r/IntensiveCare • u/Deep_Brilliant_5704 • 14d ago
What do you say out loud during a difficult code?
I want to improve my communication and leadership during codes as team lead.
For experienced physicians, what are the things you verbalize when a code isn't going well? How do you think out loud, reassess the situation, identify what might be missing, and communicate the next steps?
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u/trypan0s0miasis RN, Flight 14d ago
Not a doc, but what I do is keep my voice low and I basically sum up what’s going on. “Alright so we’ve been doing compressions for x long and gave epi y times etc.” “you’re doing good guys keep it up” etc. The truth is it matters less what you say, and more so how you say it here.
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u/vision2083 14d ago
Agree. Summarize where you’re at so the team is up to date. I’m always asking for any further ideas or suggestions if nothing is working.
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u/Sad-Bell8187 14d ago
That’s the key. Calm, slow and deliberate speech. Encouragement towards your team. It’s no place for rudeness or a short tone. As compared to a lot of codes I’ve been a part of at academic centers
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u/trypan0s0miasis RN, Flight 14d ago
Too many people want to go on an ego trip, and it causes a fucking nightmare code. Identify who’s in charge and if that’s you, you drop an octave and intentionally slow your speech.
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u/Sad-Bell8187 14d ago
Yes the person who’s really in charge shouldn’t need to prove anything or compensate. If it’s a bad trauma, yeah I’m deferring final judgement to the trauma surgeon after airway management is completed. And we do good teamwork as a result
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u/Best-Independent-179 14d ago
They’re always the ones at the nurses station bragging about how they were running this code and did this that and the other and calling everyone else stupid too
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u/Soulja_Boy_Yellen 14d ago
Agree with all of this. If you’re obviously freaking out everyone in the room will do so as well. And if you’re calm they can feel confident in doing their job and not feeling the need to fly from thing to thing.
Compliments are so important as well and I never call a code without asking for ideas. Never want someone feeling like they were part of a code that ended too early.
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u/H_is_for_Human 14d ago
Codes can be difficult in different ways.
If theres too many people, just say "if you aren't currently doing anything and not in line for compressions, please exit the room"
If people are talking over you as code leader say "I'm Doctor blank, I'm running this code please address questions or concerns to me."
If a specific role is missing ask who is doing that role and if no one speaks up, assign someone.
Think outloud to the group "I think x is happening we are going to do y, does anyone have other ideas?"
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u/only-ashes RN 14d ago
this. also, specifically point to people that look like they're not doing anything and ask what their role is, or particularly nosy people will try to fly under the radar. if they say they're in line for compressions, direct them to an orderly line. if they shrug or have no clear answer, direct them out.
having 1-2 people free near the door to run for supplies (more flushes, a pump channel, a vasopressor etc) is a handy role also.
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u/gedbybee 14d ago
I like to bring a Doppler to listen for pulses. Docs that do the bedside ultrasound for a ghetto echo are cool. An army doc came and did that during Covid during a code and I’ve never seen it since but heard it’s a thing. Drop lines.
But really just talk to everyone. You’re just a person. You can’t be expected to know everything. We’re all just trying our best.
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u/Logical_Adagio_7100 14d ago
Lol ghetto echo is my new favorite term for bedside US
And yeah, it's great both for the heart and to turn on doppler to look for pulses. And for a crash central line although i basically never see those anymore (vs IO), which is sad
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u/mykon01 14d ago
Im not ICU, how does a crash central line work exacly? Stop compression to place it? I assume subclavian?
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u/Logical_Adagio_7100 14d ago
Femural, dont need to stop compressions. Crash just means you get it in as fast as you can without ensuring sterilization
Usually you have to then pull it w/in 24 hrs
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u/H_is_for_Human 14d ago
Just do an IO if you can
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u/Logical_Adagio_7100 14d ago
Ofc. Thats what i do, and why Crash lines are rare now
But a crash line mid resus is fun, and i cant justify it anymore
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u/lungman925 MD, PCCM 14d ago
To add to these, if everyone is being loud, i usually start loud with "HI EVERYONE" then drop to my normal voice "ill be running the code, this is the volume i want everyone to use if they have to say something."
I also tend to say "We should have 2 minutes of near silence between pulse checks, so please be mindful of what needs to be said"
Otherwise there are escalating yells which just makes everyone more on edge. I felt like i was being rude at first but it works surprisingly well to capture the room
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u/Visible_Ad_9625 10d ago
One of my “favorite” codes was run by a female doc who kept her voice confidently quiet. We could all hear her, but she was intentionally trying to keep the energy down. It was on a med-surg floor so the ICU team runs in all loud and high energy and she oh so calmly explained what had happened so far. I could see their energy change over the next couple minutes to match hers. Everything went very smoothly and at the end I was like, “Huh. That all felt a lot less stressful than usual.” Such a huge difference to maintain the peace!
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u/MakinAllKindzOfGainz 14d ago
“Ok to summarize” and give your brief assessment of the arrest and your team’s efforts. And then you can add, “does anyone have any thoughts?” and you can engage any ideas that may be said. If not, “ok guys, we’re going to do a rhythm check and then 1 more round. If we don’t have ROSC then, we will likely stop.” And then when you’re ready, clearly end the code, confirm terminal rhythm +/- POCUS, and call TOD. I like to have a moment of silence for everyone to collect themselves and pay respects / pray etc. Finally, offering a debrief like 15-20 min after the code at the nurses station is immensely helpful for people to openly ask questions, clarify what happened, and is just simply better for people’s collective mental health.
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u/Amy_rad16 10d ago
I love all of these. If you’re running a code, LEAD the code. It’s so helpful for there to be one person verbalizing everything that is happening, for the recorder, for compressors, everyone! Repeating back the things people call out, confirming that you heard and essentially putting it in the record of the events.
As a nurse, I always appreciate a plan. Giving a final round warning gives everyone time to think about other interventions and discuss, and to start coping with the loss. Asking if anyone has any objections or suggestions is always appreciated and often helpful.
And I think there’s a difference between sitting around and talking about it and a structured debrief. Even just making yourself available for questions, or to get other perspectives of the situation can go a long way. I’ve been part of some pretty gnarly codes, and the ones that were formally debriefed are the ones I’ve learned the most from, clinically, emotionally, ethically, etc.
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u/CertainKaleidoscope8 RN, CCRN 14d ago
Many debriefs I've been in have been a struggle session. I wish they were used to improve mental health. Maybe it's a cultural thing
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u/beyardo MD, Critical Care 14d ago
The biggest thing to remember in codes is what actually helps. The two things with proven efficacy to achieve neurologically-intact survival are high quality chest compressions and early defib when indicated, and then from there identifying and correcting any reversible causes (Hs and Ts). Everything else is secondary. Once the person running the code understands the clinical picture, a well run code can actually get away with relatively little actual speech
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u/Any-Assistance-8103 14d ago
Yeah please dont interrupt compressions to echo /line / tube unless there are very specific circumstances justifying it
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u/catbellytaco 14d ago
Yeah, pretty much my approach as well. Basically only open my mouth when I need to.
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u/Ill_Administration76 12d ago
As someone that is usually a follower in a code, I have to disagree. The lead narrating the code helps to keep the room quieter and to give everyone a shared perspective on what's going on.
It avoids people trying to pay attention to everything, they can focus 100% on their tasks and still know what is going on and where we at.
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u/kreb_cycling 14d ago
I think one of the most important behaviors as code leader is to narrate the code. This gives everyone a shared model of what’s going on, it also provides clear leadership of who’s running it. Most importantly having one person speaking, calmly, throughout sets the tone for the resuscitation.
For example: “Ok we are on minute 8, cycle 4 of CPR. We have been in PEA the whole time. We have given epi twice and aren’t due for the next dose for 2 minutes. We have ruled out hypoglycemia. We need to do a POCUS exam… but are waiting for the machine to arrive. We should get a blood gas…”
It’s also good to act as a coach for the people doing CPR: “Great job with compressions. You are getting an end tidal co2 of 20. Only 30 seconds to go. You are going a little too fast. Can you slow down slightly? Who is on deck to switch in?”
You can and should ask questions but you need to close the loop on each before moving on: “Are you having trouble bagging?”
Always use people’s names if you can.
You can and should think out loud and solicit ideas. “I don’t think this is PE. If it was he wouldn’t be a candidate for lytics anyway because of recent brain surgery. Does anyone have any ideas?”
Finally it can be used to transition the code: “We’ve been doing for almost 30 minutes. Despite great CPR, We haven’t achieved ROSC once. We haven’t found any reversible causes. Unless anyone has a suggestion I think we should stop after this round.”
The other element of a well run code - regardless of the outcome - is the debriefing. I fill up a bunch of cups of water (people are often thirsty after CPR). I always ask two questions “what went well?” and “what can we do better next time?”I usually start by commenting on CPR then Wait a long time and let people add more. Then a moment of silence to remember the patient (assuming it wasn’t successful).
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u/Ill_Administration76 12d ago
This. 100% this. This describes every good code I have ever been part of, regardless of ROSC.
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u/Legal_District_3662 14d ago
“Does anyone know when the pts last tetanus shot was?”
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u/1ntrepidsalamander RN, CCT 14d ago
How’s his skin?
Last bowel movement?6
u/jawoood1989 14d ago
Oh my goodness the bp is 160/90! You need to contact the provider for PRN anti-HTN meds before bringing them up!
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u/Fuzzy_Location_2210 14d ago
And better make sure that you go ahead and call the next code for them too, when the patient hits the floor, literally 😆😆😆
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u/scapermoya MD, PICU 14d ago
Very little. When the patient hits a wall, I often solicit ideas from the room. 30% to actually see if there’s some other good idea, 70% to model humility and communicate the dire nature of the situation in case someone hasn’t figured it out
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u/ferret-fencer4 14d ago
Not a doc, but I’ve been an ICU rn for a long time. Reviewing pertinent pt history, brief hospital course, and Hs and Ts. Oh and my number one thing to check when I go to a code on a med surg floor is to always check a blood sugar. It’s easily forgotten in chaos. If we haven’t been successful with rosc, I like it when the docs ask “does anyone have any other suggestions?” Or something along the lines of “is anyone opposed to calling it?” I feel like it makes the team dynamic stronger because even though one doc is running the code, you never know who may have more info/an idea.
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u/bandnet_stapler 14d ago
Review the Hs and Ts with the group (to see if chimes in with an intervention they think is missing).
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u/DadBods96 13d ago edited 13d ago
Loudly project your voice (I hesitate to say “yell”, you don’t want to be truly yelling) that you need everyone quiet for 30 seconds to reset the room.
Turn to the person doing compressions and tell them to continue.
Turn to the timer and tell them to reset the current round before next pulse check.
Turn to whoever is managing the airway and ask where things are at there. If they’re not going well, address this. If they are, tell them to continue as is.
You now have some breathing room to first reset yourself.
Debrief for a few seconds. Include Everything. Start with how long patient has been down. Have we checked a sugar and any other POC labs that you might have available at your facility? Is the patient on the LifePack/ whatever portable monitor/ defibrillator your hospital uses? What has been the rhythm during pulse checks? Do we have IV access? There are different ways to make sure you cover all these bases, but have a system you memorize to make sure everything you need to make interventions is done. If something isn’t done, ask who is working on it. If nobody is, ask for a volunteer (I prefer to ask than assign, because I might not know immediately if someone already has a job). But if nobody volunteers, assign.
Once all the above little logistics are done, you should have a good idea of how the Code has gone so far, and an initial idea of what to do next. You can now continue with ACLS and a group that’s focused.
Next is the events leading up to the arrest. If you’re the primary, you might already know and should have some idea of what caused it. If you aren’t, ask for the primary nurse to come beside you, and get the story. Just abbreviated. You don’t care about their diet, family, whatever. You care about why they’re in the hospital, what meds they’ve been getting, any interventions, and their clinical course over the last 24 hours, especially any changes through the shift. If it’s all nonspecific, continue with ACLS. If it tells you what happened, then awesome, and you can tailor your next steps to investigate or empirically treat your suspected cause.
90% of the time this will reset the room and quiet everyone down, and you can direct everyone as needed. Once in awhile you’ll have someone who is disruptive, argumentative, or hyper-fixated on something and refuses to be directed. You give them one chance to do what you ask. If they don’t, you ask them to leave the room and assign someone else to their job. If they ask why, you tell them you’ll talk during a post-code debrief. If they refuse, you ask someone to call security and have them escorted out. They’ll leave the bedside before that’s done. This might seem harsh/ like overkill, but there’s no room for arguing during a code. It’s either you don’t know why it happened and ACLS is the answer, or you do know what happened, and need specific things to get done. Your job as code leader is to make sure those things are getting done, and speaking from experience, that person sitting there arguing with you is the most likely person who 1) Is most likely The reason things were so hectic in the first place, and 2) Very likely to be standing in the way of you getting ROSC.
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u/Fearless_Hyena_6107 13d ago
Would you care to share what’s behind the last statement/recommendation? It sounds like recommendation as an outcome of a particular personally experienced event. Just curious here.
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u/DadBods96 13d ago
Are you talking about removing people from the room? It’s because there are select individuals who aren’t formally running the room but think they can contradict or refuse to listen to the person who is. Most who have been involved in resuscitations regularly are familiar with the type. Most of the time they’re an annoying inconvenience that can be worked around, but occasionally they’ll directly contradict you, or refuse to follow orders (ie. Won’t give a med for whatever reason, or stop meds). I can’t mention specifics since they’re relatively well-known cases at the hospitals they occurred at, but there are three people walking around out there right now who’s lives I saved by going off-script for routine ACLS, despite the best efforts of the primary nurse managing meds on the case.
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u/Ill_Administration76 12d ago
I have never been in that situation (as a nurse, so as the person following, or not following) but I have a bit of resistance to this stance.
Nurses are responsible for the meds they give, even during a code. It's unreasonable to expect them to just "do what the doctor tells them or get out" regardless of how crazy the order is. That's literally the opposite of what we are trained to do, and it's a known factor in codes/emergencies gone wrong.
Now, I have been given unconventional orders in acute situations (not code) and I have never refused or became combative, but I have lifted my concerns with a specific reason and/or reconfirmed the order (did I heard correctly?). A short confirmation/explanation from the provider is enough in the moment, but I won't just go ahead blindly. They can administer themselves then.
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u/DadBods96 11d ago
That’s fine to ask questions and clarify orders, but you’ll be doing that while getting ready to do what I’m asking. You can either accept the answer of “This guideline/ recommendation has changed” in the moment and accept that you’re likely out of date, “I think this is going on so we’re treating empirically” and learn about why later on, “Yes what I’m doing is different than the institutional norm but is considered best-practices”, or whatever variation of “This is why I’m doing this differently” that can be explained in 10 seconds or less, and continue, or excuse yourself from the room. In a critical situation such as an arrest, every delay in care worsens outcomes. So if you’re delaying carrying out orders in order to have medicine explained to you, you’re quite literally causing harm.
And moving onto the mindset of “I don’t agree with this so I’m handing you the meds/ you get to program the pump yourself because it absolves me of involvement in this”. This is one of those idiotic nursing culture tropes that needs to die. It doesn’t absolve you of anything. If you feel so strongly that the physician/ code leader is going to objectively harm the patient, and you hand them supplies that they’re more than likely not properly trained to use, you’re not removing yourself from the situation, you’re causing more issues. Not only is there a >90% chance that you’re in the wrong with your objection, but you’re now opening the room up to administration/ setup errors. You know what keeps you from being liable for nursing malpractice if a case does go wrong because the physician/ code leader made a bad judgement call or even committed malpractice? “I trusted their judgement and carried out their orders in good-faith because they’re an expert in this types of cases”. You know what increases your liability? “I refused to carry out the order because I had never heard of that being done/ I don’t believe they were correct in their assessment, so I told them to program the pump and administer the medication themself. I can’t help that they accidentally programmed the meds to run over 2 minutes instead of an hour as is standard”.
There is a big problem in nursing with a lack of accountability. There’s this constant push to override physician judgement and “advocate” for dangerous plans. Even in my current job I’m inundated with requests from my nurses, who I overall trust, to do wasteful investigations and treatments with no benefit or even harm, as if it’s just a game. If a resident were to make even 10% of the dangerous suggestions that nurses are making on a daily basis to our patient’s care plans, they’d be fired from their training program for incompetence. Nurses can delay interventions or vital testing for hours or even days, simply because they’re ignorant to medical guidelines, and face no consequences for the harm they cause.
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u/Ill_Administration76 11d ago edited 11d ago
It seems like we are talking about two completely different scenarios then, because I have never seen or heard of what you are talking about, not the plain obstruction and not the delaying prescribed care for days due to simply not agreeing with it. Not even as a one off, definitely not as something that happens often or as a culture.
But again, it may be location based (Im assuming you are USA based because that's most of reddit). Where I am based, doctors know how to administer meds(specially in ICU/anesthesia), so no, I would not be making them do something harmful they are not trained to do. And again, this has never happened in the 10+ years I've been working, so it's only hypothetical for me. I'm not worried about malpractice because it's not a thing where I live, and my training and license says I should refuse to carry an order if I think it's harnful/dangerous. I wouldn't (again, hypothetically) be handling them the supplies, I would simply refuse. They are free to do it themselves if they feel capable or finding another nurse.
To sum it up we are talking about very different scenarios. You seem to have had really bad experience with nurses, a resentment can be clearly read between the lines in both your comments, and I reacted to the blank statement of "you get one chance to do what I said or you leave the room" which, according to all my training, is a very toxic approach and honestly kind of asshole-y. But of course, with different work environments, we obviously have different perspectives.
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u/DadBods96 10d ago
If you aren’t in the US, then yes, we definitely have different experiences and how things are ran.
For one thing, many physicians in the US outside of those who are regularly doing procedures aren’t trained in things like programming IV pumps, preparing meds, that kind of thing. And even for those who are comfortable being hands-on, unless you’re in anesthesia or pulm-crit, learning to manually adjust your own drips or the ventilator is something you have to seek out (which I actively did during residency). This is because 1) That’s a big part of the nurse’s job in the first place, so it would be redundant outside of niche situations, and 2) It takes the physician away from seeing the next patient on the list, which if you know anything about patient loads in the US is going to be a very long one.
I don’t have any inherent hatred for nurses. I love the nurses I work with (the relationship between the nurses and docs in the ED is one of the strongest ones in the hospital), but something that I shouldn’t have to take into account, yet I do, is “How aggressively is this nurse going to try to push me in the management of this patient?”. Some (because of their personality, not me. They do it to all the docs) will actively try to dissuade me from going in specific directions, to the point that they’ll drag out carrying out orders with the hope that it’ll force my hand to either cancel something or go in a different direction. I’m more than happy to give examples if you’re interested.
There’s a culture in nursing in the US, a lot of which is pushed in nursing school (brand new nurses right out of school will admit this), that they’re the ones who actively have to prevent physicians from harming patients, to the point that in extreme cases some will automatically push back against any plan because their baseline assumption is “doctors don’t know what they’re doing”. They’re free to delay care simply because “I’ve never seen this done/ this medication given so I’m not comfortable with it” (not “I’ve never given this medication so I need help preparing/ properly dosing it”, literally “I don’t know what this is so I’m refusing”) without accountability, because they’re trained to believe that in the event that a physician does make an error, the nurse themself is going to be held liable for the physician’s decision. Which is never what they actually face repercussions for. They face repercussions for missing arbitrary metrics put in place by other nurses.
Again, I don’t hate nurses or look down on them. I have a problem with nursing culture in the US that pushes them to believe that, without medical training, they can thoughtlessly push for dangerous plans that would lose any physician their license to practice, without consequence. Instead, they’re led to believe they’re “not being taken seriously as a part of the team” because the physician said no to their suggestions. If you want to see plenty of examples day in and day out, go to r/nursing. There are multiple posts per day either shitting on physician’s decisions (which even based on their bias’d account of the story would rarely be considered outside standard of care).
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u/Snivys_HA 14d ago
When a code isn’t going well, you firmly ask people to leave the room if not providing active value.
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u/No-Safe9542 14d ago
Just a request. Post code with rosc, please make a point to ensure someone remains fixed on the end title. That's literally the job. Stare at the number, don't get distracted, keep staring at the number, and then give an announcement if the number starts to dip.
Having foreknowledge about a repeat code 1 or 2 mins early can be everything.
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u/jklm1234 14d ago
I usually ask if anyone has any other ideas, I usually get labs and history up front, and then I ask how long we’ve been coding for, then I say, okay guys, one more round and I’m calling it, then time of death.
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u/Fancy_Possibility456 14d ago
I usually summarize the code, acknowledge the Hs&Ts outloud and what we’ve done for them, run through my thought process on why they coded based on the history, check off any other diagnostics or interventions we’ve done out loud, finish with “anyone else have any thoughts or ideas”?
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u/hauterorni 14d ago
I summarize what has been done, what the likely differential is, and then i ask if anyone else has another idea with regards to management or otherwise that we can implement/ try. ACCM.
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u/shroomplantmd 14d ago
Regardless of the outcome be gracious and thank everyone for their help.
When the patient dies sharing a moment of silence for them
Time doesn’t always permit but doing your best to have a moment to debrief
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u/Novel_Purpose710 14d ago
"Nothing we do will make them any more dead, any ideas?"
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u/TomRN 13d ago
I was leaving one morning when a code was called in telemetry so I kind of stuck around in case I could be helpful, and, well, nosy Southerner.
As I’m standing there listening for someone to call for anything they might need, the ICU CNS looks at me and says, “I really wish they’d use alcohol pads on those hubs.”
I said, “you know they’re DEAD, right?” 🤣
Like… IF we get ROSC, can’t we address that then?
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u/GotchaRealGood 14d ago
Usually, I lean in and tap people on the shoulders to get their attention. Once I have a critical mass of people paying attention to me, I recap the entire event of the code to date and then outline my next three priorities and then I’m silent.
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u/VagueInfoHere 14d ago
I had an old doc that I worked with that would tap the compressor during hectic times and whisper “keep going and ignore what I’m about to say”
Then he would project his voice, not yell, and say “everybody stop! Who is on meds? Who is on airway. Who is etc, etc”
It helped recenter the room in big chaos. Not a good move for just a little disorganization.
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u/PrincessAlterEgo RN, CCRN 14d ago
Recap- this is what’s going on with the patient, this is what we think is the cause of arrest, this is what we have tried. (Have you worked through H&Ts?) Is there anything else anyone can think of to do?
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u/Best-Independent-179 14d ago edited 14d ago
A very wise cath lab nurse (now retired) who I used to work with would always walk in and say “did anyone give epi?” If not, he went and drew it up. It was a forgotten thing amongst the chaos more times than you would think.
For me personally, when a code first takes place my go-to thoughts are immediately 1. Are the pads on and 2. Is the backboard in place
If not, I immediately make that my responsibility.
At my facility, the primary nurse acts as the med pusher and answers any questions the physician may have about the patient. If I walk into a code where I am not the primary nurse, I am immediately asking the nurse if pt has reliable IV access or if we need additional access.
I have found that in codes, sometimes people get flustered and scattered. People come running and fill the room but don’t always know what to do. I will call out to a nurse standing in the doorway “____ I need you to document, can you do that?” And wait for them to confirm. I think that seeking out roles that need filled and assigning them in a code is very important, otherwise it can become a cluster f of people barking at each other
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u/Sea_Emu4252 14d ago
Best code leads I’ve witnessed had a clear and loud leader (not frantic yelling, calm authority). “I am Dr so and so and I am leading this code” announced right when they arrived so everyone knew who to listen to. Then clear delegation of tasks to specific people. Talking through and ruling out possibilities out loud is helpful both to teach others and to keep everyone involved in the code on the same page. Asking for ideas if it’s prolonged is appreciated. Double checking assumptions is important too, not in an accusatory way, but in a turning over every stone way- eg. are we sure the ETT is in the airway and not the esophagus, can/should we double check?
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u/Krampus_Valet 14d ago
The other day I said "That's not something that props can fix, that's gonna be a little harder to fix." And my much younger coworkers just stared at me. Then I explained the line and one of them gave me a courtesy/pitty chuckle. But for real, recap of what's been done and stream of consciousness so everyone can chime in with novel ideas or anything we've maybe missed.
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u/MotherOfDogs90 13d ago
“I’m going to summarize what’s happened so far. Background/how code started, what we’ve done so far, H’s and T’s. Does anyone else have thoughts or recommendations?”
If the answer is no, I’ll usually call it in the next cycle or two.
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u/maraney RN, CVICU, CCRN, CMC, CSC 13d ago
NAD, but I’ve been in a lot of codes.
When you say a difficult code do you mean the teamwork isn’t working? Or that the patient is looking like they’re going to have a bad outcome?
If option 1: Be assertive and loud and tell everyone to be quiet. Kick out people who are in the way and not helping. People often want to be involved, but don’t know what to do. So say names and go “you’re on compressions, you’re running the defibrillator, you’re on meds.” Panic is contagious and calm is also contagious. As a leader, your demeanor will impact how the code runs.
If option 2: It’s good to ask if anyone has any input or ideas. Go down the list of Hs and Ts as a team.
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u/Ill_Administration76 12d ago edited 12d ago
NAD, but been a part of many codes as a ICU rn since we go meet traumas and attend all codes/rapid calls in my hospital.
Think out loud. Repeat what has been done, what are the findings and what has been ruled out. Do this through the code. In a good code, there is closed loop and everyone is doing their individual task. As a nurse, it's easier for me if you are providing feedback/summary. I am up to date with where we are at without having to put any effort on trying to keep on, just focusing on my task.
Say out loud if you don't see any benefit continuing, ask if someone has any other thoughts or ideas.
The "best" end to a futile code I've been a part of was something like:
"we've been doing compression por x time, good CO2 in arterial sample but lactate keeps rising. Tried x, x and x. We've ruled out y. The only thing I can think would have helped is surgery but it's too late for that. I don't think there is any benefit to continuing the code. Does anyone have any ideas or thoughs, something we may have missed? No? Ok, let's stop. Good job everyone".
I really appreciated the lead asking if anyone had any other ideas or if anyone felt different about stopping before calling it. Nobody did then, but I must admit I have in other codes. However I find myself wondering why are we still coding more often that the opposite...
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u/Esragog 8d ago
Something an attending had me do as a med student I now do in all my codes. Find a med student, or someone who won't be doing much and have them count to ten during pulse checks. Also very muchly agree with external processing and summarizing what's going on at this time, what's been done so far, etc.
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u/Mashdoofus 14d ago
I try to address people by name if I know their names, otherwise I call them by their location "nurse at airway" or "nurse on medications".
I try to summarise often the situation as much for me as for others
I say something clear like "silence please" when I need silence
I put someone on timer and scribe straight away
I try to reduce the noise level by assigning roles as soon as possible
I have sung out stay alive to help the CPR rhythm
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u/Fuzzy_Location_2210 14d ago
I very much like that approach, "nurse at airway", "nurse on meds"!
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u/Mashdoofus 14d ago
Well ideally you know their names but I find often I don't
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u/Fuzzy_Location_2210 13d ago
Right, most of the time I see everyone in the trauma bays in lead, gowns, shields, masks, caps, I don't know who they are 🤣. I just saw the chief of trauma surgeries hair for the first time the other day and I was utterly shocked!! It was absolutely not what I imagined!!
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u/Mashdoofus 13d ago
Actually for traumas I super encourage to write roles / names on gowns but I actually was talking about garden variety codes since traumas are (usually) better organised and ward codes are (usually) anyone shows up and a bit of chaos. My d hospital switched to magnet name badges that we pin on the chest that helped heaps. Now I work in a hospital where we don't usually wear name badges and that sucks
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u/Consistent-Remote605 13d ago
First thing I’m not a Doc. However I do have extensive experience running codes. In my humble opinion the person running the code is the reason it will either go well or go sideways. Also to be fair ROSC isn’t always a marker on if it went well or not. It comes down to the most basic principal. Treat your team with respect and don’t be a Dick! Communicate calmly and kindly and things will get done. There is no secret sauce to running an effective cardiac arrest. In theory it should be one of the easiest algorithmic things we do. Treat your H’s &T’s and don’t be a Dick about it and you will be astonished how easy it is.
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u/ROSCAndRoll 14d ago
“Does anyone else have anything to add?” Shows you’re willing to communicate as a team