Codes

[MAC10]

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Just curious how airway is handled during codes at other hospitals. I was wondering beacuse I am really starting the dislike the way things are handeled at my institution of learning. Medicine runs the codes here, anesthesia (and usually half the hosptial) also shows up for codes. Half the time the medicine resident gets pissed when anesthesia steps in to intubate. The other half its a medicine resident that likes to stay as far away from procedures as possible and gives it up to somebody..anybody. Then when anesthesia shows up they have to pry the repiratory therapist out of the way cause he or she is bagging (usually all kinds of wrong ways if its at the VA) or intubating ???? I dunno it just makes sense to me that anesthesiologist would take charge of airway during codes. The patient is crashing for godsake, its no time to be fumbling around, intubate the esophagus a couple of times, before medicine decides to give it up.
Does this happen at other places??
I dont think im going to be able to standby watching this next year...

 

[Tenesma]

in the ATLS guidelines (and also for ACLS) the recommendation is that the MOST experienced laryngoscopist secures the airway. So if it is a competition between EM/FP/IM/ENT/SURGERY or Anesthesia, Anesthesia wins.... However this is complicated by hospital policy as well as who is the primary attending for this patient. Most hospital policies agree that the primary attending for that patient can decide who provides care and under what circumstance (ie: if the ER attending wants his resident to intubate instead of anesthesia resident - then he/she can arrange/supervise that) However, it gets legally sticky should it go to court, because the lawyer can ask why the most experienced laryngoscopist wasn't used.

At codes, the only time i would let a medicine person do anything with the airway is if 1) i had a lot of time to hang around 2) the patient didn't look like an obviously difficult airway 3) the medicine person came across as somebody willing to improve their technique.... otherwise I told them to shove it (in a nice way).

the problem with codes is that it is usually dogshow because their no (or ineffective) leadership.... the way around that is to ask "who is in charge" and if everybody looks dumbfounded either assume leadership or designate the more senior person as the leader.

 

[jetproppilot]

Again, folks, the turf battles you are experiencing in teaching institutions disappear for the most part in private practice. The hospital you acquire priveleges at will already have some protocol for response teams to codes. In my former practice, the ER M.D. responded to codes, not us. We would be called only if he/she had problems with the intubation. I was there 7.5 years and I wasn't called very much.
Once that hospital began using intensivists, they took care of the intubations in the ICU (usually).
At my current crib, we have an in-house CRNA 24 hours a day, and they respond to the code, not the MDA. I know this will probably disturb some of you, but every time an MDA has to leave the OR for some un-anticipated event, it may lead to delays in the OR. Again, a team approach in medicine is what is seen most of the time after residency. I've never seen a medicine dude or an ER dude who is struggling with an intubation be reluctant to give it up to someone who can intubate in their sleep.
Another point is: in most practices, CRNAs will be your colleagues, not your enemy. One of the best laryngoscopists I have ever seen is a CRNA from my previous practice. Mitch LeBlanc. The smoothest intubation I have ever seen. I LEARNED from him. Lets assume you have flawless technique. Ever put in a Miller 2, and you can almost see the bottom of the cords, but not quite? Mitch showed me a little trick that involves justa little wrist movement that'll give you that extra couple millimeters of view that means the difference between getting it in vs. missing. Remember, if someone was intubating for a living while you were still in high school, chances are you can make yourself an even bigger stud if you learn from them, no matter what their professional title is.

Just curious how airway is handled during codes at other hospitals. I was wondering beacuse I am really starting the dislike the way things are handeled at my institution of learning. Medicine runs the codes here, anesthesia (and usually half the hosptial) also shows up for codes. Half the time the medicine resident gets pissed when anesthesia steps in to intubate. The other half its a medicine resident that likes to stay as far away from procedures as possible and gives it up to somebody..anybody. Then when anesthesia shows up they have to pry the repiratory therapist out of the way cause he or she is bagging (usually all kinds of wrong ways if its at the VA) or intubating ???? I dunno it just makes sense to me that anesthesiologist would take charge of airway during codes. The patient is crashing for godsake, its no time to be fumbling around, intubate the esophagus a couple of times, before medicine decides to give it up.
Does this happen at other places??
I dont think im going to be able to standby watching this next year...

 

[hoyden]

11

 

[OldManDave]

Again, folks, the turf battles you are experiencing in teaching institutions disappear for the most part in private practice. The hospital you acquire priveleges at will already have some protocol for response teams to codes. In my former practice, the ER M.D. responded to codes, not us. We would be called only if he/she had problems with the intubation. I was there 7.5 years and I wasn't called very much.
Once that hospital began using intensivists, they took care of the intubations in the ICU (usually).
At my current crib, we have an in-house CRNA 24 hours a day, and they respond to the code, not the MDA. I know this will probably disturb some of you, but every time an MDA has to leave the OR for some un-anticipated event, it may lead to delays in the OR. Again, a team approach in medicine is what is seen most of the time after residency. I've never seen a medicine dude or an ER dude who is struggling with an intubation be reluctant to give it up to someone who can intubate in their sleep.
Another point is: in most practices, CRNAs will be your colleagues, not your enemy. One of the best laryngoscopists I have ever seen is a CRNA from my previous practice. Mitch LeBlanc. The smoothest intubation I have ever seen. I LEARNED from him. Lets assume you have flawless technique. Ever put in a Miller 2, and you can almost see the bottom of the cords, but not quite? Mitch showed me a little trick that involves justa little wrist movement that'll give you that extra couple millimeters of view that means the difference between getting it in vs. missing. Remember, if someone was intubating for a living while you were still in high school, chances are you can make yourself an even bigger stud if you learn from them, no matter what their professional title is.

Extremely well said! Smart folks know that real-world experience counts monumentally...all the evidence based med & journal articles stacked to the moon will not help you if you cannot get the tube in. If there is someone with such vast experience & they are kind enough to offer it to you - take them up on it! You do not have to 100% adopt their techniques, but you can always glean value from what you learn & your pts will be the ones who benwfit in the long & short run.

 

[zippy2u]

In the real private practice world , the only codes you go to are the ones in the OR, RR and holding area. A code on the floor is neglected by anesthesia dept due to medicolegal ramifications. Only go to the floor code if you are specifically called for by your name. And no, my name is not "Anesthesia".

 

[s204367]

I can hear and feel your frustrations....Just remember..in the ACLS protocol, ABC =Airway first. If I am called to a code and the medicine residents are not willing to move aside I'll ask nicely once, but I routinely remind them that A in ABC stands for Airway, and not Attempt a femoral line for 20 minutes...I'm a bit aggressive, and usually there a one or two of my surgery buds around. I'll just push the bed out and place teh tube. The medicine folks running a code is usually quite humorous and a little scarry at the same time. Usually only a second year resident....

In terms of transporting....yes, a major pain in the ass at my residency too. Especially if you are finishing up with one unit patient, only to pick up another for your next case.......while transporting a patient to the unit from the OR I do believe is the responsibility of the anesthesia team, it is my strong belief that unit patients should be brought to the OR by the unit nurse plus respiratory.

 

[ISU_Steve]

Sorry to butt in, if my opinion as a non-physician isn't welcome, then please tell me .

Codes on the floor (general care wards) at every hospital I have worked at have usually been intubated either by an ER doc (in small hospitals), the resident responsible for that floor (in teaching hospitals), or a respiratory therapist such as myself. In a lot of smaller (non-teaching hospitals) the most skilled intubator at night is often the RT.

Just a related side note: Get to know your RT's and treat them well- we can be a very valuable resource when the fecal material impacts the rotating blade. We're also a good resource for anything and everything ventilation or airway related. If you have a question, feel free to ask, most RT's are very appreciative of physicians who go out of their way to treat us as professionals and are more than happy to pass along whatever knowledge we can.

And one more thing.....please, please, please become familiar with alternate airway adjuncts (Combitubes, LMA's (Laryngeal Mask Airways), etc) and their use. Few things are more bothersome to an RT in a code situation than to have a physician who doesn't know when to give up trying to tube and just settle for a non-visualized airway.

Just my humble opinion as an RT. Hope you find this somewhat useful.

Steve Richey, CRT, EMT-I/D
Predental student

 

[IceDoc]

I'm doing my internship at a community hospital with only an internal medicine residency. Officially all of the on-call people (floor and unit), respiratory, security, and the chaplains must respond. Anesthesia is available as an "if available" basis. The medicine residents as a group would never dare attempt intubation(never done it before....emergency situation...). However, the anesthesia-prelims (like me) have no problem giving it a shot because, frankly, anesthesia takes their sweet time getting there, if at all. My totally unofficial changable-by-situation policy is that I'll take one attempt with the blade and if I don't clearly see the chords I don't intubate (I REALLY don't want to tube the esophagus during a code) and will pass it off to the next person (again, if available). Our respiratory therapists are pretty good and about half have no problems intubating someone. I'm happy for their help and have no problem learning from them. In general, there is no turf battle, and while it may not be the best person at first, the ladder gets moved up quickly enough. It's also not a turf battle because there isn't an turf/ego to protect. You just do what needs to be done.

Incidentally, doing my internship here has been a great development for my code skills because the housestaff are a small group and we respond to codes hospital-wide. I have arrived first at about 4 so far (and of course participated in many more...perhaps too many), and I feel comfortable running them, at least initially. Obviously I can still improve, and I have no problem handing off to someone superior. But no longer am I the medstudent standing outside the doorway peering in or just hopping up there for some compression action. I have the feeling that the large academic institution codes simply have too many cooks in the kitchen.

By the way one question/problem I've had: When you're the first one there, and no one who knows airway is at the head of the bed, what do you do? The answer is obvious that you have to ventilate and secure the airway, but I find it's really hard to concentrate on that one task (especially if it's not going well) and run the show as well. Any comments/suggestions?

 

[jetproppilot]

Just out of pure curiosity 😉 - who is transporting the patients from pre-ops, wards, etc to the OR and from OR elsewhere in the private practice? Not that I object to do that WITH somebody else, but it seems to be the responsibility of the anesthesia residents ONLY at the teaching hospitals...

I feel your pain. I used to HATE the fact that I (the anesthesia resident) was the only one pushing the patient to the OR. Know what? I'm the head of the department now and I still push stretchers. Lemme explain.
Like you, I hated doing "scut" (I still don't particularly enjoy it), and in my first couple years outta residency, I flat-out REFUSED to push anyone to the OR. I figured I had been abused enough during residency for such menial tasks and I wasnt gonna do them anymore. No matter what. Nobody available to get the patient in the room? So its gonna delay the case 15 minutes 'til the transporter is back or the circulator finishes setting stuff up? The CRNA is trying to take a pee in between cases? TOUGH. I'm not gonna do it.
I realize now I was wrong. That was the wrong approach to take. One of my current partners is in that first-few-years-outta-residency phase. But I think he's starting to see the light.
See, in most practices, your scope of stuff to worry about and manage is drastically different than residency. As a resident you are worrying about one patient at a time. In our practice, the on call MD is in charge of "running the board", that is, making sure everything is happening on time, and everyone is where they should be. Was the CABG sent for? Are they in holding yet? Is Lisa the holding nurse ready? Does she know we also have 2 epidurals to do? Is the transporter bringing the patient from day surgery to holding? If not, ya know what? If I'm not strapped for time, I'll walk over to holding and ask the day surgery nurse to help me push the patient to holding. Does that suck? Yes. But remember the morning is about the busiest time for us, and if I can do something to help the flow, I'm gonna do it. Because ultimately I'm helping myself. If I'm in the OR and I notice its been 4 minutes since I heard "moving help room ten please", and I glance into room 10 and they're just waiting for anyone to come help them get the patient from the OR table to the stretcher, know what? I'm gonna grab the roller board and pull the patient over.
This helps me, and the perception of my department. It helps me by speeding everything up so I can go home and play with my two year old and get a hug from my wife at 7pm instead of 9pm. Believe me folks, if you think about EVERY little delay, ten minutes here, ten minutes there, it adds up over a 12 hour period, probably adding an hour or two to the day. SO, who gets hosed? YOU! The oncall anesthesiologist.
Everyone pitching in to do everything helps morale. Our CRNAs notice when we help them with little stuff- putting the monitors on, starting the paperwork, etc. Surgeons notice that the anesthesiologists are doing EVERYTHING we can to get cases in and out. And when you think about it, its pretty rare for you to help someone, and that helping someone interfered with your work. How long does it take to walk into OR 10 and help the crew move the patient? 30 seconds. Literally. And you've just contributed to OR efficiency and morale.
What I'm trying to say is that I've evolved into a wiser MD. I leave my ego at the door, and I come to work ready to rock and roll. I will do ANYTHING to make the day more efficient, which makes EVERYBODY happy: I'm happier cuz I go home earlier, the surgeons are happier because they see us busting our ass to get their patients taken care of, and the OR is happier. We are respected much more by everyone because we are willing to do anything. Kinda ironic, huh?

 

[jwk]

In the real private practice world , the only codes you go to are the ones in the OR, RR and holding area. A code on the floor is neglected by anesthesia dept due to medicolegal ramifications. Only go to the floor code if you are specifically called for by your name. And no, my name is not "Anesthesia".

Maybe in YOUR private practice you don't go to codes outside the OR, but that doesn't mean it's true everywhere. Every hospital is different. An anesthesiologist from our department carries a code beeper 24/7.

 

[hoyden]

11

 

[zippy2u]

JWK, You did everything right at the code in fact, you were the HERO despite the pt passing away . Your name is on chart because the hospital demanded that a nurse record all names involved and meds given to pt. , you got 1million/3million insurance because the phuckin' hospital wants you as a deep pocket too despite the requirement for only $250,000/750,000 in Florida . Lawyer sues everyone on chart and wants a part of that 1million/3million-- welcome to Florida,Hero!

 

[AJM]

It's interesting and disturbing to hear about all these turf battles taking place during codes at your hospitals. I've worked as a medicine resident at two major academic medical centers, and at no point has this kind of thing come up. At both of these hospitals, I've run more than my fair share of codes, and there are always clear and defined roles for everyone on the code team. There is always an anesthesia resident in house with the emergency airway pager, and they will respond to every code. Sometimes they can be a little slow in showing up, at which time the medicine residents or RTs will manage the airway. But we always get out of the way when anesthesia shows up, because the anesthesia residents are clearly the most experienced at airway management.

Actually, the only time I've seen an anesthesia resident have to push someone away from the head of the bed was when they were a little delayed to the code, and then failed to announce that they were here to anyone when they arrived. The RT who was bagging the patient had no idea the airway team was even there until the resident physically pushed him aside.

IMO, a code is definitely no place for a turf battle -- medical practitioners need to leave their egos at the door and do what's best for the patient.

 

[MAC10]

It's interesting and disturbing to hear about all these turf battles taking place during codes at your hospitals. I've worked as a medicine resident at two major academic medical centers, and at no point has this kind of thing come up. At both of these hospitals, I've run more than my fair share of codes, and there are always clear and defined roles for everyone on the code team. There is always an anesthesia resident in house with the emergency airway pager, and they will respond to every code. Sometimes they can be a little slow in showing up, at which time the medicine residents or RTs will manage the airway. But we always get out of the way when anesthesia shows up, because the anesthesia residents are clearly the most experienced at airway management.

Actually, the only time I've seen an anesthesia resident have to push someone away from the head of the bed was when they were a little delayed to the code, and then failed to announce that they were here to anyone when they arrived. The RT who was bagging the patient had no idea the airway team was even there until the resident physically pushed him aside.

IMO, a code is definitely no place for a turf battle -- medical practitioners need to leave their egos at the door and do what's best for the patient.

The problem here is that there is no airway team. Everyone just kind of shows up. I agree with you it would make sense that the anesthesiologist would be intubating during the code. In the most recent incident,when the CA-2 stepped in, the medicine resident got upset when the b/c he wanted to let his intern intubate. I dunno a code situation doesnt seem like the ideal time to teach the art of intubation or wage turf battles.