An excerpt from House of Perdition.
Ten minutes into the code, and I could already feel the difference. I could feel her broken ribs grind against each other with every compression. The first set of compressions had been stiff, like trying to force a thick textbook to bend in half, the sternum protecting the heart and lungs. Each compression was unforgiving, and the chest recoiled with a force equivalent to your own. Over a thousand compressions later, the chest wall had become almost too compliant. I could feel my hands sink deeper in her body as it began to cave. There was no visible recoil of the chest. There was no rigidity. The only discernible sensation was that of broken ribs scraping each other back and forth with each effort.
“Pulse check. New compressor. Let’s go! Where are we with labs and the arterial line?” the code leader yelled out. “Rhythm is PEA, next compressor back on the chest, let’s go.”
Thank God. Two rounds in, and I was already soaked with sweat. The room felt like a thousand degrees between all the people, the lights, and the machines. Making it worse was all of the personal protective equipment (PPE). Each of us had a pair of non-sterile purple gloves, a non-sterile yellow gown, a green N95 mask, and a clear face mask. Nothing was breathable, and I could feel the sweat pooling in the fingertips of my gloves.
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Then, I made a rookie mistake. I took off my gloves to let my hands breathe for a minute. Suddenly, I was back at the front of the compressor line. I tried to pull on a new set of gloves, and the thin plastic immediately shredded. My skin was still too wet from the earlier exertion, causing the gloves to stick and tear instead of slide into place. I grabbed another pair. Same result. As I started to panic, I decided to slide on a pair of larger gloves just in time.
“Pulse check! Next compressor, be ready! Is the family aware of the situation?” yelled the code leader.
One, two, three, four, staying alive, staying alive.
“Callan, push harder! The end-tidal CO2 tracing is looking worse.”
“OK!” I yelled back too sharply.
ONE, TWO, THREE, FOUR, STAYING ALIVE, STAYING ALIVE.
My ego bruised by being singled out, I pushed even harder. I doubted extra pressure was doing anything, though. We were coming up on two thousand compressions into this code by now. The sharp edges of the broken ribs were no longer noticeable. There was minimal resistance when I compressed, just an inference of structure, nothing holding, nothing pushing back, just folding under pressure.
FIVE, SIX, SEVEN, EIGHT, STAYING ALIVE, STAYING ALIVE.
I looked up at the end-tidal CO2 tracing on the vitals monitor directly across from me. Shit, no better. On my right, there was frank blood bubbling up into the endotracheal tube. The jagged edges of her broken ribs had likely punctured her lungs. She was definitely bleeding internally. Even Charlie, as the code leader, recognized the situation as futile and now appeared resigned to the inevitable.
“Pulse check! Where is the family? We need to talk to them.”
I peeled off my sweat-soaked gloves and threw them away as I cycled back to the end of the compressor line. I no longer cared about the struggle of putting on the next pair. It felt like I had run five miles wearing a trash bag in the middle of a July heatwave.
Jesus, I need water. Can I grab some? I thought about it for a second, but the thought of having to put all the PPE back on and the optics of leaving an ongoing code made me stay put.
I need to be here for the patient.
Over thirty people had initially responded to the code blue. At this point, Charlie, the ICU attending physician, ICU bedside nurse, charge nurse, ICU pharmacist, respiratory therapist, and the four-person ICU resident team were all who remained.
“The family wants us to keep going,” Charlie stated, shaking his head. His eyes did not leave the floor.
The code had been going for at least forty minutes, and I was next on the chest.
Should I say something?
I didn’t want to keep going. I didn’t say anything because I did not know anything. I did not know the labs or what medications had been given. I did not know her comorbidities or past medical history. What I did feel, though, was that to continue was wrong.
“Alright, back on the chest. We will do a few more rounds before we call it.”
I stepped up to the side of the ICU bed and tried to not let the defeated tone of the code leader faze me.
One, two, three, four, staying alive, staying alive.
Why are we still doing this?
I shook my head, trying to keep the thoughts away and focusing on anything else. The new pair of large gloves felt extra loose. I felt the squish of sweat with every compression as if I was wearing two half-filled water balloons on my hands. The end-tidal CO2 tracing barely budged with each compression. The chest was colored a mixture of reds and dark browns from every capillary being broken over the last forty minutes.
“Alright. Let’s call it. Callan, get off the chest. Time of death, 0852.”
The aura of a room after a failed code cannot be transcribed. The physical act of doing nothing has a feeling of uneasy permanence. The finality of stillness stings after the flurry of maximum effort. The conscious decision to stop feels heavy, as if you aren’t simply marking an event. I had heard other physicians say the person dies at the beginning of a code, and a code blue is simply the attempt at resuscitation.
Were we doing that “for” the patient or simply “to” the patient?
The image of Charlie stating the time of death as I took my hands off the patient’s chest kept replaying in my mind.
I am the last person who touched her “alive.”
Matthew Russell is a Harvard-trained, board-certified anesthesiologist based in Tennessee. He earned his undergraduate degree from the University of Wisconsin-Madison, where he studied pharmacology and toxicology and Spanish, before receiving his medical degree with Alpha Omega Alpha honors from the Medical College of Wisconsin in 2020. He completed his anesthesiology training at Brigham and Women’s Hospital and Harvard Medical School in Boston.
Dr. Russell currently serves as an assistant professor at Vanderbilt University Medical Center and medical director of anesthesiology at Vanderbilt Tullahoma-Harton Hospital. His clinical and leadership experience includes roles with U.S. Anesthesia Partners and service as a medical officer in the Tennessee Air National Guard. His interests include patient safety, multidisciplinary teamwork, process improvement, and servant leadership. He is committed to advancing high-quality, human-centered care while supporting the physicians and teams who deliver it.
He is the author of House of Perdition, available on Amazon and from True Vine Publishing. He shares updates on LinkedIn.
