My First Code
My interns and residents had been talking for weeks about how bad a code situation is, and so when the patient was found unresponsive in his hospital bed today, I figured it’d be neat to go watch. Neat being my Hollywood, glam and glitz, heroic understanding of a code; terrifying would probably fit better. Yes. I figured it’d be terrifying to go watch.
I was amazed at the scene when I arrived, watching from outside the door. I got there only 10 seconds after the Code 66 had calmly been announced overhead (Code Blue scares patients, I guess), and already 25 people were in the room, with supplies, the crash cart, and it was loud. About 8 people were actively around the patient, with others supporting the 8, while some other people were trying to move the patient in the next bed out of the room. I did my best to stay at the periphery, out of the way, and help out when I could. People were quietly talking about how the patient was found, that he was supposed to be discharged today–and who knows where the rumor mill went from there.
A small woman was doing CPR on the gigantic patient (and luckily soon switched with a much larger male nurse), while others were checking pulses or trying to configure the defibrillator. Interns and residents were trying to start femoral lines, palpating weak pulses that trickled by with each chest compression. Two people were bagging the patient with oxygen. The ICU fellow was calling for meds and thinking aloud (I would soon learn the 5 H’s and 5 T’s), while the intern responsible for the patient was announcing the patient’s morning labs and vital signs (“K was 3.6 this morning! Blood pressure was 110/65!”), all of which were stable and within normal limits. The pharmacist was doling out medications from her kit as fast as they were being called for.
Toward the end, the senior resident responsible for the patient was in tears, and the room grew more quiet, with fewer audible voices drowning out the sounds of the code equipment and the oomph of each chest compression. There were fewer looks at the patient, and more at the clock. The pharmacist announced the passing time. “Four minutes since arrest” became “nine minutes” became “fourteen minutes” became finally “twenty minutes,” and the patient was pronounced dead.
“The key is to stay calm,” my resident told me. I told her I didn’t think I’d ever be calm in a situation like that, and she shared her secret: “I just assume the patient is already dead, and anything I do can only help them.” I think she may be right.
Thanks Graham. I had my first hospital day today and have been wondering about code situations. I think your resident’s words will probably be very helpful for me when the time comes.
Hey Graham, I hope that the patient who coded wasn’t on my onc service! Kidding aside, being a resident participating/ running a code is a pretty harrowing experience, although your resident’s philosophy about coding patients is quite correct. As for the code you went to, your observation that it was loud is a huge problem. I find that most codes are chaotic and that’s the last thing that a patient needs. Med orders aren’t heard, it’s hard to keep track of what’s been done, etc. Ideally, there should only be one person talking (the leader) and there really shouldn’t be more than a half dozen people involved in the code (1 airway,1 chest compression, 1-2 people getting access, 1 nurse, and 1 pharmacist). I find that most people will probably die if there in a code anyway, but I’ve noticed that there have been some potentially salvagable cases that were botched because of chaos and confusion.
I am not a medical person–but I do like your blog. What is the origin of “code blue”? shouldn’t it be “code red” for emergencies?
That’s pretty good advice from your resident. I’ve never heard that before.
Sometimes it’s very interesting to watch how various people react during a code.
Long-time reader… I’m also a junior clerk. I’ve been given the same advice, and it really helped put the situation in perspective. I’m not sure if this is true, but I’ve heard that 80% or more of patients who code in the hospital are not going to leave the hospital alive. There’s a lot of ethical questions to be raised if that is the case. Regardless, always remember to check a patient’s code status after your primary ABC’s if you’re the first one in the room!
One problem with only the leader talking – communication suffers and the code itself dies. The recorder (that’s me over there, a 30-year veteran of critical care, now a supervisor) needs to know What is Happening and When. The leader, not always infallible, needs feedback and suggestions. The other members of the team need to communicate loss of IV access, progress of intervention (“epi’s in; atropine in, set at 200 joules, CLEAR!!) A quiet code is an unsuccessful one – one about to be “called.”
I’ve worked many dozens of full arrests in the last 4 years, and it quickly becomes second nature, especially when you work with a regular group of people for a while and roles become defined. And your resident is right, they are dead, you can only make the situation better.
I’m still trying to find out the etiology of the codes… but for now, here is a summary of the color code:
CODE BLUE = MEDICAL EMERGENCY
CODE YELLOW = HAZARDOUS MATERIALS INCIDENT
CODE RED = FIRE
CODE ORANGE = BOMB THREAT
CODE PINK = INFANT / CHILD ABDUCTION
CODE SILVER = HOSTAGE SITUATION
CODE BLACK = VIOLENCE
there’s a code brown, but i’m not sure it’s a real one; maybe check, http://www.poopreport.com
the one time i observed the code, everyone ssemed so calm, it was nerve-wrecking to me. and that advice is so fitting. it helps thinking that way.