The crash call had activated more than once before we reached the ward. That pattern alone, a repeated alarm from the same location, signals a patient whose condition is profoundly unstable, someone who has arrested, been brought back or partially resuscitated, and then deteriorated again. By the time the call went out specifically requesting anaesthetic assistance, it was clear this was beyond standard ward team management. 

I attended alongside a colleague from the anaesthetic team. On arrival we found a large framed man with a significantly elevated BMI (Body Mass Index). His abdomen was substantial, and his torso was covered in bruising, the kind of widespread discolouration that speaks to serious underlying pathology rather than any single injury. CPR was already in progress, being delivered by the ward team who had responded first. 

The immediate clinical problem on arrival, beyond the arrest itself, was the airway. A junior doctor was bag-mask ventilating the patient, manually squeezing a self-inflating bag to force air into the lungs via a mask held over the face. In ideal conditions, bag-mask ventilation is adequate for short periods. In a high-BMI patient in cardiac arrest, it is extraordinarily difficult to maintain. The weight of a large abdomen pushes against the diaphragm, significantly reducing lung compliance and making each breath require much greater force to deliver effectively. The seal between mask and face is harder to achieve and maintain. The airway was insecure, and ventilation was compromised.

I offered a size 5 iGel supraglottic airway device. The iGel, as described in a previous episode, is a soft gel like device that sits above the vocal cords and creates a seal around the larynx without requiring a cuff. It is faster to insert than an endotracheal tube and does not require laryngoscopy or pause in compressions to place. In this patient, inserting the size 5 iGel gave a marginal but meaningful improvement in ventilation. Not perfect. But better than what we had.

Almost immediately, the iGel became the site of a secondary problem. The patient was producing a continuous stream of vomit and blood through the device. This is one of the most demanding and viscerally confronting aspects of resuscitation in practice, a reality that clinical training describes but cannot fully prepare you for. Regurgitation during cardiac arrest is common. The loss of protective airway reflexes, combined with the passive pressure that CPR compressions place on the abdomen, means stomach contents can and do travel upward.

I used suction catheters continuously to clear the iGel and maintain whatever airway patency we had achieved. This required sustained, active management throughout the resuscitation: suctioning, repositioning, maintaining the device seal, while compressions continued around me and the rest of the team worked the arrest. In a high-BMI patient already producing blood and vomit, every breath delivered was a small victory against the physics of the situation.

The monitor showed asystole throughout. Asystole is the complete absence of electrical activity in the heart. Where PEA, described in earlier episodes, produces a misleadingly organised looking rhythm, asystole produces a flat line. There is no electrical signal. No mechanical contraction. No output of any kind. It is the rhythm most strongly associated with death, and in the vast majority of cases it indicates that the heart has suffered irreversible damage or has been without adequate perfusion for too long to recover.

The patient remained in asystole for approximately one hour. CPR was maintained throughout that period, delivering mechanical circulation to preserve whatever residual cerebral and cardiac perfusion was possible. One hour of continuous resuscitation is an enormous undertaking, physically and emotionally, for every person in that room.

Four defibrillation shocks were delivered during the resuscitation. This requires explanation, because asystole is a non-shockable rhythm. The standard Advanced Life Support algorithm is unambiguous on this: do not shock asystole. Defibrillation works by simultaneously depolarising all cardiac muscle cells to create a brief window in which the heart's own natural pacemaker cells can re-establish an organised rhythm. That mechanism requires some residual electrical activity to work with. A completely flat line has nothing for the shock to reset.

The decision to attempt defibrillation despite a documented asystolic rhythm was made on the basis that, given the duration of the arrest and the clinical picture, there was no meaningful harm in trying. It is worth understanding this within its proper context: at the point those shocks were delivered, the team was managing a patient in whom survival was vanishingly unlikely, and the four shocks represented a considered decision to exhaust every available option before moving towards the conclusion the clinical picture was pointing to. They did not convert the rhythm. But they were given.

With the patient in prolonged asystole and the clinical picture painting a clear picture, the anaesthetist took a femoral blood gas sample, drawing blood from the femoral vein in the groin rather than the more commonly used radial artery in the wrist. In a patient with no cardiac output and after a prolonged arrest, peripheral access is frequently impossible or unreliable. The femoral vessels are large and accessible even in a high-BMI patient, making them the most viable sampling site under these conditions.

The team made the deliberate and correct decision to wait for the blood gas result before formally stopping resuscitation. A venous blood gas (VBG) taken during prolonged cardiac arrest provides critical information about the body's metabolic and acid-base state: the pH, the potassium level, the degree of acidosis, and the lactate. These values, in context, help the team make an objective, evidence based decision about whether any realistic prospect of survival remains.

When the results came back, they confirmed what the clinical picture had been indicating throughout. The biochemical evidence of prolonged, irreversible cellular damage was unambiguous. The decision to stop was made.

Cases like this one sit differently to the ones where the patient walks out of ICU. There is no ROSC moment, no transfer, no recovery to reflect on. There is just the sustained effort of a team doing the right thing, in the right order, for the right reasons, arriving at an outcome that was probably inevitable from the moment the crash call first went off.

That does not make the case less valuable. It makes it more so. The management of high-BMI patients in cardiac arrest is one of the most physically demanding scenarios in emergency medicine. The airway challenges are real and significant. The bruising on this patient's body before a single intervention had been attempted tells a story about underlying pathology that the team had to work around rather than with. And the use of objective biochemical data from a blood gas to inform the decision to stop represents exactly the kind of evidence based, dignified approach to ending resuscitation that every patient deserves.

Not every crash call ends with a survivor. But every crash call deserves a team that shows up completely. This one did.

All identifying details have been fully removed to protect the dignity of the patient and the privacy of all staff involved. These accounts are written to educate, to reflect, and to acknowledge the reality of what healthcare workers face in acute settings. New episodes every week at www.skillfullscrubs.co.uk.