Do you know what it really means to be a “Full Code”? You should.
Last week, the proverbial dragon of chaos manifested itself in a simple sentence overheard while passing by a patient room. “Oh, okay, yeah we need to get him back in bed . . . like stat.” It wasn’t the sentence that stood out, or even the tone, but rather the source: The hospital’s rapid response nurse, Molly. She is a highly-trained nurse who floats among units, checking in on patients who may soon require a higher level of care – a COVID patient who might need a ventilator in the next few hours is a good example. Molly has seen it all, and she is unflappable. When she uses the word ‘stat’, it gets people’s attention.
Instinctively, I go and retrieve our unit’s “code cart,” which is exactly what it sounds like, containing all manner of invasive life-saving equipment. I return just in time to see the respiratory therapist slam the head of the bed down and begin pounding the patient’s chest. Okay, yup, this is real; no mistaking this. I call the emergency line, sending the “Code Blue” call out overhead. The experts are here, and more are on their way. I’m good to just get out of here, right? I’m about to scurry away when Molly’s voice interrupts me: “Alright Nathan, you’re next for chest compressions.”
I pause for a half-second before replying: “I’m next for chest compressions.” Basic and Advanced Life Support classes always emphasize the importance of closed-loop communication during hospital codes, confirming that you’ve received and understood your orders. At this moment, I’m thankful for that training. This small exercise of protocol helps me relax and remember that there is a protocol. I take a deep breath and try to remember my training: “Alright, compress to the beat of ‘Stayin Alive*,’ keep your arms straight, and push with your back, not your shoulders.”
The physician arrives and calls for a rhythm check. Everyone steps back, and I take the respiratory therapist’s spot in preparation. A robotic voice states, “No shock advised.” A nod from the physician and I place my hands, one atop the other, on the patient’s sternum. I begin compressions.
I always thought nothing could prepare someone for the experience of performing real-life CPR. Most medical simulations are painfully unrealistic, and I had no reason to believe that the CPR dummies were any exception. Where the dummies feature a pliable chest wall easily compressed, surely human bones and cartilage would put up a bigger fight. Wrong. Turns out, those dummies are incredibly realistic. This person’s chest was unnaturally, creepily soft. For a split second, I had the surreal feeling that this was all a fake code – an elaborate simulation designed to foment team-building. A glance at the patient’s face broke the illusion. Nope, this person is real.
In CPR training, we’re told that high-quality chest compressions are likely to cause some degree of trauma. “You’ll probably break ribs, and that’s okay,” they say. But this was different. The realization hit me like a brick: Just three minutes into chest compressions, this patient did not have merely a broken rib or two. Rather, their sternum and ribs were clearly in fragments, providing no resistance whatsoever to my compressions. This realization sparked another: If each compression really does need to reach a depth of 1/3rd of the chest wall – and it does – then is the only way it happens. Good CPR necessarily requires double-digit fractures.
I didn’t have time to consider the weight of these realizations, and I kept my attention on the task at hand. Two minutes later, my time was up and I yielded to my replacement. Despite another twenty minutes of herculean efforts, the patient did not survive.
Honestly, I wasn’t particularly torn up. I had not been assigned to this patient during my shift – I had simply been in the right place at the right time. But the experience did make me consider whether we do a good job educating patients on what CPR is actually like, especially concerning its efficacy and side effects. You see, not only is CPR incredibly traumatic (I wasn’t joking, this study estimates the average number of fractures at about 11), but it is also not nearly as effective as the general public believes. The American Heart Association, an organization with every incentive to pump up the efficacy of CPR, reports that among patients 65 and older, just 18% who code in the hospital survive to discharge. Outside, very few make it to the emergency room alive.
Much of the misperception surrounding the efficacy of CPR can be traced back to Hollywood. Hit shows like “ER” regularly portray codes, and nearly three-quarters of them depict the patient surviving their cardiac arrest. This leads to an all-too-common scenario wherein patients and doctors don’t even discuss code status when admitted to the hospital. Since CPR is thought to be effective, patients assume “Do Not Resuscitate” orders to be reserved only for those clearly approaching their final days. This is not true.
Now, don’t misunderstand me. I’m not telling you to refuse life-saving or sustaining interventions. If you want us to do everything we can, we will. And of course, survival statistics are much better for the “healthy dead”; those who are young and without co-morbid conditions. However, if you’re of advanced age or poor health, you need to ask yourself whether you want your last minutes to be spent with a crowd of strangers traumatizing your ailing body with little chance of a positive outcome. Given the choice, perhaps you’d rather spend that precious time surrounded by your loved ones. You have a right to make an informed decision on this matter.
So, if you are admitted to the hospital for any unexpected reason, you should insist that you speak with your physician about your code status. Before you decide you want the full extent of the ‘miracle’ of modern medicine, you should know what you’re buying.
*Yes, this is often part of official curricula – compressions need to be done at 80 to 100 beats per minute, and singing “Stayin’ Alive” in your head is an effective way to keep pace.
Edit: Original Title and Byline appeared as “Double-Digit Fractures” and “Do you know what you’re getting into with the “miracle” of modern medicine? You should.”