Who runs codes at your residency program?

[waldenwoods]

I've never seen a pediatric code. I've only seen a handful of adult codes, and in my experience, the second-year IM resident runs the code, makes the decisions, talks to the family and the third-year resident is present to supervise. I was talking to a pediatric resident at my "home" program who said the attendings run the codes, which surprises me--if you don't learn to run codes during residency, when do you pick up that skill before you're an attending?

Just curious how other residency programs do this. Although I don't like the thought of chest compressions and how painful that may be (and what if it's the last thing the patient is aware of before he dies?) and I'd rather not participate in something that makes the patient uncomfortable, I do believe we have to respect patients' and their parents' wishes, and I feel that it's important to learn how to be an effective leader during a code. I guess there isn't really the need for this in outpatient specialties, but for people who are interested in inpatient medicine, it's relevant to our future careers.

---

Members don't see this ad.

 

[oompaloompa]

I've never seen a pediatric code. I've only seen a handful of adult codes, and in my experience, the second-year IM resident runs the code, makes the decisions, talks to the family and the third-year resident is present to supervise. I was talking to a pediatric resident at my "home" program who said the attendings run the codes, which surprises me--if you don't learn to run codes during residency, when do you pick up that skill before you're an attending?

Just curious how other residency programs do this. Although I don't like the thought of chest compressions and how painful that may be (and what if it's the last thing the patient is aware of before he dies?) and I'd rather not participate in something that makes the patient uncomfortable, I do believe we have to respect patients' and their parents' wishes, and I feel that it's important to learn how to be an effective leader during a code. I guess there isn't really the need for this in outpatient specialties, but for people who are interested in inpatient medicine, it's relevant to our future careers.

I guess it depends on the volume of your program and the kind of tertiary care it provides. Of course I'm not rushing off to codes everyday, but I participated in 4 codes in my intern year of residency and I guess I "ran" one of those for ~ 4 minutes until help arrived. May not sound like much, but when you're bagging someone, 4 minutes is forever. Remember, with kids it's usually a respiratory thing, so compressions are rarely indicated (doesn't mean some "bystander" won't do them). Of course, I'm excluding the ICU, where some kids can and do code frequently.
As far as the attending running the code, I've never seen it happen outside of the ER, primarily because most codes don't happen in the hours that an attending is easily accessible. A tet baby will put on his cutest face at 10am when the boss is watching, but you better believe that little bastard will decide to flip out at 3am when no one but your sorry intern ass is around. That's just the way it works.

I'd rather not participate in something that makes the patient uncomfortable.

Seriously? Well, I would suggest a specialty like radiology or pathology then, certainly not pediatrics. I a kind person with absolutely no sadistic tendencies, but I don't delude myself into thinking that a day goes by without something I ordered or did causing a child pain. I wouldn't have chosen it if it wasn't necessary, and given the general public's preference for discomfort over death, amazingly we're still in business.

 

[edmadison]

At my program, it was whoever was around and senior: attending or senior resident, but we were essentially a community programs so we had very few codes. At the gigantic children's hospital down the road (where I rotated), it was the PICU fellow who was in charge. This seems to be pretty common.

Ed

 

[group_theory]

Although I don't like the thought of chest compressions and how painful that may be (and what if it's the last thing the patient is aware of before he dies?) and I'd rather not participate in something that makes the patient uncomfortable,

If your patient is awake and can feel you doing chest compression, chances are you don't need to do chest compression.

Think of it this way - you are doing chest compression because the patient is essentially DEAD ... no heart beat (or very poor heart beat with poor perfusion). If the patient is awake enough to register the pain of chest compression, then you probably don't need to continue chest compression (since there is adequate circulation and oxygenation/ventilation for the brain to be able to process the info). If the patient needs chest compression, patient comfort is the last thing on your mind (aside from code status and what the patient/family wants). Either you do chest compression and give that patient a chance to live, or don't do chest compression and the patient remains dead.

 

[kristing]

I was from a community based program with an ICU attending always present and no peds fellows. So when the codes were done, an attending was always present or got there right quick.

Part of the reason you don't see as many in peds, is that they aren't called over the loudspeakers like in medicine. Usually it's like "oh crap, this kid is going down" but technically not coding yet, so things and people get assembled and it's never really said out loud. Because when the people are all there and the badness turns into a code, no one pushes the button to announce a code because everyone is already there. Get it?

I saw a total of 2 codes my whole time in residency that were official "codes". Some of my fellow residents who have black cloud tendencies saw many times that. That said, I guess I am also not couting badness that happens in the NICU because not-good things happen ALL THE TIME and again, people don't really say "THERE IS A CODE HAPPENING".

I am also not one to hang out in the PICU in my free time, and I would very quickly transfer a kid to the PICU if I felt he was going down instead of muscle through it myself. So maybe that's why. Plus, I am doing outpatient/research, and this is what I always wanted to do, so I knew I didn't have to gun for the coding kids.

It sucks having to hurt people. It really does. I understand where you are coming from on this. If you are planning on being in an in-patient specialty as you alluded to, you are going to have to get used to this. I love being in peds though, where really we don't do useless tests (or try really hard not to) if it means causing more pain and it won't change our treatment. In medicine where I trained, am labs were the norm. And when I did some medicine my intern year (in a DO internship), when I questioned this, I was poo-pooed. Where I trained in peds, we really limited the discomfort as best we could. That said, if it has to get done, and will make the kid better in the long run, some times you just gotta do it.

 

[oldbearprofessor]

I've never seen a pediatric code. I've only seen a handful of adult codes, and in my experience, the second-year IM resident runs the code, makes the decisions, talks to the family and the third-year resident is present to supervise. I was talking to a pediatric resident at my "home" program who said the attendings run the codes, which surprises me--if you don't learn to run codes during residency, when do you pick up that skill before you're an attending?

As others have alluded to, you need to separate out codes done in the NICU/PICU/CVICU/ER from those done on the wards. In pediatrics, true CPR requiring codes on a general ward service are uncommon to rare (or less). Hospitals with residency programs will generally have a designated team to handle these. The team may or may not include an attending (e.g. anesthesia, EM) or fellow (critical care). Residents are usually a major part of this team - but because of the rarity of "floor" codes, may end up deferring to a fellow or attending if one is there. Most pedi residents will participate in only a small number of ward codes in their training.

In the NICU/PICU/ER, at most places, codes are not "called" but when a "code" event occurs, some mechanism (beeper, etc) is used to get response personnel to the bedside. It is most common in large units to have an attending be around or at least a fellow and they would typically "run" the code in that setting. There are certainly places though in which the NICU only has a resident at night and they would be the boss then. It would be common for the resident to be one of the "doers" more than the "boss" in an NICU though.

 

[bjackrian]

In our main pediatric hospital our codes are run by the ICU (fellow do begin with, attending if needed) with the assistance of the residents (both ICU and floor), anesthesia, RT, RNs, etc. At our community hospital site, there are two pediatricians in the hospital overnight: a PL-2 resident and an attending neonatologist who respond to all pediatric codes (both in the hospital and in the ER). Scary!

 

[MedGoatTX]

Where I went to med school it was the PICU fellow who was designated to run codes. At my residency, it is theoretically the senior resident but frequently ends up being the PICU fellow anyway depending on which one shows up.