncertain of how to navigate their emotions, and what to say on air.  The outpouring of love and support from humanity at this calamity.  The stark reminder bestowed upon us at the preciousness and fragility of life.  The amplification in the news of the prioritization of the mental health of the NFL players.  This prioritization propels me to draw attention to the dire need for enhanced mental health resources and destigmatization of mental health for healthcare professionals that encounter the intersection of life and death everyday.  Unfortunately, during my involvement with the Code Blues, there was a lack of a formal debriefing process- especially if it was in the middle of the night on-call.

 

Unfortunately, during my involvement with the Code Blues, there was a lack of a formal debriefing process- especially if it was in the middle of the night on-call. Click To Tweet

 

There wasn’t a pause or a check-in, and the expectation was that you were to continue to answer the next page, go admit the next patient as if nothing happened.  I remember facing the enormous boulder of more work to do post-code- the needed documentation, the answering of pages and repeated pages from the ER, ignored for too long during the code, now tugging at my presence to go admit the next patient. There was no time to process. And over the years all of the anxiety, the shock, sadness, and sometimes elation, and many tears, some of which were lucky enough to escape my eyes closer to the time of these soul-rocking events, went wholly or at best partially unprocessed.  I know many training programs and hospital systems now have processes in place, but for those of you reading this, knowing that there aren’t supports in place, or more common perhaps, in a place where the support isn’t enough, to ask, nay demand for the infrastructure of support to be built, to be reinforced, and protected.  Healthcare professionals need the time, space, and safety to process so much.  And we aren’t provided with the time, space, or safety to do so, leaving it all too often to us to find the capacity in our exhausted states.  The consequences have varied widely from dissociation and detachment, sarcastic jokes of depersonalization,  leaving medicine all together, to voluntarily leaving the earth all together.  Recognize that witnessing, leading, and being part of a Code Blue, which in essence is an unexpected loss of life, once, let alone more than once, is a lot for a human being to endure.  Healthcare administrators, medical trainee governing bodies, and physician leaders must help us healers heal so we can continue to heal others, and thrive.

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