Running a code

[frosted2]

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Take the talent with you. Seriously. I basically don't need anything from the med-surg nurses. Got my own glidescope, my own RSI drugs, the code carts are all standardized, I've got two nurses and a tech with me.

It's like when you call the nursery folks down to help with the precipitous delivery. They know you don't do this very often and might not even know where the tools are so they show up with several people and all their fancy tools, and you're grateful for it. Be like them when you show up to a code.

I wish this was the standard at the hospital I work for. Only the ER doc and their scribe for the day respond to a code.

 

[Angry Birds]

The only code I've ever showed up to in my community hospital where I wasn't in charge was in the OR and I was no kidding like the 40th person there (and the surgeon and anesthesiologist were doing a bang up job already.)

A code was called in the OR at my hospital. I went and saw there a 60 year old surgeon and a 50 year old anesthesiologist working on the patient. As a somewhat recent residency grad who people thought was a medical student on the first day of work due to my age, I asked meekly, "I'm Dr. Angry Birds, the ER doctor. Do you guys need my help?" I thought they would say no and I'd be on my merry way back to the ER. But, they looked up at me and say, "yes we could use you."

So, I stick around. I'm a bit sheepish though and don't take the lead initially. Within 10 minutes, I realize that they don't know what they are doing at all. The surgeon was calling for doses and meds that must have been used in the 1950's. So, I put my big boy pants on, and took over the code completely. The patient was successfully revived and survived...and the surgeon and anesthesiologist were profuse in their praise of my efforts.

Lesson of the story: never assume anyone else is the leader, despite age or experience. As the ER doctor, it should probably be you. I should've rephrased my initial question to, "I'm Dr. Angry Birds, the ER doctor. I usually run the codes, but I don't want to step on toes if you have it handled. Do you want me to take over as code leader or, if you don't need me, I can go back to my dungeon. Which do you prefer?"

 

[anbuitachi]

A code was called in the OR at my hospital. I went and saw there a 60 year old surgeon and a 50 year old anesthesiologist working on the patient. As a somewhat recent residency grad who people thought was a medical student on the first day of work due to my age, I asked meekly, "I'm Dr. Angry Birds, the ER doctor. Do you guys need my help?" I thought they would say no and I'd be on my merry way back to the ER. But, they looked up at me and say, "yes we could use you."

So, I stick around. I'm a bit sheepish though and don't take the lead initially. Within 10 minutes, I realize that they don't know what they are doing at all. The surgeon was calling for doses and meds that must have been used in the 1950's. So, I put my big boy pants on, and took over the code completely. The patient was successfully revived and survived...and the surgeon and anesthesiologist were profuse in their praise of my efforts.

Lesson of the story: never assume anyone else is the leader, despite age or experience. As the ER doctor, it should probably be you. I should've rephrased my initial question to, "I'm Dr. Angry Birds, the ER doctor. I usually run the codes, but I don't want to step on toes if you have it handled. Do you want me to take over as code leader or, if you don't need me, I can go back to my dungeon. Which do you prefer?"

How can the anesthesiologist not know what to do in a code. what? did he sleep for 30 years. insane stuff
I'm guessing it's a very small hospital if you had to go to the OR for a code from the ED..

 

[anbuitachi]

So this doesn't happen in the ED for me right now, but when I'm covering the inpatient side, I frequently end up being the person who is not only the code leader but the only person who has any airway training. When I am in that situation, I throw in an LMA rapidly and go back to running the code. Definitive airway can come later if we even make it to that point.

Why not just try the tube. It takes 5 seconds. I just shove the tube in between chest compressions during pulse check. Do the LMA if you can't get the tube. Protect the airway as much as you can! if the 75 yr old guy vomits while coding, which isn't uncommon, it's pretty much game over even if you get ROSC. the pneumonia will kill him later if he makes it that far. He'll just die in the ICU

 

[Angry Birds]

Why not just try the tube. It takes 5 seconds. I just shove the tube in between chest compressions during pulse check. Do the LMA if you can't get the tube. Protect the airway as much as you can! if the 75 yr old guy vomits while coding, which isn't uncommon, it's pretty much game over even if you get ROSC. the pneumonia will kill him later if he makes it that far. He'll just die in the ICU

5 seconds? It takes five seconds to remove the tube from the wrapper.

 

[rbnsafsadgf]

Why not just try the tube[?]

Obviously, not entirely always comparable, but if one can ventilate fine via a LMA or mask, why spend the time? It might even be the better thing for the patient.
Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. - PubMed - NCBI

 

[anbuitachi]

Why not just try the tube[?]

Obviously, not entirely always comparable, but if one can ventilate fine via a LMA or mask, why spend the time? It might even be the better thing for the patient.
Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. - PubMed - NCBI

Cause tubes are better at airway protection, esp if you can partially ventilate thru LMA but the volume isn't great. And LMA in chest compression id imagine would have a even worse seal.
And yep i read that study before. Not sure why you linked it though since it seems to go against your point. Basically in adults most arrests are not hypoxic arrests, so early intubation doesn't change outcome. So that means you can take your time to take the tube out of the wrapper and slowly intubate. I dont work in the ED but I cover airways during codes in other areas of the hospital. In the past people would like half jog to the code when called. Now just slowly walk there cause the study shows it makes no difference

 

[anbuitachi]

5 seconds? It takes five seconds to remove the tube from the wrapper.

I meant the intubating part. get everything ready when chest compression is happening. when compression stops for pulse check, shove the tube in.

 

[Angry Birds]

I meant the intubating part. get everything ready when chest compression is happening. when compression stops for pulse check, shove the tube in.

Dude, you must be damn good. Takes me way longer than that.

 

[engineeredout]

Why not just try the tube. It takes 5 seconds. I just shove the tube in between chest compressions during pulse check. Do the LMA if you can't get the tube. Protect the airway as much as you can! if the 75 yr old guy vomits while coding, which isn't uncommon, it's pretty much game over even if you get ROSC. the pneumonia will kill him later if he makes it that far. He'll just die in the ICU

Multiple reasons I might not jump to this attempt:

1. I am the sole physician - especially early on in a code I'm trying to coordinate getting the patient on a zoll, calming the room down, figuring out or obtaining access, getting meds administered, and figuring out wtf is going on. I don't have time to muck around in the airway. If anesthesia or another second provider shows up and wants to go for an ETT, by all means they are welcome to try, as long as they don't interrupt compressions

2. Make the situation worse - relying on being able to tube someone in five seconds is not feasable. While working quickly/efficiently is advised in most airway situations, the last thing I want is someone to try and rush an ETT into someone during a rhythm check. All it takes is for someone rushing to bag the esophagus, and you have succeeded in making a bad situation worse.

3. Interruption in compressions - It can take more than 5 seconds to get the mouth open. I do not want compressions stopped for establishment of an airway. Not infrequently there are providers who call for compressions to stop while they attempt an airway, and I do not allow this to happen in my codes. Either try during compressions with DL, or better yet with video laryngoscopy, or put in a blind supraglottic device, or bag them.

4. Aspiration PNA, if it occurs, is not what is killing the post arrest patient. They die from hypoxic neurologic injury, or from whatever caused them to code in the first place.

 

[Druggernaut]

And yep i read that study before. Not sure why you linked it though since it seems to go against your point. Basically in adults most arrests are not hypoxic arrests, so early intubation doesn't change outcome. So that means you can take your time to take the tube out of the wrapper and slowly intubate. I dont work in the ED but I cover airways during codes in other areas of the hospital. In the past people would like half jog to the code when called. Now just slowly walk there cause the study shows it makes no difference

Hmm? It says early intubation does change outcomes. It makes them worse.

Though you should probably still hustle to the code, since the medicine residents will likely be working on intubation, with less first pass success and more delays/hypoxia...

 

[anbuitachi]

Hmm? It says early intubation does change outcomes. It makes them worse.

Though you should probably still hustle to the code, since the medicine residents will likely be working on intubation, with less first pass success and more delays/hypoxia...

Haha yeah it does. I've yet to have a medicine resident attempt at intubation yet before I got there

 

[anbuitachi]

Multiple reasons I might not jump to this attempt:

1. I am the sole physician - especially early on in a code I'm trying to coordinate getting the patient on a zoll, calming the room down, figuring out or obtaining access, getting meds administered, and figuring out wtf is going on. I don't have time to muck around in the airway. If anesthesia or another second provider shows up and wants to go for an ETT, by all means they are welcome to try, as long as they don't interrupt compressions

2. Make the situation worse - relying on being able to tube someone in five seconds is not feasable. While working quickly/efficiently is advised in most airway situations, the last thing I want is someone to try and rush an ETT into someone during a rhythm check. All it takes is for someone rushing to bag the esophagus, and you have succeeded in making a bad situation worse.

3. Interruption in compressions - It can take more than 5 seconds to get the mouth open. I do not want compressions stopped for establishment of an airway. Not infrequently there are providers who call for compressions to stop while they attempt an airway, and I do not allow this to happen in my codes. Either try during compressions with DL, or better yet with video laryngoscopy, or put in a blind supraglottic device, or bag them.

4. Aspiration PNA, if it occurs, is not what is killing the post arrest patient. They die from hypoxic neurologic injury, or from whatever caused them to code in the first place.

Of course know your limits. If sole provider , airway is not that important. And unless in kids it's stupid to ask to pause compressions for tube. I'd just ignore their request

 

[Dred Pirate]

How can the anesthesiologist not know what to do in a code. what? did he sleep for 30 years. insane stuff
I'm guessing it's a very small hospital if you had to go to the OR for a code from the ED..

I went to a code in the cath lab - and the cardiologist had to pull up the ACLS algorithm on his iphone. He then tried to tell me to give the mag (torsades) over 15 minutes while we were doing compressions. Obviously I pushed it. So ya - not all specialists (even though you would hope so) now how to run codes,

 

[Dred Pirate]

Of course know your limits. If sole provider , airway is not that important. And unless in kids it's stupid to ask to pause compressions for tube. I'd just ignore their request

I have this come up quit a bit, several of my ED docs insist on putting in a tube as soon as a patients codes - I was wondering (this is the only ED I have worked in) if this was common even though it goes against the ACLS recommendations

 

[Siggy]

Haha yeah it does. I've yet to have a medicine resident attempt at intubation yet before I got there

Why is this a bad thing?

The resident knows that
1. Airway isn't as important as we used to think
2. Knows their limits and if a procedure goes South would like someone more experienced present to help out if needed.

 

[anbuitachi]

Why is this a bad thing?

The resident knows that
1. Airway isn't as important as we used to think
2. Knows their limits and if a procedure goes South would like someone more experienced present to help out if needed.

Bad thing? I'm just saying ive never had a medicine resident try before i got there. I actually dont even know the hospital policy for this. Just never seen it before. If a medicine resident can try, can the nurse try? the phlebotomist nearby?

But we do get airways from the ED, or ICU, with prior intubation attempts and by then after their few tries, the airway is usually pretty traumatized and bloodied and it makes our job much harder.

 

[Siggy]

Bad thing? I'm just saying ive never had a medicine resident try before i got there. I actually dont even know the hospital policy for this. Just never seen it before. If a medicine resident can try, can the nurse try? the phlebotomist nearby?

But we do get airways from the ED, or ICU, with prior intubation attempts and by then after their few tries, the airway is usually pretty traumatized and bloodied and it makes our job much harder.

I know at my program, we're supposed to be directly supervised for all procedures. I can envision situations during codes or rapid responses where I would intubate prior to the ED attending's arrivial, however those would be extremely rare. However, if I'm calling down to the ED for an intubation, I'm going to have the meds drawn, equipment set up, patient positioned, and standing at the head of the bed by the time you get there.

 

[WildcatS11]

I know at my program, we're supposed to be directly supervised for all procedures. I can envision situations during codes or rapid responses where I would intubate prior to the ED attending's arrivial, however those would be extremely rare. However, if I'm calling down to the ED for an intubation, I'm going to have the meds drawn, equipment set up, patient positioned, and standing at the head of the bed by the time you get there.

Really, all procedures? Even central lines, as a senior resident? What about on your ICU months? When we are in the MICU as a PGY2, we are responsible for running every code/airway in the hospital - I have literally never seen an attending at a cardiac arrest on the floors - maybe in the ICU, if they're readily available - but not on the floor. Every cric I have seen/been a part of has been sans attending.

 

[anbuitachi]

Really, all procedures? Even central lines, as a senior resident? What about on your ICU months? When we are in the MICU as a PGY2, we are responsible for running every code/airway in the hospital - I have literally never seen an attending at a cardiac arrest on the floors - maybe in the ICU, if they're readily available - but not on the floor. Every cric I have seen/been a part of has been sans attending.

probably just a hospital policy thing. whether you end up doing it or not is another story. our attendings are technically supposed to be present for pretty much all procedures. but it usually ends up being at the attendings discretion until the hospital cracks down on it. its stupid for an attending to be present for an arterial line when youve placed hundreds.


Back to steroid for codes.. why is this not done again? We have 2 studies demonstrating benefit. Has there been further studies disproving this?

 

[Siggy]

Really, all procedures? Even central lines, as a senior resident? What about on your ICU months? When we are in the MICU as a PGY2, we are responsible for running every code/airway in the hospital - I have literally never seen an attending at a cardiac arrest on the floors - maybe in the ICU, if they're readily available - but not on the floor. Every cric I have seen/been a part of has been sans attending.

Technically speaking, yes. That said, there's been plenty of paras, thoras, and central lines where the intensivist was sitting in the nursing station knowing that I was doing it, but that is the official policy. That policy is consortium wide, and includes the EM residency at a different hospital.

As an IM resident at an unopposed residency, the intensivist goes to all codes and rapid responses when he's in the hospital (8-6), otherwise the ED physician goes to all codes outside of that time. Resident attitudes vary by running codes and rapid responses to running the other way.

 

[GeneralVeers]

I'm happy if someone else wants to take over the code. Usually my ED is blowing up busy in my absence.