“Code blue, ICU, 4 South, heart and vascular tower”

4 12 2011

Let’s talk about codes.  Real-life codes, not the ones you see on TV.

A code blue is called in a hospital when a patient is “crashing,” aka when they stop breathing or their heart stops beating regularly.  When this happens, the person who notices first (usually a nurse) pushes a button that sets off the alarm throughout the entire hospital.  It tells every person in any part of the hospital that someone’s dying and where they are located.  And it makes every physician (and a lot of others, too) drop what they are doing and sprint over.

The first physician who gets to the room runs the code: ordering medication, telling people when to start and stop CPR, how to control the airway, order stat labwork and imaging, and ultimately will be the person who calls time of death if that person was to die.  Another physician logs into the computer to read about the patient (who is usually, at least on nights, unfamiliar to them), interpret labs when they come back, assist on procedures if necessary.  The nurse assigned to the patient usually is telling the doctors what’s been going on with that patient, another nurse is a scribe who writes exactly what is done and at what time, another is there to draw labs, one gives medication, one acts as a runner to go and get the necessary medications and equipment for any procedures. There’s usually at least one respiratory therapist there, usually to squeeze the ambu bag.  And really, anyone can do that.

And then there is everyone else.

Because the hospital pages everyone, everyone shows up. But nobody leaves. I’m sure it’s different during the day, but on night codes, nobody has anything else important to do.  So there are like 20 extra nurses, 3 extra RTs, several students (medical and otherwise), the 2 care flight nurses from upstairs, any EMTs or paramedics who were in the ED, half a dozen miscellaneous techs, 3 or 4 additional residents, the nurse practitioner who thinks she owns the hospital, an attending, the patients on the hall who hear the excitement, and at least one member of the janitorial staff.  No joke.  Oh, and any family who should be in the room but usually get pushed out by superfluous people who want to watch the code.

Let’s review: Necessary people, 8-10.  Number of additional people who show up to help and stay for the drama: 40+.

These means a few things.  Most importantly, this is a disservice to the patient in distress.  With so many people crammed into the room and the hallway outside, it is more difficult to maneuver, administer meds, do procedures, and forget having space to wheel in the portable X-ray and EKG machines.  I haven’t seen a study to prove this, but it seems to me that this makes things move at a slower pace.

Second, the patient’s family is affecting.  If it was my relative getting CPR, I would want things to move as quickly as possible.  I would also be royally ticked off that so many people are there to see what to them is just a bit of drama to break up the monotony of the shift.  If I wanted to be in the room (which families have a legal right to be), I certainly wouldn’t want a bunch of deadweight onlookers keeping me from getting to the bedside.  The sheer number of people present can add a lot of stress to the family, especially because a lot of the “onlookers” are standing crammed into the room cracking jokes and gossiping amongst themselves.

Third, and this is a minor point, but because the nurses (and nursing students) are already on the floor and get there first, they can squeeze into the room, refuse to leave, and as a result the medical students are left in the hallway.  I spent a lot of time straining to see or hear something that would help me to learn how a code is run at each of the 4 codes I went to.  This in many ways qualifies me, and other med students, to be labeled as unnecessary onlookers, and really that’s true.  But somebody has to run those codes.  Usually, it’s a resident.  The med students need to learn how to systematically handle that emergency before the school tacks an MD on the end of our names.  Sure, the nurses need to learn how to be a good scribe, but it seems like that’s really the only thing they do during a code situation that they do not do on a daily basis.

In my opinion, there should only be 5 nurses in the room (or 3 if there are 2 extra residents), 2 docs, 1 respiratory therapist, the transient techs with the important machines, and the family.  Plus some extra personnel waiting in the hall to take over chest compressions or provide a pharmacy consult or run to grab medication or supplies.

None of the patients who coded survived.  One lady in particular actually died, and a minute later the nurse ran into where the doc was filling out the paperwork saying “she has a pulse,” and so she was stabilized and transferred to ICU.  A central line and a lot of meds later, she coded not quite 2 hours after she regained a pulse.  Apparently this is common, because sometimes for whatever reason the meds given during resuscitation take a while to take effect.  This doesn’t mean she had a better chance for survival, because at that point her brain (not to mention all other organs) had been deprived of oxygen for too long to make a meaningful recovery.  This was cruel for her son, who was standing in the hall and watching, because he really thought that his mother having a pulse meant she’d wake up any second.  But the discussion of just-because-we-can-doesn’t-mean-we-should is a topic for another day.

At any rate, I (fortunately) haven’t seen any codes during my staff month, but if anything is different, I will certainly share.  In the meantime, keep on praying for those people who struggle every day to stay alive, and for their families, especially the ones for whom it might be time to let their loved ones go.




One response

24 06 2013

This really helped me

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