Who is in charge...

[Bostonredsox]

case.

68 y/o pt on the MICU service (mine till Monday when I went off service so these events are from my co-resident who took over the service this week.)

H/o Diastolic failure, bad emphysema, OSA, poor respiratory reserve. Intubated for COPD flare and resp failure about 10 days ago by me. Relatively straightforward airway. Failed 4 consecutive weaning trials last week into weekend. Family finally agrees to trach.

Surgeon comes for perc trach at bedside planned for yesterday. Bronch guided by one of the pulmonologists, who was not the MICU attending that day, just pulm consult. one of the hospitalists who fills in because no one else will was on for the week as the ICU attending.

Trach starts. short, fat neck. apparently he was putting in a size 10 shiley. sats start to drop within the first few min. Bronchoscope is in via ETT , wire is able to be visualized. Pt codes. PEA arrest. Surgeon cannot get trach in. apparently airway is lost, not sure if tube is retracted to far or what. Anesthesia called, cannot reintubate. CPR proceeds for over an hour. eventually called.

When I heard the code I came down to lend a hand, im on a consult service, see like 845 people in the room atleast 6 of whom were physicians so I went back up to my boring renal failure consult.

In that room was the CRNA and anesthesiologist, who also happens to be a boarded ENT, 2 general surgeons, the ICU PGY3 (IM), 2 interns, the MICU attending (hospitalist this week).

Surgeon who was performing the trach gives all of the orders during the code. Asystole and PEA are shocked multiple times. Atropine is given for asystole. Vasopressin is given more than once. code not called till he had a bedside echo done showing immobile ventricles. Basically an hour or more long completely non-ACLS compliant CPR attempt.
I asked the hospitalist why he didn't assume control. he said, and hes very passive, doesn't like to ruffle feathers, but is the listed primary in our closed unit, well it happened during a surgical procedure so I deferred to the surgeon.

Who should be running this code? Is MICU attending liable for the bad outcome as protocol was not followed at all in this case as they were in the room and are the primary attending?

and my guess is huge PE. autopsy pending.

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[ThoracicGuy]

I would say the surgeon as it happened during his procedure.

 

[Hernandez]

**** happens, as long as what needs to be done gets done timely, who cares who is barking orders. There is such a thing as too many cooks in the kitchen, so there will be times I take over, but there will be times I defer to others as long as they know what's they're doing.

 

[jdh71]

Eh. I think only God brings back people from PEA. We should add tickle testicles to the algorithm for all the good it will do. Heh.

The cardiologists came up with ACLS to deal with treatable rhythms. And then I think as an after thought were like, "oh. Yeah. I guess you can do CPR on THOSE people too. I guess."

 

[Bostonredsox]

I was more or less thinking acls is the standard of care for CPR. If a patient dies after CPR, which most do, and the protocol was followed, no big deal. But if most everything's the protocol was not followed appropriately, could there be grounds for Legal recourse? And if there was, would the hospitalist also be liable as it was technically his pt, though the surgeon was the one not following protocol.

If it were me and I was the intensivist, the moment he started coding I would have told the surgeon you focus all your efforts on that airway, I will run the code. Because I'm sure he could not effectively think during the code while focusing on the huge whole he'd cut in the neck that he was not able to get a tube in.

 

[Hernandez]

I was more or less thinking acls is the standard of care for CPR. If a patient dies after CPR, which most do, and the protocol was followed, no big deal. But if most everything's the protocol was not followed appropriately, could there be grounds for Legal recourse? And if there was, would the hospitalist also be liable as it was technically his pt, though the surgeon was the one not following protocol.

ACLS is a suggested protocol and it is not a one size fit all standard of care protocol. The evidence behind it is not beyond reproach and sometimes you've got to go down the "consider expert consultation" arm of the algorithm.

Evidence based medicine isn't evidence based and you should be careful using the phrase standrd of care on anything, as medicine will likely change its opinion again on any given topic.

 

[Bostonredsox]

ACLS is a suggested protocol and it is not a one size fit all standard of care protocol. The evidence behind it is not beyond reproach and sometimes you've got to go down the "consider expert consultation" arm of the algorithm.

Evidence based medicine isn't evidence based and you should be careful using the phrase standrd of care on anything, as medicine will likely change its opinion again on any given topic.

That is a fair point.

But would you agree in the other point. You've got a guy coding with an open trach site you can't get a tube in. There are other physicians, who probably have run far more codes than you, I presume most hospitalists and intensivists run more codes than general surgeons (non surgical intensivists), in the room and able to take control so you can focus on the major problem, the failed surgical airway and respiratory arrest. If your all alone, obviously you do everything. But trying to blindly give orders while your hands are in the neck and all hell is breaking lose when there are other physicians available to assist seems like a bad idea to me. Would be like me telling anesthesia it's ok stand at the door, ill tube and then put in the line and give all the orders and review the labs myself. If I'm alone, sure, do it all the time. But if help is standing there, it probably is in the best interest of the patient to hand over the reins to the person who is not trying to obtain an emergent surgical airway that's gone awry.

 

[Hernandez]

That is a fair point.

But would you agree in the other point. You've got a guy coding with an open trach site you can't get a tube in. There are other physicians, who probably have run far more codes than you, I presume most hospitalists and intensivists run more codes than general surgeons (non surgical intensivists), in the room and able to take control so you can focus on the major problem, the failed surgical airway and respiratory arrest. If your all alone, obviously you do everything. But trying to blindly give orders while your hands are in the neck and all hell is breaking lose when there are other physicians available to assist seems like a bad idea to me. Would be like me telling anesthesia it's ok stand at the door, ill tube and then put in the line and give all the orders and review the labs myself. If I'm alone, sure, do it all the time. But if help is standing there, it probably is in the best interest of the patient to hand over the reins to the person who is not trying to obtain an emergent surgical airway that's gone awry.

I think many surgeons would take issue with that assumption.

I'm not going to assume anything, there are some people who can do just that, he'll, I've run codes while bronching the guy,

Some docs have big brass balls and have the swagger to do that, if he ****ing up then don't be stand there, nut up and take over and suggest he take care of the airway.

 

[bigtuna]

Why was this an easy airway for you and then anesthesia can't reintubate?
Failed attempt at perc trach shouldn't make the cords more difficult to visualize

 

[Med0123]

i would have deferred Code management to the anesthesiologist while the GS tries to get the surgical airway

 

[jdh71]

i would have deferred Code management to the anesthesiologist while the GS tries to get the surgical airway

Why? It's not even the anesthesiologist's patient, not really. The anesthesiologist seems like the last guy who should be taking over in the room.

 

[Med0123]

Why? It's not even the anesthesiologist's patient, not really. The anesthesiologist seems like the last guy who should be taking over in the room.

The hospitalist obviously doesn't have an ounce of leadership and the surgeon's full attention is needed to secure the airway. Who's left? Anesthesiologist-ENT attending.

 

[jdh71]

The hospitalist obviously doesn't have an ounce of leadership and the surgeon's full attention is needed to secure the airway. Who's left? Anesthesiologist-ENT attending.

Oh you meant in the context of the setting painted by the OP.

I don't know. I see the point you are trying to make but perhaps in this situation between the surgeon and the anesthesiologist it might be best for them to come up with an airway strategy and the hospitalist should have run the code.

Though most codes are kind of controlled chaos no matter how much we try to have them not be. And there really isn't anyone definite leader and the code tends to be run by the collective docs of any rank in the room.

 

[Bostonredsox]

The hospitalist obviously doesn't have an ounce of leadership and the surgeon's full attention is needed to secure the airway. Who's left? Anesthesiologist-ENT attending.

Anesthesia does not run codes here. They get the airway in and disappear as fast as Possible. If the hospitalist wasn't ready to show leadership, the IM3 would have led. Atleast that's what would have happened if this took place a week ago when I was on.

However, though this hospitalist is weak, he would have led, I think he just wasn't sure if that was ok as the pt was coding during the surgeons procedure. If our actual intensivist had been on she would have immediately assumed control or more likely, made it clear the ICU resident was in charge of the code. Surgeon and anesthesia would have worked together solely on the airway.

 

[ResidentMD]

Anesthesia does not run codes here. They get the airway in and disappear as fast as Possible. If the hospitalist wasn't ready to show leadership, the IM3 would have led. Atleast that's what would have happened if this took place a week ago when I was on.

However, though this hospitalist is weak, he would have led, I think he just wasn't sure if that was ok as the pt was coding during the surgeons procedure. If our actual intensivist had been on she would have immediately assumed control or more likely, made it clear the ICU resident was in charge of the code. Surgeon and anesthesia would have worked together solely on the airway.

Quiet observer on the forum recently. Pulm-CCM fellow now.

I think this was a case where no one really showed leadership, for the reasons you mentioned above. Someone should have taken charge, assigned responsibilities (e.g. surgeon + anesthesia with airway). The hospitalist/intensivist seemed like the right person to do that, especially if he was not comfortable with procedures at that given time. Or the pulm consult attending, who should have picked up on the fact that the code was not being appropriately run.

As someone said though, more often than once, no one wants to ruffle feathers. Its sad especially when the patient is at the receiving end of it.

On a parting note, agree with JDH's comments about PEA. Maybe thats why no one wanted to ruffle feathers

 

[Hernandez]

i would have deferred Code management to the anesthesiologist while the GS tries to get the surgical airway

It isn't the credentials, it's the person.

I'd like to hear what the surgeon did that Boston didn't like.

 

[ihearttriangles]

Hospital people could learn a lot from prehospital people when it comes to running codes IMHO. Pre hospital codes run way smoother than hospital codes for two reasons: 1)I Eveybody has clearly defined roles and 2) there are 5 or 6 people involved max. One code leader who manages the big picture. Assigns roles, assures good quality chest compressions, calls for rythm checks and clearly states the rythm, decides to shock or not shock, calls for drugs, basically is the brains of the operation. Then you have someone intubate, someone actually pushing drugs, and 2 or 3 people who rotate chest compressions. None of this 15 people in a small room running around asking "who is running this?"But With no one clearly identifying themselves as the code leader. Like watching a bunch of monkies try and make love to a football.

 

[Hernandez]

Hospital people could learn a lot from prehospital people when it comes to running codes IMHO. .

I don't know where you have seen codes run, and I don't think I won't to know either......

 

[ihearttriangles]

I don't know where you have seen codes run, and I don't think I won't to know either......

Are you suggesting that the scene described by bosox is not commonplace in hospitals? And have you ever seen a prehospital code?

 

[Hernandez]

Are you suggesting that the scene described by bosox is not commonplace in hospitals? And have you ever seen a prehospital code?

I'm wondering how many hospital codes you've seen. If you're hospital's codes are consistently disasters, something is wrong.

 

[Socrates25]

Havent you guys heard? In today's new feelgood world of healthcare, NOBODY is in charge and we all have to work together as a "team." Lets not forget that there's no one member of the team who is "in charge"

Here's the new ACLS protocol, based on medicine's new definition of "healthcare team":

1. RN observes a patient in distress

2. RN thinks about paging a code overhead, but remembers that as part of "team baesd healthcare" that no one person can make an arbitrary decision about that patient's care without consulting the "team."

3. RN observes a janitor working nearby and asks if is appropriate to call a code.

4. Janitor agrees that patient is in distress, code team is activated. RN patient waits at bedside because she is not allowed to make a decision without the healthcare "team" being available. 2 minutes pass by.

5. Code team arrives, consisting of critical care MD, critical care nurse, resp tech.

6. MD thinks about being the "team leader" but then he remembers from his re-training indoctrination program that the word "leader" is outlawed. Only the TEAM can make decisions, and they must use the recently revealed shared decision making model that the hospital's "quality control expert" devised.

7. The MD begins the shared decision making algorithm by asking if a quorum of the team is available to provide support. All agree that a quorum has been reached, but the RT thinks the janitor needs to be included as an official member of the team since he was around for the code initiation. RT reminds the team that hospital policy explicitly states that team membership is based on getting a 360 degree view of the WHOLE PATIENT and that training/credentials are not to be used to decide team membership or team leadership. Team takes a quick vote and agrees to put janitor on the team.

Yes I'm being somewhat facetious but this is where healthcare is going -- medical schools and residency programs are bending over backwards to avoid "offending" the "team" and therefore we have weak leadership in medicine who stands by idly in code situations watching a patient deteriorate, lest they "insult" a "team" member by assuming leadership.

 

[Dwindlin]

I'm wondering how many hospital codes you've seen. If you're hospital's codes are consistently disasters, something is wrong.

Enough in multiple states and hospitals to know that what Boston described is more common place than you think apparently.

 

[jdh71]

The fewer people you have at a code, the more "textbook" it is run. It's not that pre-hospital people run a "better" code, there is simply fewer people and because of that and the need to get **** done, it runs better.

It's like when you DON'T call a hospital-wide code in the ICU and just run it with the ICU team.

 

[Dwindlin]

The fewer people you have at a code, the more "textbook" it is run. It's not that pre-hospital people run a "better" code, there is simply fewer people and because of that and the need to get **** done, it runs better.

It's like when you DON'T call a hospital-wide code in the ICU and just run it with the ICU team.

This is how we generally operate. The SICU nurses call us directly as opposed to paging out hospital wide.

 

[Hernandez]

Enough in multiple states and hospitals to know that what Boston described is more common place than you think apparently.

Then perhaps I've been in nothing but hospitals with strong CC docs.or more than likely..seasoned ICU nurses.....

 

[VentdependenT]

case.

68 y/o pt on the MICU service (mine till Monday when I went off service so these events are from my co-resident who took over the service this week.)

H/o Diastolic failure, bad emphysema, OSA, poor respiratory reserve. Intubated for COPD flare and resp failure about 10 days ago by me. Relatively straightforward airway. Failed 4 consecutive weaning trials last week into weekend. Family finally agrees to trach.

Surgeon comes for perc trach at bedside planned for yesterday. Bronch guided by one of the pulmonologists, who was not the MICU attending that day, just pulm consult. one of the hospitalists who fills in because no one else will was on for the week as the ICU attending.

Trach starts. short, fat neck. apparently he was putting in a size 10 shiley. sats start to drop within the first few min. Bronchoscope is in via ETT , wire is able to be visualized. Pt codes. PEA arrest. Surgeon cannot get trach in. apparently airway is lost, not sure if tube is retracted to far or what. Anesthesia called, cannot reintubate. CPR proceeds for over an hour. eventually called.

When I heard the code I came down to lend a hand, im on a consult service, see like 845 people in the room atleast 6 of whom were physicians so I went back up to my boring renal failure consult.

In that room was the CRNA and anesthesiologist, who also happens to be a boarded ENT, 2 general surgeons, the ICU PGY3 (IM), 2 interns, the MICU attending (hospitalist this week).

Surgeon who was performing the trach gives all of the orders during the code. Asystole and PEA are shocked multiple times. Atropine is given for asystole. Vasopressin is given more than once. code not called till he had a bedside echo done showing immobile ventricles. Basically an hour or more long completely non-ACLS compliant CPR attempt.
I asked the hospitalist why he didn't assume control. he said, and hes very passive, doesn't like to ruffle feathers, but is the listed primary in our closed unit, well it happened during a surgical procedure so I deferred to the surgeon.

Who should be running this code? Is MICU attending liable for the bad outcome as protocol was not followed at all in this case as they were in the room and are the primary attending?

and my guess is huge PE. autopsy pending.

The person who steps up first.

If they appear to be struggling I make suggestions (like acls protocol).

why would you put in a size 10 trach?

How can you not pass sonething over guidewire? Slash and slide? sonething doesnt make sense. IM dude was smart, i wouldnt want my name anywhere on that code log.

 

[jdh71]

The person who steps up first.

If they appear to be struggling I make suggestions (like acls protocol).

why would you put in a size 10 trach?

How can you not pass sonething over guidewire? Slash and slide? sonething doesnt make sense. IM dude was smart, i wouldnt want my name anywhere on that code log.

Heh.

I hope I can talk you into working wherever I end up.

 

[njac]

Regarding the surgeon not following ACLS, I was on the code blue committee at my last hospital. We assessed every in house code, including those in the ED, for charting and adherence to ACLS guidelines.

Unless the code was run by an attending. Then it was considered "expert consultation" and was dismissed from review.

Does graduating from residency automatically make you the end all/be all of ACLS? Of course not. But that's potentially how administration will deal with it.

 

[europeman]

I'm a trauma surgeon currently doing a critical care fellowship...this is my perspective...

I'm a little confused why a surgical airway was not obtained. Unless he didn't know how to do it (which is very possible because many surgeons assume they can just wing a crash cric using their tracheostomy skills, when in fact, it's a totally diffrent procedure altogether).

Did you guys have the patient on end-tital capnography during the procedure? Does your vent detect co2? That would be one way of knowing initially if your tube actually came out.

but anyway, other than no one stepping up to the plate, I agree, it does not make sense for the person doing the trach to be "running" the code. Likewise, the person trying to intubate/ventilate has other things to worry about also. It should have been whoever was taking care of the patient as the ICU clinician, period.

That said, all that really needed to be done was an airway established while Anesthesia tried their best to ventilate them with nasal/oral airways and 2-handed bvm.

The medication stuff in an ICU is pretty obvious and nurses usually can run those meds by themselves - not to mention, do they really do anything anyway?

just my 2 cents

 

[Bostonredsox]

I'm a trauma surgeon currently doing a critical care fellowship...this is my perspective...

I'm a little confused why a surgical airway was not obtained. Unless he didn't know how to do it (which is very possible because many surgeons assume they can just wing a crash cric using their tracheostomy skills, when in fact, it's a totally diffrent procedure altogether).

Did you guys have the patient on end-tital capnography during the procedure? Does your vent detect co2? That would be one way of knowing initially if your tube actually came out.

but anyway, other than no one stepping up to the plate, I agree, it does not make sense for the person doing the trach to be "running" the code. Likewise, the person trying to intubate/ventilate has other things to worry about also. It should have been whoever was taking care of the patient as the ICU clinician, period.

That said, all that really needed to be done was an airway established while Anesthesia tried their best to ventilate them with nasal/oral airways and 2-handed bvm.

The medication stuff in an ICU is pretty obvious and nurses usually can run those meds by themselves - not to mention, do they really do anything anyway?

just my 2 cents

Your synopsis is my general feeling as well