Karaagre Vasate Lakshmi, Karamadhye Saraswati
Karamoole Tu Govinda, Prabhaate Karadarshanam
I learned this daily prayer from my grandmother, a mantra to start the day, chanted looking at your hands as soon as you open your eyes in the liminal space between conscious and subconscious.
The prayer is a pilgrimage around the palm, naming the presence of three Hindu deities at each aspect: Goddess Lakshmi in the fingers, Goddess Saraswathi at the palm; and Lord Vishnu at the base of the hand. By drawing upon their energies with the focus on my hands, the organs of action, I set an intention to myself and the universe at large: May these hands do something good today.
A code in the hospital is short for code blue: a code for a heart that has stopped beating without warning. It is a call to action for the designated team of doctors, nurses, and pharmacists to resuscitate this heart, ideally before the owner of the heart truly turns blue.
The overhead system at my hospital is primed with the grating screech of a microphone caught by surprise when it is about to announce such a code. The shrillness of that sustained alarm silences the whole hospital and steals my breath.
There is a brief pause, a moment to exhale while my hands reflexively check for my stethoscope before the speaker blares, “ADULT MEDICAL EMERGENCY,” ...followed by exactly where in the building I’m supposed to appear.
On my second day as a senior resident in the intensive care unit, that dreaded alarm rang, and I took off to the stairwell, running the code algorithm in my mind. Was it two rounds of chest compressions before the epinephrine? Or three?
I arrived at the patient’s room, the curtains in front of the doorway already drawn back, the drapes of the windows pulled up. Light from every direction poured onto an elderly woman, the snaps of her patient gown hastily undone, exposing her bare body as she lay on the hospital bed, the sheets crumpled and stained with unabashed shades of brown bodily fluid. The putrid stench of fecal matter wove through the fine mesh of my respirator mask, slightly delayed like thunder after lightning.
“What’s going on? Does the patient have a pulse?” This was the opening line at the mock code I had attended three months prior.
“None,” her nurse reported. Another was starting chest compressions. I got out my timer, ready to issue commands, when a voice from behind me called out, “She’s DNR! No code!” Do Not Resuscitate.
A fist clenched my stomach. No code? Why were we resuscitating her? I could sense the arrival of others on the code team: more doctors, nurses, and the pharmacist filing in behind me.
“Oh...so let’s stop compressions?” I had forgotten to announce myself as code leader, maybe in part because I felt like an imposter giving myself that title. I had only seen a handful of code situations, and never had I led one. But I was the first doctor in the room, and apparently was issuing enough authority that two others were looking to me for direction.
Then from behind, outside the room, another voice: “No! They switched! She’s full code now! Continue CPR!”
Codes are somewhat of an “act first, ask after” situation. You show up to the room with the intent of reviving a pulseless patient. You aren’t privy to their name, age, medical history, or what even drove them to a pulseless state, much less their hopes, dreams, or fears. I was once given the advice that anxiety about doing something wrong had no place in a code — the patient without a pulse is effectively dead, after all. No time for questions. If the patient is full code, the code must continue. I take my position at the foot of the bed, the first step in my mental rehearsals. My hands grip the plastic edge of the bed, knuckles white with tension. A more experienced colleague steps in beside me a few seconds later, quietly offering guidance as I announced the orders, at once quelling my apprehension and affirming my authority as the code leader.
Resume compressions! A pair of powerful hands take to her sternum, fingertips interlaced, elbows locked to generate more force on each compression. A rib cracks with the snap of a twig. The squelch of her excretion dancing raucously around the creases of the plastic mattress with each compression draws the remnants of my own lunch upward. I swallow.
Airway. Do we have a secure airway, a reliable port to move oxygen into her body and carbon dioxide out? The anesthesiologist is directly across from me, gripping a face mask securely to her jaw with one hand, while his other hand rhythmically squeezes a bag, a breath of air. Inhale and exhale.
Time for a pulse check! A purple-gloved hand invades the woman’s groin, searching behind a fold of flesh, probing deep with two fingers, then with a small ultrasound for a femoral pulse. No pulse.
Access. It is time for a dose of epinephrine to jumpstart the heart. A surgical resident appears at the bedside, expertly disinfecting an area on the patient’s leg before getting out his equipment, and planting his hand on her right knee to hold it steady. The brief sound of a drill boring through bone sounds eerily similar to one driven through drywall. He blandly plugs an intravenous access site into the new opening; fastens it in place with a clear plastic adhesive; and promptly leaves.
For four minutes, I watch the hands on her heart, the hands on her head, the hands in her groin, and my own hands gripping the foot of her bed. Four minutes to suspend the time between life and death.
Two rounds of compressions, one dose of epinephrine, and three pulse checks later, the voice from outside the room breaks my trance. “They reversed the decision! She’s DNR!”. Do Not Resuscitate is a command in the negative, characterized by what we, the medical team will not do. Perhaps a directive in the affirmative could be just as fitting: Allow peaceful death.
The compressions stop abruptly, and the many hands on the patient disappear. A nurse has the presence of mind to quickly drape a sheet over the woman’s body, reinstating some vestige of dignity.
Somehow the frenzied crowd at the scene disperses without fuss, and the fist clenching my stomach loosens its grip.
Outside the room, I see a distraught middle-aged woman in a chair, a social worker crouching at her side. I glean more background from others on my team: here was a woman in her mid-nineties with advance directives filed away for years, consistently sure she did not want cardiopulmonary resuscitation, no heroic measures to save her life.
Her family member was visiting that afternoon, chatting and taking selfies just moments before the patient had a large bowel movement and subsequently became unresponsive. Of course, the instinct when asked by a staff member, “Do you want us to attempt reviving her?” was to answer yes, and reverse the code status.
Revive is a word born of good intention. To give back life: so full of hope. Intentions, however, cannot predict outcomes, and sometimes the process cuts deeper than the product. In this case, the process took away our patient’s well-documented agency, and thrust a slippery decision into the hands of an overwhelmed family member and the orchestration of this code into my own.
I know that I don’t own the blame for this play of events. I don’t think anyone does. But that doesn’t change the fact that this patient, against her wishes, was denied a dignified death; and I too was complicit in that.
As a physician, I am fortunate to have a job in which, more often than not, my hands have done something good on any given day. Some days that means manipulating a patient’s body with precise physical exam maneuvers to deduce a diagnosis. Other days it is draining an abscess. Sometimes it is offering a hand to hold in the midst of someone’s fear, loneliness, or grief.
But there are some days, like the days of that misguided code, that I wonder whether the good that comes of some actions cancels out the harm inflicted by others. It would certainly be easier for me to reconcile if they did, but the human conscience is not a calculator. It is on these days that I find
myself at home after work with my palms pressed together in prayer: a prayer for my patients and their families, a prayer for myself, a prayer for forgiveness.