Anatomy Of A Code Blue

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Intro from Jay Allison: Sam Slavin is a third year student at Harvard Medical School. He’d never made a radio piece, but he wanted to explore the world inside a “Code Blue,” the medical term for advanced cardiopulmonary resuscitation, for the dramatic attempt to restart the heart. Sam wanted to interview everyone affected when a Code is called—from doctors to maintenance workers. We gave him a recorder, and Viki Merrick helped him along the way. He gathered 28 hours of tape with 30 different interview subjects, and this piece combines all the recollections he was given. It’s a remarkable half-hour of insights into a hospital’s most traumatic and intimate moments.

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Listen to “Anatomy Of A Code Blue”

A “Code Blue”

You’ve seen it on TV. The line on the heart monitor goes flat. Reassuring beeps are overtaken by the ominous, solid tone of death. Doctors come running, throw electric paddles on the chest and yell, “Clear!” The patient springs back to life — most of the time, at least on TV.

Yet a “code blue” can also be traumatic. A large nurse throws his entire weight onto the chest of a frail ninety-year old, cracking multiple ribs. A doctor tears off the patient’s gown. Each chest compression launches blood from the patient’s mouth showering his naked body. Drugs upon drugs squeeze blood to vital organs, but when his heart starts again most of his brain may have already died from lack of oxygen.

A “code blue” is hospital-speak for advanced cardiopulmonary resuscitation. It is an attempt to restart the heart when it has stopped. On television codes are successful 75% of the time. In reality about 20% of patients live to leave the hospital. Whether a code is a magnificent life-saving feat or a brutal exercise in futility depends entirely on the overall condition and context of the patient’s life. In many cases the outcome is very difficult to predict.

In weaving together the narrative of a code, my goal was not to answer the incredibly complex question of when or whether we should attempt to resuscitate. Rather, I wanted to explore what happens to hospital staff when grappling with acute uncertainty around our ability to combat death.

Confronting Death

I envisioned a story that was part medical documentary and part collective memory piece, drawing on many people’s experiences of working on the wards over many years. Paradoxically, I found my most powerful inspiration in the narrative form of the radio documentary Witness to an Execution by Stacy Abramson and David Isay. Witness tells the story of how lethal injections are carried out in Texas by weaving together the experiences of the full range of “death house” staff — the warden, the chaplain, the media correspondent, the “tie-down crew.”

For me, the power of Witness comes largely from what it does not do. By not focusing on a single execution, not including recordings from any live event and not editorializing, it brings us deeper into the multi-layered experiences of those who live these events on a regular basis. I don’t think it was simply coincidental and ironic that my narrative about resuscitation found its inspiration in a piece about executions. Both moments of confronting death evoke emotions that cut through the more comfortably defined parameters of one’s “role” or “job.”

Why Audio

I originally turned to audio because of its power to immerse listeners in subjective experience. While video presents a reality seen through the camera’s lens, audio compels the listener to construct a mental and emotional image from the words and voices of those who have lived it.

Audio also enabled me to capture a greater range of experience. By recording staff whose voices, accents and languages evoke their diverse backgrounds, I hoped to create a virtual conversation that might never occur due to the divisions within the hospital heirarchy. Indeed, nearly half of my subjects said they would not have talked with me if this were video. Before coming to their interviews many wanted to confirm, “No camera, right?”

Logistics, Technical Aspects and Gear

It took almost eight months of conversations with various hospitals to obtain permission to start recording. Privacy and legal concerns make this an extremely sensitive subject. I ultimately connected with leaders who shared a love for public radio in an institution that is actively working towards providing medical care with greater transparency.

In addition, recording in the hospital turned out to be a technical challenge. There is a powerful ventilation system in every room that must remain on for purposes of infection control. When I first switched on my Marantz PMD660 in a space that seemed quiet to the naked ear, I thought the gear was malfunctioning because I could not escape the hollow roar of the ventilation. I’d nearly resigned myself to this background sound, when several generous people in the hospital’s media services department allowed me to use their basement recording studio. This was the one place in the hospital where they could shut the vents. None of the staff I brought down to record even knew the place existed.

When I finished, I had close to 28 hours of tape with 30 different interview subjects. I was so set on recording the widest possible range of voices that I continued until no one else would talk to me. This made editing a mammoth task.

I wanted the piece to follow the general narrative arc of a code — the cardiac arrest, the resuscitation attempt, the outcome of survival or death and reflections on the experience. I used Hindenburg editing software to arrange my favorite clips according to this chronology and loaded them into a single session. The content was still more than three hours long. At this point transcribing enabled me to see the piece with fresh eyes and cut more boldly.

The final piece was a little less than 30 minutes — roughly the length of an average code blue.

Collaboration

Learning how to make radio has a lot in common with learning to use a stethoscope to listen to the heart. The Transom team showed me how.

As with the stethoscope, the process begins with entering another’s space in a very intimate way while remaining acutely aware of how that person is reading and responding to your every gesture or expression. Samantha Broun showed me how to do this with a microphone, holding it just two inches from my subject’s mouth, while using silent reactions and gestures to direct the energy of the conversation or encourage a given train of thought without putting myself in the tape.

Second, there is “tuning in,” identifying the normal heart beats before listening in between the beats for additional or unexpected sounds. In a broad sense, Viki Merrick taught me to listen for the unexpected sounds. That is to say, she helped me tune in to qualities of my interview subjects that I had not listened for such as a quality of candor and directness. She taught me always to ask, “Was the interview visceral or drifting toward the cerebral?” She also taught me to listen in between the beats, focusing on the fine details — allowing pauses, creating smooth transitions and paying attention to voice levels.

Third, there is communicating what the heart sounds mean for the patient in front of you. The radio equivalent is making sure whatever topic you have immersed yourself in through months to years of research is clear to the listener in a matter of seconds. The whole Transom team, Viki in particular, helped me to keep one foot grounded in the outside world as the other drifted deeper into the world of the hospital. (Sometime this required quite a bit of tugging on that foot.) I am deeply grateful for these conversations about how to make the piece meaningful for a general audience. They certainly made it a better story.

Inspirations

Radiolab explored doctors’ personal preferences about resuscitation as well as some grim statistics in their episode, The Bitter End.

This article from the New England Journal of Medicine brought to light the discrepancy between codes on TV and real life.

I discovered Witness to an Execution thanks to Rob Rosenthal’s HowSound podcast.

I often found myself thinking back to A Piece of Collective Memory, in which Catherine Welch weaves together multiple experiences to evoke the feeling of a workplace that was a world unto itself.

Thanks

Thanks to the Neil Samuel Ghiso Foundation for Compassionate Medical Care and the Scholarship in Medicine Program at Harvard Medical School for financial support. And to Jay Allison, Viki Merrick and Samantha Broun for invaluable mentorship. Thanks to Jerry Berger, Michael Donnino, Jenny Greene, Susan Haviland, Irv Heifetz, Joyce Klein, Tom Laws, Nadim Mahmud, Laura Rock, Jeffrey Rothschild, Malcolm Slavin, Danielle Souza, Gordon Strewler, Bushra Taha and Angelo Volandes for making this project possible. Thank you to the Beth Israel Deaconess Medical Center (BIDMC) for giving this project a home, with particular thanks to the BIDMC Code Committee and the BIDMC Department of Media Services. Special thanks to all the BIDMC staff members as well as the patients and families who volunteered to share their stories especially: Sharon Casey, Physical Therapist; Margot Cronin-Furman, Social Worker; Kiran Kilaru, Physician, Marie Lessage, Housekeeper; Christian Ohazulume, Chaplain; Patricia Paradis, Nurse Educator and Supervisor; Cory Porter, Nurse; Adarsh Thaker, Physician; Patrick Tyler, Physician; and Haider Warraich, Physician.

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Support for this work provided by the
National Endowment for the Arts
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Samuel Slavin

About
Samuel Slavin

Originally from Cambridge, Massachusetts, Sam is currently a third year student at Harvard Medical School completing his clinical work at the Beth Israel Deaconess Medical Center in Boston. He studied history and literature at Yale, focusing on how writers make complex medical and scientific ideas meaningful to the public. This interest led him to work on public health projects in Haiti, the Dominican Republic, Mexico, New York City, Boston and the Navajo Nation. In these settings, he interviewed both patients and clinicians about their experiences of illness. The power of hearing their stories in their own voices sparked his desire to explore audio storytelling. Anatomy of a Code Blue is his first piece for radio. You can reach Sam at samslavin [at] gmail [dot] com.

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  • Oscar Russell

    4.10.16

    Reply

    This just played on Radio National in Australia. I’m a first year resident medical officer at Royal Adelaide Hospital in Adelaide, South Australia. This was a very powerful, sobering and highly accurate portrayal of what it’s like being part of a team responding to Codes and dealing with the aftermath, even in hospitals like mine across the Pacific (including the horrifying tune played by our Code Blue/MET pagers here!) Brilliant piece of audio.

    • Sam Slavin

      4.16.16

      Reply

      Thank you for sharing this comment, Russell. I am deeply glad to hear that our piece resonated with your experience.

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