Rhapsody in Code Blue

Anyone can call for the symphony to start.

Perhaps the internal medicine intern stopping by on morning rounds.

Or the telemetry operator, observing one wavy line rapidly morphing into another.

More commonly, it’s the bedside nurse. As she stops by to address a chirping IV pump, finished with its antibiotic infusion, she spots that something is off. A bluish tinge to the patient’s lips. A glassy look in their eye. An unusual beat on the EKG strip.

She calls his name, and instead of a grumpy ‘what?’ she is greeted with silence. She feels for a pulse. Nothing. Frantically, she presses the button on the wall. CODE BLUE.

With that single note, the orchestra assembles, called to arms with jarring alerts on pagers, phones, and overhead alarms. The musicians arise from hectic ICUs, sleepy call rooms, and bustling central pharmacies, heeding the call to action.

Before the conductor takes the stage, the room is adrift.

The players crowd the tiny hospital room, overflowing into the hallway.

But as the code leader arrives, roles are assigned, and the performance can begin.

First, the percussion.

One. Two. Three, the percussionist counts, beating on the patient’s chest. It’s a precise instrument—each compression must be two inches deep, no more, no less. He paces like a metronome set to exactly 100 beats-per-minute.

Next, the strings.

Nurses, residents, and phlebotomists unfurl their tourniquets and un-sheath their catheters, preparing to carefully thread IVs, arterial lines, and central lines into the patient’s veins. Like a bow across the strings of a violin, their lines traverse the room from fluid bag to vessel. They employ slow, guided precision as they glide tubes into vessels.

The brass fills out the sound.

Like the valves on a trumpet, plungers of premade syringes of epinephrine are pressed in rhythmic blasts. A cacophony of other drugs supports the melody—atropine, amiodarone, adenosine—an entire array of additional antiarrhythmics aid the ensemble, drawn up and pushed out like the slide of a trombone.

CLANG go the cymbals.

CLEAR yells the nurse with the defibrillator.

Though the show is already underway, the ushers continue to traverse the aisles.

Runners pop in and out of the room, bringing more drugs, more flushes, more line kits. With each venture out to the stock rooms, they pass by the audience, onlookers from the floor and family members of the patient. The runners remain focused on their mission, faces averted from wandering eyes, some moved to tears by the performance.

After a few verses—two or three rounds of compressions—the woodwinds arrive to a glorious solo.

The anesthesiologist steps forward to the head of the bed, with her instrument in hand. Her laryngoscope slides over the tongue as the percussion ceases for just one moment, giving her a few rest measures without constant beating to intubate. The endotracheal tube slips through the vocal cords and, like air through the barrel of a flute, a 400cc breath passes melodically through the tube filling the lungs.

At the edge of the stage, the pianist taps away on his keys.

The pharmacist stands at a computer, monitoring every dose given and scrutinizing the inpatient medication list for causes of this tragedy. He supplies the final harmony to the rest of the orchestra, providing cues to the players as the show unfolds.

At the end, a sonata. A smaller ensemble takes center stage helmed by a melancholy bassoon.

All the other movements have come to a close. A chaplain wearing his clergy collar understands what’s left to do. He pulls aside family members and gracefully sets the stage of expectations. The curtain will soon fall, and he wants the audience to be prepared.

The song concludes.

The players depart stage-left.