Charlene, the nursing supervisor, stomped into the nurses station. Erica urgently called out to her. “Charlene! We need to call a Code Purple.”

“No way,” Charlene said, shaking her long blonde hair.

“Every room is full. Everyone has more than the usual number of patients. Even the hallway is full. We don’t have beds to move these people to,” Erica insisted. “Where are we going to put any other ambo patients who come in?”

“I’ll get back to you.” Charlene left the room.

Erica shot a worried look at Molly.

The medic phone rang. Medic phones, which kept Emergency Medical Services in touch with hospitals, resembled walkie-talkies attached to police scanners. As Molly pressed the radio button, the other nurses nearby groaned. “What’s this one going to be?” one nurse sighed.

Molly answered the call. “Pines. Go ahead.”

A medic’s voice crackled over the speaker. “We’re bringing in a seventy-two-year-old male. Working code. Five-minute ETA.”

“Crap,” Molly muttered after she released the button. No time to waste. A working code meant that CPR was in progress.

“We have to make room for a code, y’all,” Molly said, in her unmistakably Southern drawl. Erica didn’t have time to reply before the phone rang again.

Molly reached over and hit the button. “Pines.”

“Medic forty-two en route to your location with a fifty-eight-year-old female in respiratory distress. We have her on BiPAP.” Bilevel positive airway pressure was a method of assisted breathing. The patient probably would have to be intubated.

“What’s your ETA?” Molly asked.

“Ten minutes.”

Erica summoned Charlene again. “Charlene! We’re getting two working codes.”

As the nursing supervisor during a shift when higher level administrators were not in the building, Charlene had the authority to reroute ambulances. But today, she appeared to be more interested in impressing the higher-ups with an enormous patient load than in making sure the patients were safe and the nurses were able to do their jobs.

Charlene gave Erica a long look. “Okay, you can go on purple.”

“Can you fill out the justification form? I have to prep for the codes,” Erica said, already moving toward the supply closet. To call a Code Purple, the ER had to list the number of patients in the ER and waiting room, the longest wait time for patients, and the number of beds available. Charlene would have to explain the financial loss to hospital administrators.

Charlene backed away, palms up. “Oh no, you’re the one who has to justify this closure.” She turned on her heel and strode off.

Erica looked at Molly in disbelief. Molly fumed. This place is exploding, she thought. We’re expected to work at max capacity with no breaks and no acknowledgment or assistance from administration.

At least it was a weekday. One of the more ludicrous hospital policies dictated that on nights or weekends, the nursing supervisor had to page the administrator on call to get permission for a Code Purple. That administrator could be anyone on senior management, including IT or finance personnel. A major medical decision could be made by someone with no medical training whatsoever. At Molly’s previous hospital, the finance director was on call on a day when the ER was flooded with new arrivals. Focused on billing as many patients as possible, he had refused to call a Code Purple even when the physicians insisted that the number of patients was unsafe. A patient easily could have suffered or died because the staff was so busy checking on others. Eventually, an irate ER doctor yelled at the administrator until he agreed to divert the ambulances.

As Erica texted “Code Purple” to the staff and notified EMS and hospitals countywide, Molly and three other nurses scrambled to make room for the incoming patients. They lifted people off hallway stretchers and into standard chairs dragged in from the waiting room. They moved patients from rooms into beds in the hallway. The patients hated being in the hallway because it was a fish tank: Everyone could see you, hear you, rush by you, and knock into your bed. But the nurses had no other choice.

The first code, the 72-year-old man, would be Molly’s. She wheeled a crash cart into a newly vacated room and paged the respiratory therapist on call: “We have a Code Blue coming in. ETA three minutes. And another patient coming in on BiPAP.”

Molly opened an intubation bag to check that it contained all of the necessary supplies. She went to the medication room to retrieve the drugs needed to paralyze and sedate a patient before intubation, in case they would be needed. She set up the cardiac, blood pressure, and oxygen monitor, then visited each of her four patients to ensure they had easy access to a call light. “I’m about to be tied up for a long time with a critical patient,” she told them.

The double doors at the ambulance entrance opened. Two medics raced down the hall, pushing a gurney on which another medic kneeled, rhythmically pressing all of his weight onto the patient as he performed CPR.

The recorder nurse, who documented the proceedings and kept track of time, guided them into Room 5, which nurses had cleaned only seconds before. Molly was glad to see Clark Preston follow them. Handsome and flirtatious, brash and irreverent, Dr. Preston was loved by some nurses and hated by others. Molly thought he was funny—and decisive, which was important in a code.

When the medics entered, the group quickly arranged themselves on either side of the gurney, hoisted the patient onto the ER stretcher, and whisked the gurney out of the way. As Molly hooked up the patient to the monitor, a technician started an IV.

One of the medics addressed the room: “Seventy-two-year-old male. Witnessed cardiac arrest while eating dinner at a restaurant. En route he was given three epi, two atropine. We bagged him because we were unable to intubate.” Bagging referred to a plastic mask attached to an oxygen source. Squeezing the ambu bag caused the mask, which covered a patient’s nose and mouth, to force air into the lungs.

The respiratory therapist had the intubation supplies ready. “Give me a 7.0 tube,” the doctor said. He intubated the patient, and said, “Molly, listen.”

Molly ducked under the medic, who was still performing CPR, now standing on a foot-high step stool. She reached under the medic’s arms with her stethoscope. She squeezed her head beneath the medic, and listened to the patient’s torso for air movement; air in the stomach meant the intubation tube was in the wrong spot. Then she listened to the lungs.

“Equal bilateral breath sounds,” Molly said.

The respiratory therapist attached a CO₂ detector, bagged the patient, and watched. “Positive color change on CO₂ detector.”

The clatter of the gurney carrying the second critically ill patient echoed from the hallway.

“Secure the tube,” Dr. Preston said. “Let’s run an ISTAT.” The tech quickly drew blood to test whether the patient had a chemical imbalance that could be corrected.

“When was the last epi?” the doctor asked.

“Four minutes ago,” said a medic.

“Give another round of epi. Let’s give two amps of bicarb and an amp of calcium,” Dr. Preston said. “Hold CPR.”

The medic stepped down from the stool, trading positions with a new tech. Because CPR was physically strenuous, CPR providers switched off with every pulse check, two to three minutes apart.

Molly quickly felt the patient’s femoral artery at the groin. “I don’t feel a pulse,” she said.

“Continue CPR,” Dr. Preston replied. The tech resumed compressions. “Bring me the ultrasound machine.”

Dr. Preston swiped gel on the patient’s chest. “Hold CPR,” he said. He passed the ultrasound wand over the patient’s heart.

“I do not see any cardiac activity. What is the total downtime on this patient?” he asked.