Drugs and codes

[Doctor Bob]

I'm not sure if this is standard or not... or maybe there's a reason I'm missing...

I've found that a lot of the anesthesia residents here will not attempt an airway on a coding patient on the floor unless they first push fentanyl and succs. Or some other combination of drugs. It adds a few minutes to their set up process. At the last code, the resident started to flip through the chart looking for (as he later told me) contraindications to using succs. I snarked at him and told him you don't need drugs; the patient is (essentially) dead, just put the tube in.

I have been unsuccessful in finding a reason for this teaching other than "it's what we were told to do". So I'm wondering if there's a reason. Sure, if you can't get the mouth open, a little paralytic might be useful. But just as a matter of course? It seems to me that you don't need induction meds when the patient is coding.

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[GaseousClay]

I'm not sure if this is standard or not... or maybe there's a reason I'm missing...

I've found that a lot of the anesthesia residents here will not attempt an airway on a coding patient on the floor unless they first push fentanyl and succs. Or some other combination of drugs. It adds a few minutes to their set up process. At the last code, the resident started to flip through the chart looking for (as he later told me) contraindications to using succs. I snarked at him and told him you don't need drugs; the patient is (essentially) dead, just put the tube in.

I have been unsuccessful in finding a reason for this teaching other than "it's what we were told to do". So I'm wondering if there's a reason. Sure, if you can't get the mouth open, a little paralytic might be useful. But just as a matter of course? It seems to me that you don't need induction meds when the patient is coding.

It is because they are residents and just learning what to do. You already know that no one is teaching them to do that. I have seen many an ER resident break teeth, attempt 5x DLs and then call us with a bloody mess, I have been unsuccessful in finding a reason for this teaching as well.

 

[urge]

I'm not sure if this is standard or not... or maybe there's a reason I'm missing...

I've found that a lot of the anesthesia residents here will not attempt an airway on a coding patient on the floor unless they first push fentanyl and succs. Or some other combination of drugs. It adds a few minutes to their set up process. At the last code, the resident started to flip through the chart looking for (as he later told me) contraindications to using succs. I snarked at him and told him you don't need drugs; the patient is (essentially) dead, just put the tube in.

I have been unsuccessful in finding a reason for this teaching other than "it's what we were told to do". So I'm wondering if there's a reason. Sure, if you can't get the mouth open, a little paralytic might be useful. But just as a matter of course? It seems to me that you don't need induction meds when the patient is coding.

That's odd. Where is their attending?

 

[Apollyon]

It is because they are residents and just learning what to do. You already know that no one is teaching them to do that. I have seen many an ER resident break teeth, attempt 5x DLs and then call us with a bloody mess, I have been unsuccessful in finding a reason for this teaching as well.

Just a question - how many is "many"? Sorry for the derail. In my 20+ years of intubating (from EMT-Intermediate, through paramedic, to EM attending), I've never broken even one tooth. Am I just that fastidious? My program director would NOT stand for substandard intubating, if we were breaking teeth, and making the airway into rare meat.

 

[Icefrog]

I'm not sure if this is standard or not... or maybe there's a reason I'm missing...

I've found that a lot of the anesthesia residents here will not attempt an airway on a coding patient on the floor unless they first push fentanyl and succs. Or some other combination of drugs. It adds a few minutes to their set up process. At the last code, the resident started to flip through the chart looking for (as he later told me) contraindications to using succs. I snarked at him and told him you don't need drugs; the patient is (essentially) dead, just put the tube in.

I have been unsuccessful in finding a reason for this teaching other than "it's what we were told to do". So I'm wondering if there's a reason. Sure, if you can't get the mouth open, a little paralytic might be useful. But just as a matter of course? It seems to me that you don't need induction meds when the patient is coding.

I agree--just put the tube in. There's no reason for induction meds in my opinion. What would you do if the patient coded or near-coded in the OR? You'd turn off all the anesthetics. Giving anesthetic in a coding patient is just going to make it harder to get ROSC.

Intubation, although nice, is not even required per ACLS guidelines as long as other means of ventilation are adequate (e.g., bag-mask or LMA). What's the point of pushing fentanyl? To blunt the sympathetic response to laryngoscopy? Why would you want that if people are pushing 1mg epinephrine q 5 minutes?

 

[Mman]

Just a question - how many is "many"? Sorry for the derail. In my 20+ years of intubating (from EMT-Intermediate, through paramedic, to EM attending), I've never broken even one tooth. Am I just that fastidious? My program director would NOT stand for substandard intubating, if we were breaking teeth, and making the airway into rare meat.

I'd submit that a lot of that is probably just lack of follow up. Most dental injuries aren't teeth falling out into your hands or snapping off from the laryngoscope pushing against them, they happen later because the tooth got weakened from a hairline crack during the DL. And when you intubate in the ED, the patient likely isn't getting extubated for a while and when they do they've had so much going on that a chipped tooth probably won't be discovered for quite some time. And when a patient gets home after a week stay in the ICU, they probably don't know why their tooth is cracked, just that it is.

We get a lot of followup on it because many patients are coming in for short, elective procedures and specifically being warned about the risk of dental injury preop. So when they get a chipped tooth, it's on their mind where it came from.

It's the old if you haven't seen a complication you either haven't done enough of them or haven't looked hard enough for evidence of the complication.

 

[WholeLottaGame7]

I'm not sure if this is standard or not... or maybe there's a reason I'm missing...

I've found that a lot of the anesthesia residents here will not attempt an airway on a coding patient on the floor unless they first push fentanyl and succs. Or some other combination of drugs. It adds a few minutes to their set up process. At the last code, the resident started to flip through the chart looking for (as he later told me) contraindications to using succs. I snarked at him and told him you don't need drugs; the patient is (essentially) dead, just put the tube in.

I have been unsuccessful in finding a reason for this teaching other than "it's what we were told to do". So I'm wondering if there's a reason. Sure, if you can't get the mouth open, a little paralytic might be useful. But just as a matter of course? It seems to me that you don't need induction meds when the patient is coding.

Assuming you mean the full blown legit already-dead code, then it is probably just because there are like 50 people in the room and they haven't figured out the big picture and **** is crazy and they're inexperienced and haven't thought it through yet.

But, there are many flavors of codes; some of which you can make worse by giving or not giving particular medications. Very few "codes" are alike, and I've given all different kinds of combinations of meds. Very rarely (if at all), however, does it include a narcotic. Usually just an amnestic (midaz, prop, etomidate), a paralytic (roc or sux), and a pressor (phenyl or epi).

 

[WholeLottaGame7]

Just a question - how many is "many"? Sorry for the derail. In my 20+ years of intubating (from EMT-Intermediate, through paramedic, to EM attending), I've never broken even one tooth. Am I just that fastidious? My program director would NOT stand for substandard intubating, if we were breaking teeth, and making the airway into rare meat.

More than "rarely" but less than "all the time."

With the general dental health of the ED population plus the possibility of facial trauma, it is surprising that you haven't had any dental misadventures. You're literally either better than everyone else in the world at intubating, or as Mman said, just haven't done enough (though 20 years is a long time). Or maybe you're just referring to breaking teeth that shouldn't be broken.

 

[Noyac]

God I miss residency.

 

[urge]

Seriously, where is their attending? I would not expect them to be without one. ER intubations are extra challenging because most of the time there were prior not so gentle attempts.

 

[urge]

Seriously, where is their attending? I would not expect them to be without one. ER intubations are extra challenging because most of the time there were prior not so gentle attempts.

 

[Doctor Bob]

These are codes on the floor, not in the ED. So by hospital policy, the anesthesia resident who responds to the codes gets first crack at the airway. And they are unsupervised as it's usually a CA-2 so the expectation is that they can put plastic through the cords.
And don't get me wrong, they do a fine job of getting the patient intubated... once I kick them in the pants to just drop the syringes of meds and pick up a blade.

I think the inexperience is a big part of it... Everyone reverts to a position of comfort when put into uncommon situations. The hectic yell-fest goat-rodeo that is a floor code is not the common environment for anesthesiologists in general, so the residents revert to their standard algorithm. In that regard the experience is good.

Ok, I just wanted to be sure there wasn't some pathyphys reason for giving meds in these situations that I was missing.

As for complication follow ups... I work in the ICU mostly these days so I sit on these patients for days/weeks afterwards. I haven't seen busted/cracked teeth from ED intubations in all my time here. Lip lacs on the other hand... it's like in the heat of the moment people forget patients have lips and work to get them out of the way.
The only time I had someone whose teeth broke out during an intubation was someone who got intubated in the OR... To be fair, the baseball bat the guy took to the mouth beforehand probably had a lot more to do with it than anything else. But the poor resident's attending hounded him about it during signout when the patient was delivered to the SICU post-op.

 

[Shimmy8]

Our attendings do not respond to floor codes or icu intubations unless it's a known difficult airway.

Usually a resident or CRNA, try to send 2 people but doesn't always work that was logistically.

Like above, I've given all kinds of different meds (or none) as there are all kinds of different codes.

 

[G-Man82]

At my place it's the anesthesiology resident who is rotating through te icu that has to respond to airways. Their backup is the PACU attending. If it's a true code, then they are instructed to put the plastic between the cords. An attending isn't required for that. If they have to push drugs because there has been ROSC or this patient was in distress and it wasn't a true code, then they have to call an Attending.

 

[Apollyon]

I'd submit that a lot of that is probably just lack of follow up. Most dental injuries aren't teeth falling out into your hands or snapping off from the laryngoscope pushing against them, they happen later because the tooth got weakened from a hairline crack during the DL. And when you intubate in the ED, the patient likely isn't getting extubated for a while and when they do they've had so much going on that a chipped tooth probably won't be discovered for quite some time. And when a patient gets home after a week stay in the ICU, they probably don't know why their tooth is cracked, just that it is.

We get a lot of followup on it because many patients are coming in for short, elective procedures and specifically being warned about the risk of dental injury preop. So when they get a chipped tooth, it's on their mind where it came from.

It's the old if you haven't seen a complication you either haven't done enough of them or haven't looked hard enough for evidence of the complication.

You're talking nuance here - the grey zone. The guy in the second post is painting the picture of "Ellis 3/looks like meth mouth/tooth lost down the airway" - black and white. He's not talking chipped tooth. You and he are both talking apples, but he's red delicious, and you're Cortland (or Fuji, or Gala).

More than "rarely" but less than "all the time."

With the general dental health of the ED population plus the possibility of facial trauma, it is surprising that you haven't had any dental misadventures. You're literally either better than everyone else in the world at intubating, or as Mman said, just haven't done enough (though 20 years is a long time). Or maybe you're just referring to breaking teeth that shouldn't be broken.

Thanks? I have missed tubes, but never unrecognized. I did have two dislodge when I was EMS - one by overzealous volunteers, and one that was a ****show that two EM residents said I missed, but the attending backed me - the paramedic - over the two residents. I would swear in a courtroom that it was in, in the apartment, and that I secured it. We concluded (notwithstanding the residents) that it dislodged in the driveway into the ED. One resident actually stated, and then doubled down on, that the tube was in the esophagus, but the patient was ventilating through the tube, backwards up, and then down the trachea (?). I would also swear in a courtroom that I have never put traction on the incisors; I saw an RT when I was a resident that was levering on the incisors, and I have no idea why they didn't break. That ain't me. That ain't never been me.

I had a co-resident that dropped 3 lungs in 20 subclavian CVL insertions. I don't know if that was 1-2-3, or 18-19-20, or interspersed throughout. However, I DID know that, if ***** had the needle in hand, you should go the other way. With alacrity.

But, as I said, I am derailing.

 

[Planktonmd]

I have seen terrible dental injuries from ER intubations and usually by ER attendings who claim that they never miss an intubation and never break a tooth!

 

[Mman]

You're talking nuance here - the grey zone. The guy in the second post is painting the picture of "Ellis 3/looks like meth mouth/tooth lost down the airway" - black and white. He's not talking chipped tooth. You and he are both talking apples, but he's red delicious, and you're Cortland (or Fuji, or Gala).

Not sure it's a grey zone. You said in 20 years you have never broke a tooth. I'd say that's either you haven't done enough (of which I doubt if you've done it that long) or haven't followed each closely enough. Many broken teeth aren't discovered for quite some time after an intubation. They don't all snap off in front of your eyes while you are looking. I've had patients spit them out in PACU 30 minutes after a procedure ends.

 

[itwasalladream]

Doctor Bob, I think there's a good chance I recently trained where you're at, if your profile info is accurate.

Are these actual codes with chest compressions going on? Because I've been to a bunch of codes and never pushed drugs on a truly coding patient if compressions were occurring, nor did I hear of that practice among any of my colleagues. Now I also went to a bunch of situations where the patient needed to be intubated urgently (i.e. in the next 15-30 minutes) and a lot of people were running around panicking like the pt was going to expire any second. 9 times out of 10, there was plenty of time to briefly check the chart for landmines, set up safe intubating conditions, push whatever I felt was needed, and get the tube in, all within ~5-7 min of getting the call (at our place a code call was different than an "anesthesia STAT" call which I'm referring to here). Occasionally, the right decision was not to intubate at all. A quick evaluation keeps ya from feeling like a tube jockey, too.

Now if a patient is pulseless, and the resident goes and checks the chart before doing something, you got me. Maybe you got a (few?) clueless resident, and if they're actually being taught that, it's not something I was taught.

 

[pjl]

Damage from ED 2 weeks ago, in OR yesterday.
Lets just say we see it.
*Removed extra snarky comment

 

[fakin' the funk]

Reasonable to give succinylcholine if it's the kind of code where patient is semi-arousing during bouts of quality compressions and/or is trying to punch you while you are DL'ing

 

[Apollyon]

Not sure it's a grey zone. You said in 20 years you have never broke a tooth. I'd say that's either you haven't done enough (of which I doubt if you've done it that long) or haven't followed each closely enough. Many broken teeth aren't discovered for quite some time after an intubation. They don't all snap off in front of your eyes while you are looking. I've had patients spit them out in PACU 30 minutes after a procedure ends.

See, I think that, if we actually knew each other, in real life, we would be at LEAST cordial, and, more likely, very collegial. Then, someone comes after you, and sounds like an absolute **** - even though I, as an American, speak 3 other languages, and don't defame other countries or their people, nor do I defame other specialties. In other words, this following poster from another country, with a different mother tongue, who thinks he is better than anyone else (not medically speaking, but in general).

Again, you first spoke of chipped and cracked teeth. However, then, you mentioned people literally spitting them out. Those are quite different, in my mind. However, as I thought more of it, I realized something - more than half the patients I've EVER tubed were codes, the VAST majority of whom were not resuscitated (thank you NIV!). As such, those are those who could never tell me that I loosened or dislodged their tooth.

So, notwithstanding priggish ***** who **** on every other doctor, I still stand by my point. I am not saying it didn't happen (dental injury), but I have NEVER reefed on a patient's incisors. And, I never will. I have had sore forearms from trying to lift the mandible of "Wilbur", but I always go forward, never back. But, you know what? I will NEVER lie to you. I appreciate the candor that you have shown, and I believe that you deserve the same in return.

I have seen a lot on SDN. I see, among the posters in the anesthesiology forum, that there are a few lazy ****s. There are a few that are quite average. However, if not the majority, the plurality are anonymous heroes - those that, for internal reasons, do the best job they can, every time. They are those that, who might gripe here, bail out the CRNAs, with a smile, and a calm demeanor, and not a callous attitude, or a snarky, or even abusive, comment. They are those that, when you see them, you smile - you don't say, "oh damn - it's HIM". They are those that, given your choice, are those for whom you would ask, for your family.

As I don't have any anesthesiologist coverage in my hospital (only CRNA), I don't have anyone to call to come **** on me (although I did say DIRECTLY that I have missed tubes), or to do ED sedation (when I was in Hawai'i, a patient was transferred in for a shoulder reduction (accepted by ortho, who were there waiting), and an anesthesiologist whom I'd never seen was there at 10pm, and he had this ass-kicking small pump on which he had propofol, which I thought was SO COOL - now, when my CRNAs say that they won't sedate anyone outside the OR, I internally roll my eyes), or to rescue my airways. I'll admit, it's scary. When I do egregiously break a tooth, I'll rationalize it somehow (like, at least they're alive, or, they're dead anyways). But I shall never take for granted my fellow physicians.

Now, quite honestly, my derail is over.

 

[chocomorsel]

Apollyon, quite honestly, that was a weird derailment.

However, how come your hospital doesn't have anesthesiologists? Are you a tiny hospital out in the middle of nowhere?

Of course, I don't believe that whole shtick about tiny hospitals out in the middle of nowhere not having a horrible time recruiting because there are all kinda physicians out there, some who like the city, and some who like the little towns in the middle of nowhere. Most of the time, the hospitals don't want to pay for an anesthesiologist.

 

[deleted171991]

It's simple, @chocomorsel. The rural hospital gets a Medicare subsidy if they hire a CRNA. If they hire an anesthesiologist, nada. Even at the same salary, the CRNA option wins.

@Apollyon, welcome to our section of the forum. There are good and bad physicians, depending on the specialty. It's a matter of human character, too. I know some ED residents or fellows who are impressive, and a similar number I would not take my enemy to.

I liked your comment about people smiling when they see certain colleagues. I have heard it recently from one of my fellowship attendings, and I noted it, because I am the kind of anal arse who gets pissed off when seeing bad patient care, and occasionally vent my frustrations, while he is a totally laid back person who could watch bad patient care happening under this nose, and still have a smile on his lips. So I asked him why he does that.

 

[Mman]

See, I think that, if we actually knew each other, in real life, we would be at LEAST cordial, and, more likely, very collegial. Then, someone comes after you, and sounds like an absolute **** - even though I, as an American, speak 3 other languages, and don't defame other countries or their people, nor do I defame other specialties. In other words, this following poster from another country, with a different mother tongue, who thinks he is better than anyone else (not medically speaking, but in general).

Again, you first spoke of chipped and cracked teeth. However, then, you mentioned people literally spitting them out. Those are quite different, in my mind. However, as I thought more of it, I realized something - more than half the patients I've EVER tubed were codes, the VAST majority of whom were not resuscitated (thank you NIV!). As such, those are those who could never tell me that I loosened or dislodged their tooth.

So, notwithstanding priggish ***** who **** on every other doctor, I still stand by my point. I am not saying it didn't happen (dental injury), but I have NEVER reefed on a patient's incisors. And, I never will. I have had sore forearms from trying to lift the mandible of "Wilbur", but I always go forward, never back. But, you know what? I will NEVER lie to you. I appreciate the candor that you have shown, and I believe that you deserve the same in return.

I have seen a lot on SDN. I see, among the posters in the anesthesiology forum, that there are a few lazy ****s. There are a few that are quite average. However, if not the majority, the plurality are anonymous heroes - those that, for internal reasons, do the best job they can, every time. They are those that, who might gripe here, bail out the CRNAs, with a smile, and a calm demeanor, and not a callous attitude, or a snarky, or even abusive, comment. They are those that, when you see them, you smile - you don't say, "oh damn - it's HIM". They are those that, given your choice, are those for whom you would ask, for your family.

As I don't have any anesthesiologist coverage in my hospital (only CRNA), I don't have anyone to call to come **** on me (although I did say DIRECTLY that I have missed tubes), or to do ED sedation (when I was in Hawai'i, a patient was transferred in for a shoulder reduction (accepted by ortho, who were there waiting), and an anesthesiologist whom I'd never seen was there at 10pm, and he had this ass-kicking small pump on which he had propofol, which I thought was SO COOL - now, when my CRNAs say that they won't sedate anyone outside the OR, I internally roll my eyes), or to rescue my airways. I'll admit, it's scary. When I do egregiously break a tooth, I'll rationalize it somehow (like, at least they're alive, or, they're dead anyways). But I shall never take for granted my fellow physicians.

Now, quite honestly, my derail is over.

No need to derail. I am being cordial. My point is that anybody who intubates enough people is going to damage some teeth. There is no way to prevent that. It happens. Patients often have terrible dentition. Related to my point that it happens to everybody is that the time frame for discovering a dental injury is often such that you would never know from ED intubations whether it happened or not.

I'm not blaming YOU for anything. I'm saying it's a known complication that cannot be prevented 100% of the time.

 

[urge]

1 I, as an American, speak 3 other languages

2 I have seen a lot on SDN. I see, among the posters in the anesthesiology forum, that there are a few lazy ****s. There are a few that are quite average. However, if not the majority, the plurality are anonymous heroes

1 That is highly unAmerican, and, in fact, suspicious. Thank God the NSA is watching.

2 How can you assess clinical performance from reading a forum? Especially considering that 3/4 of what is said here is BS.

 

[Apollyon]

1 That is highly unAmerican, and, in fact, suspicious. Thank God the NSA is watching.

2 How can you assess clinical performance from reading a forum? Especially considering that 3/4 of what is said here is BS.

"Speak, that I may know thee." Although not impossible, it is quite difficult to constantly sound intelligent. I, personally, find that more reliable. It's easy to fake a lot, but not brains. Whatever. Happy thanksgiving!

 

[Doctor Bob]

Are these actual codes with chest compressions going on?

Yes.

Because I've been to a bunch of codes and never pushed drugs on a truly coding patient if compressions were occurring, nor did I hear of that practice among any of my colleagues. Now I also went to a bunch of situations where the patient needed to be intubated urgently (i.e. in the next 15-30 minutes) and a lot of people were running around panicking like the pt was going to expire any second. 9 times out of 10, there was plenty of time to briefly check the chart for landmines, set up safe intubating conditions, push whatever I felt was needed, and get the tube in, all within ~5-7 min of getting the call (at our place a code call was different than an "anesthesia STAT" call which I'm referring to here). Occasionally, the right decision was not to intubate at all. A quick evaluation keeps ya from feeling like a tube jockey, too.

In those situations, I agree, I'm all for pushing meds and making it a pleasant experience for the patient.

Now if a patient is pulseless, and the resident goes and checks the chart before doing something, you got me. Maybe you got a (few?) clueless resident, and if they're actually being taught that, it's not something I was taught.

Ok. Well, it's good that I'm not missing something. I'll look at it as a teaching moment I can provide for the residents; explaining the difference between "this person needs a tube now" and "this person needs a tube NOW".

 

[Random Anesthesiologist]

Seriously, where is their attending? I would not expect them to be without one. ER intubations are extra challenging because most of the time there were prior not so gentle attempts.

Some attendings will give senior residents the go-ahead to proceed with tube placement in a code while they are on the way. The resident may literally be 5 min closer because of hospital size and elevator dynamics.

I've never used meds in a nonresponsive pt during a code.

 

[teeva]

Where I trained, half the time during codes on the floor requiring chest compressions the patient didn't have an IV anyway. Upon entering the room, I'd find a medstudent at one groin getting labs, an intern at an arm looking for a vein, and a junior resident at the other groin poking around for a femoral line, a senior resident looking for the chart, and a bunch of nurses charting everyone's names and time of arrival. With some fancy acrobatics and ninja skills I'd manage to make my way to head of the bed, intubate, confirm placement, tape the tube, and hand it over to RT and GTFO.

Depending on the institution, attending presence was not always required, required only if drugs would be pushed, or always required.

 

[Urzuz]

Where I trained, half the time during codes on the floor requiring chest compressions the patient didn't have an IV anyway. Upon entering the room, I'd find a medstudent at one groin getting labs, an intern at an arm looking for a vein, and a junior resident at the other groin poking around for a femoral line, a senior resident looking for the chart, and a bunch of nurses charting everyone's names and time of arrival. With some fancy acrobatics and ninja skills I'd manage to make my way to head of the bed, intubate, confirm placement, tape the tube, and hand it over to RT and GTFO.

Depending on the institution, attending presence was not always required, required only if drugs would be pushed, or always required.

Please disclose the name of this hospital so I can avoid it like the plague.

 

[IlDestriero]

Please disclose the name of this hospital so I can avoid it like the plague.

I think that's probably pretty common. They are the ones on the floor in close proximity. The attending is in a meeting, in their lab, or in the faculty cafeteria. They may come, but they're not the first responders.

 

[cbrons]

Our attendings do not respond to floor codes or icu intubations unless it's a known difficult airway.

Usually a resident or CRNA, try to send 2 people but doesn't always work that was logistically.

Like above, I've given all kinds of different meds (or none) as there are all kinds of different codes.

Why would a CRNA respond to a code? Aren't there intensevists and actual doctors there to manage difficult airways?

 

[IlDestriero]

Why would a CRNA respond to a code? Aren't there intensevists and actual doctors there to manage difficult airways?

A CRNA would respond to a code to be the airway expert. Anesthesia's role is usually to drop the tube and leave. Most of the time, we've got other stuff going on elsewhere. Sometimes in a trauma we stay to gather data and make subtle suggestions that will benefit us shortly in the OR.
If I find myself running a code somewhere it's because the resident/fellow in charge is dropping the ball and the ICU team isn't there yet to take over. I've seen them drop the ball as well upon occasion, and that's where some subtle suggestions come in handy again.
That's one of the rarely discussed roles of a good anesthesiologist. The ability to see the forest for the trees and make some subtle suggestions to the surgeon, etc. to help stay out of trouble.

 

[Urzuz]

I think that's probably pretty common. They are the ones on the floor in close proximity. The attending is in a meeting, in their lab, or in the faculty cafeteria. They may come, but they're not the first responders.

While attendings may not be present, I would hope the senior resident has the sense to not look for the chart while the patient is coding. And any hospital that relies on medical students and interns to get labs and venous access has some serious issues. And to add to that, he stated that most of the patients on the floor who code don't have an IV to begin with -- um, what?

 

[teeva]

It was at hospitals located in the basement of hell, i.e. big inner city county hospitals with poor and indigent population.

No IV access on coding pts happens occasionally. Tends to be the CHF ESRD CAD DM HTN ESLD waiting for placement or social issues for discharge, who ends up coding in the middle of the night during vitals check. The pt has been sitting in the hospital so long their IV no longer works. No one knows anything about the pt except for night float team and whatever print out sheet they have on their little sign out sheet.

Non-pulseless codes were often a struggle because when you entered the room, everyone stared at you expecting a tube to magically pop itself in, whereas in your mind you have to assess the pt and come up with a safe plan to get the tube in and not cause cardiac arrest because of meds you may need to push and/or failure to secure the airway after pushing meds. And while doing that, you also had to pray the pt had a working IV or easily visible veins you could stick yourself. And sometimes you had to refuse intubation because it wasn't necessary. Sometimes it was just a sleeping pt and when you arrived the pt woke up and is wondering why there's so much commotion and tells you they're fine and to please go away so they can go back to sleep. Or the pt who had to wait til 10pm to finally get dialysis and dozes off or syncope but tricky to differentiate.

In other places, I think it's common for CRNA to respond to codes. They're usually assigned PACU or aren't in a case so they can leave the OR suite. Attendings are supervising and can't leave immediately, unless CRNA needs help and another attending can take over some rooms. Not every place has ICU fellows responding to codes and responsible for the airway.