The 9-Hour Code

Throughout my clinical experience in school, I have collected many stories, just as my teachers had warned me. Through all these countless experiences, one outshines every other as probably the most prominent and ethically complex situations I've ever been in.

It wasn't the time I tripped over that patient's Foley catheter and almost pulled it out, or the time that man with a lobectomy insisted I keep listening for breath sounds. Don't let the title of this post fool you folks, the situation I am referring to is in fact, a 9-hour code.

First, a little background scenario of our patient for all the students reading this. A 65 year-old man presents to the ER with increasing shortness of breath, orthopnea, and dyspnea upon exertion. Our patient also has a history of aortic stenosis, diabetes and hypertension. Vitals on admission were a blood pressure of 140/76, heart rate of 122, temperature of 36.7, while breathing at a shallow rate of 22 bpm. It was determined that this man would have to undergo an aortic valve replacement.

Flash forward five days later and our patient is in the Cardiac Care Unit post surgery, holding stable on a Bear 1000 ventilator (SIMV Vt 700mL, 12bpm, 70 percent, PEEP 8, PS 8). Thirty minutes after the first vent check of the shift, significant pulmonary edema could be seen throughout the vent circuit and HME. Copious amounts of blood were being suctioned through the endotracheal tube, and peak pressures were rising on the vent. Within an hour, the patient could no longer be managed on the Bear 1000.

We switched our patient to a heated wire circuit, and the Servo-i ventilator (for the pressure-regulated volume control mode). Even with the ventilator working to keep the peak pressures down while ensuring our set tidal volume, high pressure alarms were going off with readings in excess of 60-75 cmH2O. He could no longer be managed on the vent.

For the next eight and a half hours, the patient would be bagged until the sats reached 100 percent, then a sterile suction catheter would be inserted down the ET tube to remove the frothy, bloody secretions.

Bag to 100 percent. Suction. Repeat.

Bag to 100 percent. Suction. Repeat.

Now, like any good team of therapists and students, we worked in cycles. Bag and suction two rounds, then swap out. Through all of this work, it was the family's wish to make the patient DNR, while allowing us to continue bagging. So we did.

Eight hours, and two 3000cc suction canisters later, we got the patient back on the ventilator.

He would unfortunately pass away the next morning.

The respiratory department was commended for going the extra mile in this case, as were the nurses and doctors. And I, as a student, got my first real lesson in pressures with mechanical ventilation, and the resolve of a health care team and a family determined to hold onto hope. However, amongst all the "job well done's" that night, for me, the real lesson was in ethics.

People can give you a number of different opinions on the extraordinary measures taken in that code (and the therapists I share this story with, do), but it's up to each and every person to draw their own line in the sand.

With that being said, what do you think? How do you feel? Is there an ethical point in which the patient should just be mercifully let go, or should we as therapist and health care workers keep fighting for the glimmer of life that may or may not be there?