Code

[sebsvenmdc]

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Saw my first code today. Geez, some stressful business, ladies and gentlemen. All 25 of the nurses were screaming for "anesthesia" for an intubation. How often do anesthesiologists get called to do this stuff? I mean, it's dependent on whether you work in a hospital or private practice, right? But it seems that there are probably private practices that hire out to hospitals (i.e. not all hospitals are teaching hospitals with non-private practice docs)? I guess intubating and being the go-to person in times of emergencies is something you just learn to get used to and adopt, but I have to admit...it was definitely stressful and nerve-wracking!

 

[periopdoc]

One of the coolest thing about my job is that scenario. There is little better feeling than walking into a room full of highly trained people who have lost their heads and announcing ladies and gentleman, anesthesia is here lets get to work. When I come in calm, cool, collected and exude control, the frenetic situation instantly changes. I direct individuals to do the jobs that they are trained to do and very quickly an orderly calm pervades the room as everyone gets to work. Then I, or my junior resident, slip(s) the tube in and we quietly leave.

My RT's love me.

In my private practice locums gig we are backup airway for the ER docs. So far I haven't had to manage an emergent, out-of-OR airway...

- pod

 

[urge]

One of the coolest thing about my job is that scenario. There is little better feeling than walking into a room full of highly trained people who have lost their heads and announcing ladies and gentleman, anesthesia is here lets get to work. When I come in calm, cool, collected and exude control, the frenetic situation instantly changes. I direct individuals to do the jobs that they are trained to do and very quickly an orderly calm pervades the room as everyone gets to work. Then I, or my junior resident, slip(s) the tube in and we quietly leave.

My RT's love me.

In my private practice locums gig we are backup airway for the ER docs. So far I haven't had to manage an emergent, out-of-OR airway...

- pod

You sound a bit delusional. Have you ever had that checked out?

 

[sevoflurane]

In my private practice locums gig we are backup airway for the ER docs. So far I haven't had to manage an emergent, out-of-OR airway...

- pod

Same here. I could care less for intubating on the floors. Let the ED take it and don't ever fight to have it. It will definitely increase the amount of work you do while on call. And.... ED loves to intubate. At my new gig I've had to intubate one person on the floor because ED couldn't get it. Was on standby for a difficult AW extubation. That's it, and I like it that way. Synergistic relationship if you ask me.

 

[Noyac]

One of the coolest thing about my job is that scenario. There is little better feeling than walking into a room full of highly trained people who have lost their heads and announcing ladies and gentleman, anesthesia is here lets get to work. When I come in calm, cool, collected and exude control, the frenetic situation instantly changes. I direct individuals to do the jobs that they are trained to do and very quickly an orderly calm pervades the room as everyone gets to work. Then I, or my junior resident, slip(s) the tube in and we quietly leave.

My RT's love me.

In my private practice locums gig we are backup airway for the ER docs. So far I haven't had to manage an emergent, out-of-OR airway...

- pod

Reminds me of Alec Baldwin in the movie where he is a doctor (can't remember the name of the movie right now) when he is on the stand and says, "So when you ask me do I think, I am god." Or something like that.

Just screwin with ya POD.

 

[periopdoc]

Malice, and it was at his deposition.

[YOUTUBE]LqeC3BPYTmE[/YOUTUBE]



- pod

 

[Idiopathic]

It is what it is. Probably had 100 of these as a resident, usually the ones that bug me are the low acuity elective floor intubations...I'd much rather tube someone in a code than take away the spontaneous respirations of a MICU patient on BIPAP for a semi urgent intubation (at 3am)

 

[BobBarker]

The anesthesia interns run the codes at the hospital where we do our internship. 500+ bed hospital. Good experience, obviously. Forces you to make the jump from med student to doctor rapidly.

 

[pillowhead]

I hate codes. They're always such a cluster. And the patients have often already vomited by the time I get there often because some stupid person who has done three intubations before tries to be a hero and gooses it while continuing to bag furiously because they KNOW they got it (i.e. many RTs, ER interns, and one of my all time most annoying experiences, the idiot cardiology fellow). If someone else wants to take this responsibility away from anesthesiology, fine by me.

 

[Paseo Del Norte]

Saw my first code today. Geez, some stressful business, ladies and gentlemen. All 25 of the nurses were screaming for "anesthesia" for an intubation. How often do anesthesiologists get called to do this stuff? I mean, it's dependent on whether you work in a hospital or private practice, right? But it seems that there are probably private practices that hire out to hospitals (i.e. not all hospitals are teaching hospitals with non-private practice docs)? I guess intubating and being the go-to person in times of emergencies is something you just learn to get used to and adopt, but I have to admit...it was definitely stressful and nerve-wracking!

I am not sure what kind of hospital you are at, but I am doing a summer critical care rotation (RT not medical school) in a level I trauma centre and every code that I have been on has been this way. It is my personal bias that having too many people is a disaster and a goat screw waiting to happen.

I occasionally moonlight as an ER nurse and the best codes I have ever been on were in smaller hospitals where it is a doc, myself, a CNA or Tech and a LPN. I have somebody chart and watch the monitor while the Tech does compressiosn and I give meds, help the doc with the tube and bag. Sometimes we will switch out as people tire. Honestly, I think this works much better than a cluster. You have a few people who know their roles and the doc is able to easily see the big picture and communicate without having to yell commands several times to several people.

 

[Idiopathic]

The anesthesia interns run the codes at the hospital where we do our internship. 500+ bed hospital. Good experience, obviously. Forces you to make the jump from med student to doctor rapidly.

Are you at OU? I seem to remember this being a selling point at Integris.

 

[BobBarker]

Are you at OU? I seem to remember this being a selling point at Integris.

Yes, and it is just as advertised. No scut, no abuse. All the good stuff.

 

[Green912]

Despite what many frantic people on the floor think, advanced airways doesn't resuscitate patients. Good CPR, Good BVM w/an oral airway, electricity and maybe drugs are higher on the ACLS algorithm.

 

[psychbender]

All 25 of the nurses

This, right here, is why I prefer pre-hospital codes. Everyone there would have been better served if the vast majority of the people in that room returned to tending their virtual crops.

 

[Narcotized]

.

 

[Licoricestick]

Easily one of the 3 worst dumbest most *****ic ******est scenes in movie history. On the level of "Glitter," "Gigli," and a bad Pauly Shore movie. Seriously, who writes this shet?

People who couldn't get into surgical training.

 

[ssmallz]

I am not sure what kind of hospital you are at, but I am doing a summer critical care rotation (RT not medical school) in a level I trauma centre and every code that I have been on has been this way. It is my personal bias that having too many people is a disaster and a goat screw waiting to happen.

I occasionally moonlight as an ER nurse and the best codes I have ever been on were in smaller hospitals where it is a doc, myself, a CNA or Tech and a LPN. I have somebody chart and watch the monitor while the Tech does compressiosn and I give meds, help the doc with the tube and bag. Sometimes we will switch out as people tire. Honestly, I think this works much better than a cluster. You have a few people who know their roles and the doc is able to easily see the big picture and communicate without having to yell commands several times to several people.

QFT, nothing is worse than being at a code and seeing 5 different people trying to run it and no one quite knowing where to start. Everyone starts barking orders and nothing gets done. At one of my hospitals we had a code team consisting of select PAs and nurses. Although there was no doc running it, it ran pretty efficient b/c everyone knew their role and the ACLS guidelines were followed. FWIW RTs did the intubating there but I don't think they were allowed to give drugs, only some ativan.

 

[ssmallz]

It is what it is. Probably had 100 of these as a resident, usually the ones that bug me are the low acuity elective floor intubations...I'd much rather tube someone in a code than take away the spontaneous respirations of a MICU patient on BIPAP for a semi urgent intubation (at 3am)

Even worse than that is getting called at 3am for an elective intubation and then finding out the pt is DNI. Nursing staff then goes "can you stick around, we're trying to get the DNI rescinded" which of course they never do but will waste a half hour of your time. 😡 These will invariably always happen at some ungodly hour when you could be getting sleep and will always be followed by a stat c-section just as your head hits the pillow in the call room. Good times

 

[cfdavid]

Easily one of the 3 worst dumbest most *****ic ******est scenes in movie history. On the level of "Glitter," "Gigli," and a bad Pauly Shore movie. Seriously, who writes this shet?

You can't deny it was amusing as hell though! I really liked that movie, in fact....

 

[cfdavid]

Regarding codes, I just recertified ACLS and while the new guidelines aren't coming out until December, it's rumored that advanced airways will be further deemphasized.

Also, I hear lidocaine may be taken off as very little evidence as to actual efficacy in V-fib/V-tach w/out pulse/unstable. Good ole fashioned UNINTERUPTED (minimally) CPR is the most effective, and anything interupting CO is grossly detrimental, and that includes stopping CPR for an advanced airway IN CODES. CPR and electricity (when warranted) are far and away the most important two interventions in a code.... Human nature, however, always will want to "do something", hence the perhaps overemphasis on advanced airways and pharmacological interventions....

That being said, I think it's likely that advanced airways will still be requested perhaps beyond the scope of what EBM in codes is suggesting.


cf

 

[sebsvenmdc]

You can't deny it was amusing as hell though! I really liked that movie, in fact....

Seriously, I thought it was very entertaining. It captures some of the stereotypes of the most arrogant surgeons very well. It's kind of funny too...isn't this guy an OB-GYN doc in the movie? I don't think treating some of the gyn emergencies (i.e. hemoperitoneum) in a woman is ingenious, one of the examples he mentions in his little tirade.

 

[cfdavid]

Seriously, I thought it was very entertaining. It captures some of the stereotypes of the most arrogant surgeons very well. It's kind of funny too...isn't this guy an OB-GYN doc in the movie? I don't think treating some of the gyn emergencies (i.e. hemoperitoneum) in a woman is ingenious, one of the examples he mentions in his little tirade.

I guess he was the only dude around to handle the ruptured ovarian artery that night..... But, no, I don't think they ever eluded that he was an OB/GYN. He was, however, board certified in Cardiovascular "medicine" and trauma surgery.....

 

[sebsvenmdc]

I guess he was the only dude around to handle the ruptured ovarian artery that night..... But, no, I don't think they ever eluded that he was an OB/GYN. He was, however, board certified in Cardiovascular "medicine" and trauma surgery.....

Lol, ok, my bad...dude, you've seen this more recently than me or your memory is superior because I forgot those details.

 

[Antibodies]

Lol, ok, my bad...dude, you've seen this more recently than me or your memory is superior because I forgot those details.

I think he says it in the clip.

 

[RabbMD]

Seriously, I thought it was very entertaining. It captures some of the stereotypes of the most arrogant surgeons very well. It's kind of funny too...isn't this guy an OB-GYN doc in the movie? I don't think treating some of the gyn emergencies (i.e. hemoperitoneum) in a woman is ingenious, one of the examples he mentions in his little tirade.

I do not want to give away the movie, but this ridiculous scene was done by the character for a very specific reason. It was quite intentionally over the top (the character Alex Baldwin was playing was essentually intentionally acting this arrogant).

 

[Narcotized]

I guess he was the only dude around to handle the ruptured ovarian artery that night..... But, no, I don't think they ever eluded that he was an OB/GYN. He was, however, board certified in Cardiovascular "medicine" and trauma surgery.....

Which makes me wonder if a.... lawyer.... wrote this scene. Just where is the American Board of Cardiothoracic Medicine located?

 

[Socrates25]

The only people who should be intubating are paramedics in the field and MDs in the hospital (whether they be ER docs, anesthesiologists or whatever).

RTs should NEVER intubate anyone, and any hospital who allows them to do so needs to be put out of its misery.

 

[Paseo Del Norte]

The only people who should be intubating are paramedics in the field and MDs in the hospital (whether they be ER docs, anesthesiologists or whatever).

RTs should NEVER intubate anyone, and any hospital who allows them to do so needs to be put out of its misery.

Why should paramedics be allowed to intubate? One could argue that the field is the last place you want to perform an intubation.

 

[sebsvenmdc]

I think he says it in the clip.

I didn't watch the clip.

 

[cfdavid]

I do not want to give away the movie, but this ridiculous scene was done by the character for a very specific reason. It was quite intentionally over the top (the character Alex Baldwin was playing was essentually intentionally acting this arrogant).

Indeed. And sebsvenmdc, yeah, I did recently watch Malice. Lots of twists and turns, and a serial killer thrown in for good measure......lol

 

[Idiopathic]

Why should paramedics be allowed to intubate? One could argue that the field is the last place you want to perform an intubation.

i believe an Anesthesiology cover story in the last year attests to this

 

[hoyden]

The only people who should be intubating are paramedics in the field and MDs in the hospital (whether they be ER docs, anesthesiologists or whatever).

RTs should NEVER intubate anyone, and any hospital who allows them to do so needs to be put out of its misery.

Can you logically explain why you consider paramedics to be acceptable to manage the airway and the RTs are not by your standards? Neither is a physician..

 

[Idiopathic]

both arguments are ridiculous, putting plastic in an airway in an emergent situation is a technical skill and does not require an MD to be capable. with that said, field intubations are probably not great ideas, whether by MD or EMT or RT. personally, I believe in a hospital setting, anesthesia or some ER docs should be the only ones intubating, but thats for another day.

 

[leviathan]

The only people who should be intubating are paramedics in the field and MDs in the hospital (whether they be ER docs, anesthesiologists or whatever).

RTs should NEVER intubate anyone, and any hospital who allows them to do so needs to be put out of its misery.

I don't know what corner of the world you come from, but the RTs here are highly trained and educated individuals who I would trust over a paramedic any day of the week. Why the hate on RTs?

 

[Paseo Del Norte]

I don't know what corner of the world you come from, but the RTs here are highly trained and educated individuals who I would trust over a paramedic any day of the week. Why the hate on RTs?

Just like United States EMS, the education of respiratory therapists is most likely different from the States to Canada. If I had to take a guess, the Cadadian schools on average probably prepare their entry level practitioners better. In fact, I remember having a conversation where somebody quoted the clinical requirements for a Canadian RT and those hours were over double what the RT students receive in my area of the country. (Myself included as a prospective RT.) This has been my experience (anecdotal) with many of the nurses and absolutely with EMS. (Or, at least the PCP versus Paramedic depending on the Canadian province.)

With that, I partially agree with his/her point, minus the hating. If a hospital has a physician that can intubate, I would rather that physician do the intubating. I am a big believer in having the most experienced person intubate therefore, I would always defer to an anaesthesia provider or other physician that has routine airway experience. Even as a flight nurse who "can" intubate, I will do my best to either avoid intubating or defer to a physician. In addition, I would rather the physician take on the liability of the intubation. That sounds cold, but that is the responsibility that comes with spending a decade or so in medical school.

 

[Johnisit1234]

Despite what many frantic people on the floor think, advanced airways doesn't resuscitate patients. Good CPR, Good BVM w/an oral airway, electricity and maybe drugs are higher on the ACLS algorithm.

How often have you seen good BVM with an oral airway in place? i mean, how often have you seen an oral airway in place? and even if you do have one in place, how often have you seen good, effectice BVM? at the hospitals i rotate through, NEVER. it's usually insufflating the stomach, not getting any air to the lungs. that deoxy blood with good chest compressions is going to be worth crap eventually. just my personal opinion.

 

[Paseo Del Norte]

What is BVM?

Bag valve mask; we commonly utilise the term BVM in EMS as a way of describing a self inflating bag device that typically employes a one way duck bill type valve (typically) and an oxygen reservoir. The term "Ambu Bag" is a synonym.

Often, I note people people will say "good BVM." While you could argue that this is not a proper way to use "BVM," the term "BVM" is often used as a way of explaining the action of using a BVM.

 

[psychbender]

Mask ventilation? Thanks!



Huh? An oral airway makes mask ventilation really easy, most of the time. If you keep the airway pressure low, minimal air will go into the stomach.

I think that was part of his point. He was making an observation that it is unfortunate that OPAs are not actually used to aid in quality mask ventilation in other parts of the hospital. On most occasions where I have seen mask ventilation outside of the OR, the mask has been shoved down on the patient's face, the neck flexed, and someone is trying to squeeze the bag about once every one to two seconds. Net effect, not good mask ventilation at all.

 

[Depakote]

What about aspiration?

An oral airway/ambubag doesn't seem like it would help much to protect the airway in a code situation.

 

[pgg]

Huh? An oral airway makes mask ventilation really easy, most of the time. If you keep the airway pressure low, minimal air will go into the stomach.

It usually makes it easy for us. Non-anesthesia/EM trained code responders often don't have the kind of stylishly confident and refined grip, seal, and head positioning that are 2nd nature to us and make us look so cool at codes. 🙂

 

[Sergio99]

Hello,

I haven't followed up closely on the newest developments in this area, but the last time I checked I think it was pretty well established that paramedics are better off ventilating by mask than intubating. It is better to have a patient partially well ventilated with a mask than not at all with a tube in the esophagus. Once you insert an ET tube in the wrong hole and fail to recognize it, the patient has no more chance.

That is the reason why, even though nobody can ventilate by mask as well as an anesthesiologist, it is still preferable to have them do that rather than intubate in the wrong hole.

Greetings

 

[jwk]

Bag valve mask; we commonly utilise the term BVM in EMS as a way of describing a self inflating bag device that typically employes a one way duck bill type valve (typically) and an oxygen reservoir. The term "Ambu Bag" is a synonym.

Often, I note people people will say "good BVM." While you could argue that this is not a proper way to use "BVM," the term "BVM" is often used as a way of explaining the action of using a BVM.

You honestly have heard someone say "good BVM", and hear it often? Really?

The ancient term for us old farts is AMBU, which I realize is a brand name somewhere. I've heard of "ambu-ing" or "bagging", but never "good BVM". I think that's the generic term AHA came up with since they didn't want to say "Ambu" in their ACLS books. 😉

 

[jwk]

Hello,

I haven't followed up closely on the newest developments in this area, but the last time I checked I think it was pretty well established that paramedics are better off ventilating by mask than intubating. It is better to have a patient partially well ventilated with a mask than not at all with a tube in the esophagus. Once you insert an ET tube in the wrong hole and fail to recognize it, the patient has no more chance.

That is the reason why, even though nobody can ventilate by mask as well as an anesthesiologist, it is still preferable to have them do that rather than intubate in the wrong hole.

Greetings

That's why EMS is also moving to things like CombiTubes or even LMA's. Blind placement, minimal training, no need to interrupt chest compressions, and more than likely, better ventilation than someone with all too infrequent experience actually trying to bag someone. I think REALLY decent mask ventilation is far more difficult to master than placing an ETT on most patients.

ALSO - there is a BIG difference between intubating under controlled circumstances in the OR and doing it lying on your belly in the middle of the interstate - been there, done that, no fun !!!

 

[Paseo Del Norte]

You honestly have heard someone say "good BVM", and hear it often? Really?

The ancient term for us old farts is AMBU, which I realize is a brand name somewhere. I've heard of "ambu-ing" or "bagging", but never "good BVM". I think that's the generic term AHA came up with since they didn't want to say "Ambu" in their ACLS books. 😉

Absolutely, I hear this term used with a fair amount of frequency. You must remember, I spend a good deal of time responding to scenes and working with first responder and Basic EMT trained providers who work for volly and paid/semi-volly services in rural communities. The terminology could also be a regional thing.

 

[rsgillmd]

Absolutely, I hear this term used with a fair amount of frequency. You must remember, I spend a good deal of time responding to scenes and working with first responder and Basic EMT trained providers who work for volly and paid/semi-volly services in rural communities. The terminology could also be a regional thing.

Probably regional. Granted I haven't been on an ambulance since 2005, but up to back then I never heard the term BVM used as a verb. I heard it used plenty of times as a noun, as in "Grab the BVM." Usually as a verb it was "Easy bag" or "The firefighters are bagging the patient."

BVM is probably mainly an EMS term. Most people say "Ambu bag." Every now and then "BVM" still slips out of my mouth and I get blank stares from the nurses.

As far as mask ventilation goes, as good as most basics/medics think they are in the field, (in my experience) they invariably improve when given the feedback of exhaled tidal volume and peak pressure generated from the anesthesia machine. I certainly did.

The St. Barnabas (Livingston, NJ) medics temporarily used LMAs back in 2003/2004 but apparently went back to Combitubes. The rescue device in Memphis, TN and Boropark (Brooklyn, NY) is also a Combitube. Having used both devices on mannequins, and LMAs countless times on patients, I think LMAs are easier and faster, but that's my personal opinion.

 

[rsgillmd]

This thread seems to be going off on a tangent. Let me try to bring it back to the original topic:

Yes, anesthesia personnel (residents, attendings, or CRNAs) frequently respond to codes and for other floor intubations, but it will vary by institution.

People running around like chickens with their heads cut off will vary from institution to institution as well as on the location of the code (floor vs ICU). With training/experience you will realize that excitement/yelling accomplishes nothing. Being calm in the middle of a code may occasionally induce calm in others.

New guidelines or not, I heard many times during residency, "Thank god, anesthesia is here." This not because we run the codes, although I have on occasion taken charge when the code team seemed clueless, but because it is still a commonly held belief that successful resuscitation will likely only occur after successful intubation.

It is also common to see people gawking and taking up space, but contributing nothing to the resuscitation. These are usually the people I kick out of the room if I'm running a code.

It is normal to feel excited, especially when you are early in your training. The goal is to put that excitement to good use. Eventually though all of this will become routine.