Hospital Code Teams

[pushinepi2]

Ok, this post may just be the end result of a ridiculously busy shift.... but what the heck. The SDN is always good for a bolus of sardonic humor.

What the heck is the purpose of a hospital code team? This must be the most fragmented and illogical concept I've ever seen executed. At a local community hospital, I had the privilege of witnessing this feat of medical genius first hand. So, there I was, swamped with dictations, when the hospital operator pages out a "code blue" in the lobby. The ED nurses start running for the nearest monitors and "go-bags" and security manages to secure an elevator. I asked the charge nurse why everyone was running and she said that the ED peeps were SUPPOSED to go to the lobby. Inpatient floors were a different story, evidently. I needed a break from dictations anyway, so I hopped a ride on the train to celestial station.

So, our stretcher loaded with rescue randy bags arrives at the side of an obviously drunk young man who slipped in the main lobby. He was quite audibly dropping "F" bombs about his back pain. From several feet away, I appreciated his patent airway. My colleagues were out en masse. Here are some memorable quotes:

1) IM Resident: (Shouting) "There's no code! No code! He's breathing!"
2) Anesthesia attending: "Well, I guess he doesn't need to be intubated."
3) Critical Care Nurse: "Get me a collar, someone!"
4) Medical Student on IM Rotation: "Get a fingerstick! What's the fingerstick?"

Its clear that this 300 lb dude is going to buy himself a ride to the ER. While orchestrating his movement to the spine board, the crowd very suddenly diminished. The dust hadn't settled before at least two dozen people had retreated. Thankfully, a surgical resident ran up to offer her assistance.

Surgical resident: "Vitals! Vitals!"
EM Resident: "What? Stop shouting."
Surgical resident: "VITALS! Anyone have 'em?"
EM Resident: "Are you serious? Why? He's breathing and most definitely has a pulse."
Surgical resident: "Well, I'm here for access! That's my job."
EM Resident: "Really. Well, I don't think he's in urgent need of a central line."
Surgical resident: "Oh."
EM Resident: "But, you're more than welcome to help us load him onto the backboard and order any necessary diagnostic tests."
Surgical resident: "Uhm, no thanks."

So, as we're lifting this small package onto the spine board, I hear this same surgical resident explaining to her medical student about how cardiac arrests are run.

Surgical resident: "So, internal medicine runs the code. Anesthesia takes charge of the airway. I'm there to get a line."

I could no longer help myself. I turned to the medical student and explained to her how codes are run in the emergency department. "When someone comes in full arrest," I said, "the first thing we do is pick up the phone. I ask cardiology about the etiology of the arrest while consulting with anesthesia about the most appropriate induction agent. Medicine thankfully gives us their input on how many rounds of epinephrine the patient will require."

Third year medical student: "Really?"

And I was silent. I could not speak... I looked into the heart of light, the silence.....

In it for the prestige,

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[FionaS]

Our code teams (or crash teams) cover all the hospital and the surroundings, except for the ED. Consists of (at the minimum) anaesthetist, ODA (assistant to the anaesthetist), gen med SHO and HO (resident and intern), plus some nurses - critical care outreach during the day, night sisters at night. In the smaller hospitals, the crash team covers the ED as well.

Usually lots more people pitch up, guess it makes the day go quicker.

I've only ever seen a surgeon get involved in one arrest - where I had to quietly whisper in his ear that it was now 30:2 - and to go a little faster with the compressions... Fun times!

 

[AmoryBlaine]

Well that gets my morning laught out of the way...

The first "code" I saw as an M3 went like this...

Surgery Chief
Surgery Intern
M4 Sub-I x 2
CC nurse x 4
Anesthesia PGY-2 ("for the airway")
RT x 2

This was in an ICU room that was on the smallish side to begin with. Outside the door was clustered literally every nurse from that wing of the SICU.

No drugs pushed, no line, certainly no compressions.

Sheesh.

 

[psychbender]

No drugs pushed, no line, certainly no compressions.

Sheesh.

So...you had twelve people just standing there? Or was it eleven people watching one person do stacked shocks, with some occassional ventilation? Jeebus.

 

[Dr.Evil1]

These "code teams" are generally worthless unless someone steps up and runs the show. I have seen someone try to intubate an awake and talking patient and I have also seen people completely disregard the airway trying to get IV access when it was just an airway problem.

 

[igcgnerd]

At the hospital I work at, if a code is on the ground floor where the ED is (mostly the lab, offices, and radiology), ED personal respond to it. Usually this consists of a FP resident on EM rotation (we only have an FP program), one or two er nurses and a tech. Our primary goal is to get them back into the ED as quick as we can. In the ED when code is called, an ED attending (usually with a resident), RT, and an ekg tech respond.

 

[FionaS]

These "code teams" are generally worthless unless someone steps up and runs the show. I have seen someone try to intubate an awake and talking patient and I have also seen people completely disregard the airway trying to get IV access when it was just an airway problem.

The anaesthetist always runs the arrest, unless they're finding the airway very difficult. Then, if not other ITU/anaesthetic doctors has turned up (though they usually have), it's the medicine SHO.

 

[AmoryBlaine]

So...you had twelve people just standing there? Or was it eleven people watching one person do stacked shocks, with some occassional ventilation? Jeebus.

Nah, I said "code" b/c although it was technically called it was really just an urgent intubation. That didn't stop the room from filling with people.

 

[pushinepi2]

I can't tell which codes are more memorable... those from my paramedic days or the more recent ones.

Another from the annals of cardiac pathology: It seems that even EM residents get swept up into the virtual storm of happenstance that is a cardiac arrest on the floor. Last year, I was drafted into the "code team" as part of the MICU service. When some poor soul on the oncology floor decided to wax a little asystolic, my senior resident pulled me along for the ride.

This particular code was attended to by the following motley crew:
1) senior medicine admitting officer
2) CCU resident
3) MICU resident (my senior)
4) surgical admitting officer and bodyguards, consisting of a sub I and two medical students
5) Several coordinators
6) Jaywalkers
7) Random civilians
8) A nursing administrator
9) Respiratory therapist
10) The easter bunny

When I peeked my head into the room, I noted some rather spirited cardiac compressions going on. Someone was trying to ventilate with a BVM. Two surgical looking people were frantically stabbing at the patient's groin in hopes of access. "Someone get me the doppler!" was the next audible command. Mind you, this patent had a decidedly absent definitive airway. I guess that might not matter as much in light of the recent AHA, "push hard, push fast" guidelines.

Anyway, I asked very politely for an intubation box. The reply:
"I already called for anesthesia! They're on their way!"

Praise be unto them.

-Push

 

[somedude98317]

Great posts push!!! I love the story you told the medical student about how codes are run in the ER....hahaha👍 👍 👍 👍

 

[paramenace]

Thanks for the stories, Push. I too have appreciated some pathetically hillarious codes and such being run although i'm only an M3. My paramedic background sometime tells me that it is a lot easier to just shake your head, eave the room and laugh instead of crying at the sadness of in-hospital arrests. Here is to someone someday somehow getting a clue about the phrase "too many cooks in the kitchen" and simply getting an ER resident with solid ACLS knowledge together with 2 techs, 1 for compression and 1 for pushing drugs. Without a randomized double blinded study, my money would be on resuscitation rates going way up. Though the comical side of things would be nearly non-existent.

 

[emtcsmith]

To show how it really doesn't take a lot to run a code. I transported a code to the ED that was near capacity and the ED doc in the resus room turns to the medical student and says "could you let the charge nurse know I have no nurses" then procedes to finish the code with about four or five paramedic students without a flaw.

 

[LungMan]

Oh lord, don't get me started on the Code Blue!

The last code I went to was a party involving at least 30 people crammed into a hospital room the size of a smallish postage stamp. I know for a fact that I stepped on 8 of them on the way to head of the bed. 2 RTs, a paramedic from the ER, and a wandering IM doc from the clinic down the hall were all there and this poor overdosed soul was still missing a secured airway.

Someone above mentioned the clammoring for an IV? That is just what was going on here.

Why does everyone and their dog have to show up to a code? Why is it that the bedside nurse (who should know what is going on with the patient) always the last one to show up?

I asked around afterward and found out that they have Code Blue Team Meetings once a month to review performance! What a freaking joke...

LM

 

[f_w]

Back in the old days 'in the home country', the code team consisted of a senior anesthesia resident, 2 ICU nurses and the hospital security guard. These people carried in-house voice pagers and where the only ones to be notified if a code occured (I don't even think hospitals had overhead paging systems).

The doc and the nurses where there to run the code, the security guard to keep the riff-raff out of the room. If the patient was just dead, they would call it after 15min, if they got a rythm they would wheel the victim to the ICU.

 

[The White Coat Investor]

I've seen a lot of great codes run by very competent code teams (some even by internists.) Often, these in-hospital arrests were successfully resuscitated and went on to have normal lives. Most of the really great flails I've seen have been traumatic arrests losing vitals enroute! But hey, what's a little blood on the ceiling?

My personal favorite thing to see at a code is to see someone bagging without the BVM actually touching the patient.

 

[docB]

I've seen a lot of great codes run by very competent code teams (some even by internists.)

Please don't flame him. He didn't really mean that the way it sounded. And it is the EM forum so we should get a little leeway.

Remember that the most important thing the ED doc can do at a code is assume liability from the nursing staff, hospital and primary doc. That sentiment is confirmed by the fact that at every code no nurse knows the patient, the primary nurse is off documenting how everything was just peachy until right when the code was called (why is there lividity? Smack! Bad doctor!).