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The patient, in the pre-operative area, had been a hospital nurse. She said she remembered me from when I was an Intern at her hospital. She was so happy I was her anesthesiologist! I vaguely remembered her from years ago. She joked with me about how ‘green’ I had been… some of the younger nurses used to call me to the floors to “look” at patients in the middle of the night shifts (to get a Tylenol order) and she then laughed, “Honey, they just wanted to talk with your young hot stuff!”You guys judge: 20 years ago:Young, I was, hot, I don’t really know.The surgeon came into pre-op and said that we would be doing mostly local anesthesia for the procedure because her kidneys and liver were in “rough shape.”I had just finished saying that to her. We smiled at one another as the surgeon walked off after signing. Now I remembered her more clearly, killer smile, she had. I gave her very little sedation, maybe 20% of a light dose of sedation.She was a “pro” at receiving surgery; this was her 38th procedure in just three years. Bad kidney disease. This one was a little painful. The surgeon attempting to relieve blocked circulation and restore flow in her arm. I gave her additional medications but in baby doses. Total time, 45 minutes, and then we finished and she was still and quiet. All finished, we removed the surgical blue drapes. The OR team was spot-on and we had her moved over in less than a minute to the recovery bed.I would have normally hooked up all the same anesthesia monitors to her for transport (I was anal about that, anal about proper procedures and a stickler) but we were in the OR right outside PACU. It was 25 feet from where she was physically. Not a general anesthetic. I did put the pulse-ox on (always) and she was 86–87% - not great so… I hooked up additional oxygen of about 3L per nasal cannula — that took a moment because the O2 tank on the cart was low, so I got a new one from the wall on the back of the OR. I thought about the EKG and blood pressure cuff but she had not been a general anesthetic and I just sort of “felt” it was okay to hang out for a few moments with her so we (the room nurse and I) waited for her to be a little more aroused to move.A minute passed. We just calmly waited. The steady beep of the pulse ox was rhythmic.One more minute. I recall being utterly calm in this moment. Oddly calm. Years later I still remember this calmness and have spoken about it to my wife (also an anesthesiologist) on and off.Brandi, the room nurse said, “Chris… I…”It was sudden awakening, I had already sensed something as Brandi started to speak… something was not right and my hand shot to her jaw. I lifted her chin. Opened her airway and felt for breath on my hand. I hurriedly put my stethoscope in my ears and put it on her chest.I heard nothing. Listened harder. Damn. I grabbed it and flipped the bevel 180 degrees and then tapped on it — the sound exploding in my ears!Stethoscope back to her chest… “Chris, she’s not breathing.”“Brandi, there’s no heartbeat. Get help, get the crash cart. Call a code.”When you “call” a code blue in the operating rooms, literally EVERYTHING is right there either in the room or just outside to run the code and people arrive within seconds. We began the ACLS protocol and I had her intubated in 2 seconds (everything right there), anesthesia machine breathing for her within 5 seconds and CPR initiated.The surgeon burst back in the room and said some choice words followed by, “Stop. Stop everything. She’s a DNR.”Oh no. How did I not know that!?!He said, “She changed it this morning. I knew, but it was a local case… a conference with her primary physician.” He trailed off like he was reading something in the chart, ”We operated, I mean… I mean we did this to help ease her pain in that arm.” Long pause. “What happened?” His tone grew loud again, bordered on angry.“I’m not sure. Her pulse ox was showing 86% and a heartbeat but when I listened, she was asystolic? I don’t know what happened. I don’t know.” My voice was raised now.We stopped. I pulled the breathing tube out. The surgeon called time of death. He left to go see the family. We did what we always do to clean and straighten the body. New sheets. Everything neat. Never really thought about it but watching it happen was comforting. I felt disoriented a bit. Did I fuck up? How?I filled out a bunch of paperwork and then I headed to the recovery area called the PACU (post anesthesia care unit). My next case had been moved to another operating room with another anesthesiologist. I peeked in on that case, he gave me a thumbs up. I closed the door. I checked in on my previous case to release them to go upstairs from the PACU. That sign-out done, I pored through the chart of my dead patient wondering how I had missed the damn DNR (Do Not Resuscitate).The surgeon came to me, from behind where I was sitting, hand on my shoulder and said, “The family would like to see you.” No sense of anything in his voice.My mind was frustrated because I do not make mistakes, my heart was heavy because it hurts to lose a patient, any patient, under any circumstances… and now, I have to go face the family which is not something anesthesiologists routinely do even with operating room deaths. In general, the surgeon handles the family and the communications. I had done work in palliative care for a time. I was good at patient-family interactions even in tragic cases.Nine of them in the family waiting area… too many to go into one of the small conference rooms. The woman’s daughter, spitting image of her, just 30 years younger approached me and… kept coming and arms outreached… she hugged me. Softly she spoke, “Thank you for being there with her. Thank you so much,” her voice ending in a whisper. She squeezed tightly and my chest tightened on the inside reflexively with confusion and just plain raw emotion.More family members approached the hug. I was enveloped by… just love, is what it was… Love. They finally stopped. There I stood, one white doctor with nine black family members around him. It was almost like I could see us all, like I was looking down on the ten of us from above.So it wasn’t the patient who said something that made me die a little on the inside… it was her daughter:“My mama talked about you 10 years ago. She’d get those young nurses to call you up for little things because you always came up to the floor and cared.” I was so confused on the inside as to what was happening. I briefly considered I was in a dream, maybe. My eyes got teary.I recognized her daughter just then, she’s a nurse in the surgical ICU. She kept talking, calm almost, “I checked in to see who would be in the room with her and when I told her she got so happy it was you. Mama had been seeing angels all day yesterday. She changed her DNR because she knew she would die today. Said it was going be with you. Said she was ready. Said she was happy.” She then cried. I cried. I cried harder. They hugged me. I felt deeply confused.They said “thank you” to me. When it was over, I walked away stunned down deep to my own core of beliefs and my human limits of understanding this journey called Life. I felt myself being walked away and I entered the elevator. It was empty. When the doors closed, I cried by myself and in that moment a little piece of me that I had built up for years to be strong and impervious and to withstand the rigors of medicine… it simply died.That part of me never came back, never built back up. After that case I felt more. More of everything in Life. Over time it made me a better physician and then perhaps a better man.One year to that day… one year exactly, was my last operative day as an anesthesiologist. My left arm failed, left hand stopped working properly and I was forced several months later on to what turned out to be permanent disability.Although I cried and pained over losing my career many times, I do not think I have ever been as deeply emotionally hit by anything as hard as that daughter’s words that day… I felt so small in a world I maybe did not fully understand despite my education and dedication to understanding it. So tiny.Whether you believe or not in something more than humans in the universe… sometimes the universe shows you things that cannot, will not, nor do they need to be explained for that part of you that is more than mind and body… something deep within us appreciates and learns from these moments… and even, yes, sometimes, a piece of us dies a little from living life so fully.~ChrisDr. Christopher YeringtonColumbus, OhioBio: Retired from clinical anesthesiology by a disability in 2010, Dr. Yerington has turned his love of teaching and service to others to his family, medical colleagues and community. He speaks, writes and educates medical groups and residency programs about the importance of great disability and life insurance, basic physician-financial literacy and work-life balance. Chris also consoles and counsels young doctors on stress, burnout and physician-suicide. Having attended law and business schools, Chris is a perpetual student of human life, a scientist and an optimistic futurist in his heart.

There are frequent questions in Quora about the role of nurses in hospital wards. Nurses are not half-way doctors as some of the questioners seem to suggest. They are the sole occupants of a distinct and vital niche in hospital care.One day (1955) on my first week as an intern I was in the ward after visitor’s hour updating case sheets. A student nurse was taking the temperature and pulse of patients and entering the results in their charts. She was taking a full minute to count the pulse of a patient. When she came to the bed next to my table, I asked her why she had to count pulse for a full minute, will not half a minute do as we doctors did. She said she held the patient’s wrist for a minute but for the first half minute she was counting his respirations and the next half minute the pulse. If the patient knew his respirations are being counted, she said, the patient will not breathe normally, and she will not get the correct number. In our five years as medical students, we were never taught this simple tactic, but for the student nurse, this would have been her first lesson. Training of a doctor and training of a nurse are very different. Their work is also different from the doctor’s with little overlap.*This was in 1963; I was a duty assistant surgeon in the Government Royapettah Hospital, Madras. The case that was wheeled into the ward from casualty was one of blunt injury abdomen with splenic rupture as a possibility. I requested the nurse to maintain a 15-minute pulse and respiration chart. Nurses are not trained to diagnose splenic rupture. The nurse on duty had the basic knowledge of anatomy, physiology and surgery. She knew that I was looking for signs of internal bleeding hence the fifteen-minute chart. Her job was to count the pulse and respiration rate precisely at 15-minute intervals and inform me if there is an increase. I was in the theatre operating on a case of multiple stab injuries. The life of the patient was dependent upon the nurse counting the pulse and respiration with diligence every quarter of an hour and report. Nurses are that important in hospital care.Nurses do more than just follow orders. On her own initiative, this nurse got blood grouping and crossmatching forms signed by me so that if transfusion becomes necessary blood would be available without delay. I was dealing with the stab injury case when the ward nurse sent the information that the patient’s pulse rate was up to 100 from the original 84. I asked her to prepare the patient for surgery. When my case was over, I rushed to the ward. I percussed the abdomen and found free fluid in the peritoneal cavity—the patient was bleeding internally and needed emergency surgery.After the surgery for stab injuries, the operation theatre was in a mess. The theatre nurse and her attendants now performed the miracle of getting the theatre spotless for the next case in just half an hour. Not just spotless in the ordinary sense of the term but its floor and furniture were swabbed with antiseptics and cleaned off microorganisms. The nurse then scrubbed to lay the table.Laying the table for surgery is a special skill. On rare occasions when the scrub nurse is not available we doctors sometimes attempt to lay the table. Even though we know what instruments we will need we never get it right. Some instruments and linen are the same for all forms of surgery, but each operation needs an additional set of special instruments. What is proper for the operation of duodenal ulcer perforation will not be suitable for exploring the thorax for injury. In this instance when I informed the nurse that a case of abdominal injury was awaiting its turn, she would have got the retractors, clamps and sutures necessary for a wide variety of possibilities for the ‘abdomen is a temple of surprises’.I was aware of this and as a newly minted surgeon, I called my chief to come. Spleen removal I could have managed but if there are surprises, I may be hard pressed.Scrub nurses do not operate. That skill is not part of their training, but they know the steps of the operation. They know not only what the surgeon is doing but what he will do next and be ready to hand over the appropriate instruments.The patient was anaesthetised and the abdomen cleaned and draped to expose just the part where the skin will be incised. The nurse handed the scalpel to my chief; he made the incision and the nurse gave him artery forceps to catch and control bleeding points. The abdominal wall was opened layer by layer. The final layer is the peritoneum. When the peritoneum is cut in this case there will be a gush of blood-stained fluid. The nurse in anticipation has the suction nozzle ready along with pads to soak up the fluid. With the abdomen open and now mostly free of fluid the surgeon quickly searched for the spleen. The spleen was split into two by the force of the injury. Blood was flowing freely from both pieces of the split spleen. The surgeon held the splenic pedicle with its artery and vein in a firm pinch to stop the bleeding. The nurse handed over to him the clamp specially designed for the splenic pedicle. She not only had that instrument on her table but knew precisely when the surgeon will need it. The surgeon clamped the pedicle, tied the pedicle and then removed the clamp.The surgeon now examined the abdomen for other injuries. The stomach, every inch of the small intestine, the large intestine, the liver, organs under the peritoneum like the kidneys were all examined and found to be uninjured. The surgeon was now ready to close the abdomen, but he can do that only after the nurse declares that every pad, swab and instrument used in the case has been accounted for. The nurse waved the all clear and the surgeon closed the abdomen.That is the routine for any abdominal operation. The nurse, as can be seen, is a key member of an operating team. Nurse’s duties in the theatre and elsewhere dovetail with the doctor’s duties. She is indispensable in patient care.*In a well-regulated hospital, the doctors, nurses and attendants of the ward feel as if they are a family. The doctor is the father figure. He (or she) is in the ward only for an hour or two but is patently the person in charge. The nurse is the mother. She manages the ward. She looks after its cleanliness, keeps stock of the ward linen, arranges timely food for the patients, and does the numerous things that must be done to keep the ward running like a machine. In this family where do the patients fit in? This incidence gives the answer.The senior was not taking his dose of bitter medicine despite cajoling by the nurse.‘If you do not cooperate,’ said the nurse, ‘I’ll have to report to your doctor.’‘What then?’‘The medication will come as an injection.’To the senior medicine, however bitter was preferable to any form of injection. He gulped the medicine in one swallow. His daughter uses the same injection threat to make the senior’s grandchild take medicines. Yes, that is it. Patients young and old are the children of the hospital ward. They may be retirees or active CEOs but in the hospital ward as patients they are children. They may need spoon feeding; they will be sponge bathed and dressed and occasions are not wanting when they will need a diaper change. It is the nurse who is in charge of these tasks.Please do not ask such questions as ‘Can a nurse with more training became a doctor?’ It is insulting to nurses.

I’m a hospitalist, or general internal medicine doctor who works only in the hospital. So when I hear code blue I’m usually making my way through rounding on all of my patients. The first thing I do is stop everything and listen. If I’m talking to someone or listening to them, I hold up a finger to get them to pause as well. I’m listening for the room number, as soon as I hear it, I check my patient list. Usually my list is between 17–23 patients. But back when I was a nocturnist, night time doctor, that list could be triple because I had responsibility for all of the patients our group of doctors see. Checking the list is something like playing that old game show where they said no whammy no whammy no whammy! Or as kids saying not it not it not it! I quickly look through the list to see if it’s my patient. If it is, (I usually say DAMN IT! in my head) I quickly make my exit from whatever I was doing and walk/jog to the room where the code blue is.I take the elevator if it is on a vastly different floor and it is available. I have no compunction about not allowing others to stop on their floors. I say, code blue we’re going to x floor first. I don’t run multiple flights of stairs because I learned a long time ago that the floor code team is doing everything they should and if I arrive exhausted and gasping for breath, I’m not going to be able to do my job effectively. The old adage is, the first thing you do in a code is check your own pulse. You can’t help someone, if you are not calm and collected.On my way, I’m mentally running through the entire history of the patient involved, the recent test findings, and what are the most likely reasons to have caused them to stop breathing and their heart stop beating. Sometimes the answer is quite obvious. Sometimes it’s very unexpected. There is some adrenaline you feel on the way and some anxiety. None of us want our patients to crash.When I arrive, I enter the room and assess it. Is there an er doctor there, who in my facility runs all codes? If so, I offer them any history and test information I have and step back into a supporting role. At times I may offer suggestions, but that doctor is running the code so I respect her by taking a secondary role.If there is no doctor there, I state who I am and my relationship to the patient and then ask what happened. Usually, the patient’s nurse is off to the side so I go to him or her and listen carefully while s/he tells me what happened. Sometimes this changes my course of thinking. Did they choke on something? Did they stand up and suddenly pass out and stop breathing? Did they complain of chest pain or shortness of breath before they went out? I then ask what has been done so far. I give orders for things that need to be done. I point to the person I want to do the orders, so there is no confusion. I use their name if I know it.When I was a medical student I did compressions etc. But now I don’t unless there is no one else. It’s not that I don’t want to. I used to do them very well and still can. But my role now is to be the thinker— to figure out what is wrong, how to fix it, and therefore get the patient safe again.A code is controlled chaos. My job is to remain calm, confident, and competent while figuring out how to help the patient and directing care to do so. I make a concerted effort to always remain calm and encouraging. Even if I’m nervous or alarmed or upset that the patient is not doing well. Everyone in the room looks to me to be the lighthouse on the rock in a stormy sea. If I’m freaking out, they will freak out more. Then nothing good will happen.There are a LOT of people in the room at once. Some are doing specific jobs like recording on paper what has been done, compressions, ventilatory support, giving medications through the iv, getting iv access etc. Some are runners. They go get things we need, get information from the chart, etc. If one is a bystander, you stay out of the way and try to think what they may need and bring it. Glove box low, quietly bring a new box of gloves. Isolation room, quietly bring a box of gowns. Central line going in? Pass out masks to everyoneEveryone has a job to do and they do it well. Everyone has to take lifesaving courses every two years, even if we have done the same course twenty times. So our jobs and what to do is really drilled into us over the years. It becomes second nature. For instance, if I see the heart rhythm torsades on the monitor. I don’t think torsades. My first thought upon seeing that pattern is magnesium! We are drilled on this so much and go over the same info so many times that certain parts of code care is autopilot.Someone, usually the patient’s nurse, will call the family. If I can, I often will step out to speak with the family by phone or in person if they are there. If the patient is very unlikely to survive the code in a meaningful way, we often have to have a very difficult and emotional conversation. Family members are frightened and in shock. They are often overwhelmed and very emotional. They don’t want to make the wrong decision and often have difficulty thinking. So I try to be as calm, patient, and easy to understand as possible. I do not sugar coat, but I am always respectful. Sometimes people withdraw. Sometimes they reach out for comfort. I give them what they seem to need: space or hugs etc. But I don’t take anything negative they say personally. This is likely the scariest time of their lives.If during the code, the er doctor arrives, I hand off control of the situation to her.If we are able to get return of circulation, the patient is stabilized as much as possible and they go off on a stretcher with a bevy of nurses and techs to be transported to the icu. I then have to speak with the intensive care doctor to explain what happened so that they can care for the patient.If we are unable to get circulation back and it appears futile after we give at least three rounds of cpr (many times much much more— I’ve been in codes that have lasted a couple of hours) and there’s is no family, I will ask everyone in the room if there is anything else they suggest we do. If there are no suggestions, I ask if everyone agrees to call the code. If they do, I say “stop cpr. I’m calling it. Time of death x o’clock.”If there is family, I ask the family again if they want us to continue. If they say to stop, we stop. I walk back into the room and say “stop cpr. The family wishes to stop. Time of death x o’clock.”After a code, people leave the room and talk amongst themselves to decompress. It’s a stressful time for everyone and it’s important to decompress with your colleagues afterwards. Everyone does that in their own way. Sometimes people might laugh, but it’s not out of disrespect to the patient. Gallows humor is a way that some cope with the trauma of what they just experienced. Some may go to the bathroom to get a breath and be alone with their thoughts. But mostly it’s a somber time as people go back to their previous duties. Usually someone cleans up the room a bit (code rooms are a disaster afterwards with wrapers and discarded gloves and stuff everywhere.) They will often place a blanket or sheet lightly over the patient, but not cover the face. They do this to make the patient more presentable for the family that may be coming to the room to view them soon after. No one wants their last view of their loved one to be their naked body surrounded by discarded wrappers and tubes etc.If there is family to call I often do that. Then I have them speak to the charge nurse about arrangements for the body. Then I fill out the paperwork. I have to sign the code sheet that has everything we did with the times it happened recorded on it. Then I write a progress note in the chart about what happened and complete a discharge summary. If it was not my patient and I was covering, I’ll let that doctor know the outcome of the code. I often go back into the room and say a quick silent prayer in my head for the patient for their journey on into whatever is after this life.Then, as is my tradition, I eat a piece of cake.My tradition of code cake started when I was in medical school. Back then it seemed like every code I went to ended in a death. I was excited about codes and wearing the cape of heroine doctor out to save the day, even if I was just a med student— a glorified chest thumper. But despite working really really hard, many patients died. And it quickly got depressing. You see, codes are not like they are on tv. Many people who are in hospital are quite old and have many many health issues. When they code, all the cpr in the world will not fix those other health issues. So often, they can’t be brought back. Codes work best on the very young and those who code in front of help due to some relatively easily reversed issue: like a blocked artery, choking, opiate over dose, etc. For these people, return of circulation often occurs fairly quickly. The rest we try very very hard to get back, but it is their time and in the end death prevails. I’ve since seen and run many more codes since then over the years and have had a lot of successes. But it doesn’t change the fact that cpr is no where near as effective as it is on tv.One day after a particularly depressing code, I went to lunch and there was chocolate cake. I was trying to avoid sweets at lunch. But that day, I was depressed over the loss and I thought to myself, how many calories must I have burned just now? It’s gotta be a lot. CPR is very demanding exercise. Afterwards, you are out of breath, covered in sweat, and your muscles are sore after doing all of those compressions. So I thought, what’s one piece of cake? So began my tradition of eating a piece of cake after a code.Code cake helps.