We arrived on the Surgical Assessment Unit to a patient positioned in the left lateral position — lying on their left side, a placement that helps protect the airway and reduces the risk of aspiration (inhaling secretions or vomit into the lungs). Despite the gravity of the situation, they were still breathing for themselves, their airway open and unobstructed. A high-concentration oxygen mask — delivering up to 60–80% oxygen, was in place alongside a nasal cannula, a thin tube looped under the nose providing a supplemental flow of oxygen directly into the nostrils.

The anaesthetist assessed the situation and was satisfied that the patient was maintaining their own airway. Oxygen saturations, (the percentage of haemoglobin in the blood carrying oxygen) were hovering at a precarious 88–90% SpO₂. Normal is above 94%. These numbers were low. Worrying. But stable enough, for now.

The next priority: vascular access. We needed a line into a vein! Urgently. Multiple attempts were made, and eventually several 20G pink cannulas were successfully inserted into the left arm. A 20-gauge cannula is a mid-sized IV line, chosen for reasonably fast fluid delivery without being so large it risks tearing fragile veins.

But now a new problem emerged, and a sinister one. The blood pressure monitor was returning no reading at all. A blank screen where a number should be. I swapped the cuff. Nothing. Changed to a different machine entirely. Still nothing. In the heat of the moment, the uncomfortable question finally surfaced: does this patient actually have a pulse?

They did. A pulse was confirmed manually. The monitor, it seemed, was failing to detect a blood pressure low enough to register. A condition known as profound hypotension. The body was in crisis, but no alarm had sounded.

Moments later, no pulse could be found at all. The patient had arrested. CPR — cardiopulmonary resuscitation — was started immediately: rhythmic chest compressions at a rate of 100–120 per minute, physically maintaining circulation when the heart cannot do it alone.

There was another urgent problem. The patient was bleeding heavily from the mouth. A significant hazard during any resuscitation attempt, threatening to flood an unprotected airway. The decision was made to intubate: to place a definitive airway. A size 8 endotracheal tube was passed using a Macintosh size 4 blade laryngoscope ,a curved metal instrument used to lift the tongue and epiglottis, exposing the vocal cords and the entrance to the trachea (windpipe). The tube went in. The airway was secured.

Tube placement was confirmed using a disposable CO₂ monitor (end-tidal CO₂ colorimetric detector), which changes colour in the presence of exhaled carbon dioxide. This is a reliable sign the tube is in the trachea and not the oesophagus (food pipe). Oxygen saturations were maintained. The airway was protected.

CPR continued in cycles. Adrenaline (epinephrine) was administered (a drug that powerfully stimulates the heart and causes blood vessels to constrict, pushing what little circulation remained towards the brain and vital organs). In cardiac arrest, adrenaline is given every 3–5 minutes according to the Advanced Life Support algorithm.

Blood products were administered. The haemorrhage — the heavy bleeding from the mouth — had not stopped. In exsanguinating haemorrhage (catastrophic blood loss), transfusing blood is the only way to maintain oxygen-carrying capacity when the body is losing more than it can replace. Volume alone was not enough.

After approximately 30 minutes of active resuscitation — multiple cycles of CPR, adrenaline, blood transfusion — there had been no return of spontaneous circulation. The bleeding was ongoing. The surgical registrar, Mr Joe Bloggs, was informed of the full clinical picture. After careful, experienced assessment, a joint decision was made between the team: it was time to stop.

Thirty minutes is not a number arrived at lightly. It represents both the medical threshold beyond which survival with meaningful neurological outcome becomes vanishingly unlikely, and the weight of every person in that room having done absolutely everything within their power.

The patient was pronounced deceased.

These cases are shared to educate, reflect, and honour the seriousness of the work we do. Names and identifying details are omitted or changed to protect privacy and dignity. If this post raised questions for you, feel free to get in touch. New episodes every week — follow along at www.skillfullscrubs.co.uk.