The Intensive Art

It is a right of passage in my intensive care unit to become a member of the code blue team. Some people avoid it like the plague, and others crave it like cold water–living and thriving on the experience.

In my hospital, the code team is made of employees of the ICU itself. Three nurses with “lighter” assignments are given code pagers that are clipped to their scrubs and worn as a status symbol for all the world to see. Having the code pager proves to the world that you are no longer one of the new ICU nurses, that you have survived many stressful months of training, and that you are deemed trustworthy and knowledgeable enough to deal with an absolute crisis.

When the pager goes off, you simultaneously hear a hospital-wide announcement that a code blue is being called. The announcement and the pager both give you details on exactly where the code is taking place. Also at the same time, our unit clerk receives a phone call from the switchboard with the same information, which she/he announces to the ICU. The unit clerk also has a neat, fancy key that she/he inserts into a keyhole right at the front desk. With one turn of that key, every elevator in every part of the hospital immediately drops to the main floor and stays there, urgently waiting for the code team to arrive.

The three nurses with pagers drop whatever they are in the middle of doing and run. All of the hospital’s crash carts live in the ICU, so that is the first stop. A code timer on the crash cart is started, the elevator keys are grabbed, and then the team runs with the crash cart to the code blue.

Once they arrive on the floor, the code team is directed to the proper room, which is already cleared of furniture, equipment, and roommates. The code team truly doesn’t know what they’ll find until they turn the corner into the patient’s room. It could be a full blown cardiac arrest, or an infinite number of other possibilities: exsanguination, seizure, loss of consciousness, etc.*

There are three nurses on the code team. The first nurse charts (usually the newest nurse). This person is responsible for maintaining a record of who, what, when, where, why, and how. For example, the code leader will ask when the last dose of epi was. Or, more commonly, will wait for the charter to inform him when it’s been three minutes. The second nurse (usually the most experienced nurse) has the most feared job of running the cart. This involves: applying the defibrillator pads, working the monitor, defribrillating/cardioverting/pacing, getting supplies from the cart, drawing up meds, and more or less leading the nursing team. The third nurse is responsible for IV access, pushing meds, and starting infusions.

Also at the code will be the most senior ICU resident available, who immediately becomes the code leader. Occasionally, the patient’s attending physician will be present and will take the code leader position, but this is usually left to the senior ICU residents as this is considered their specialty and they are often there first. The code leader intubates, and then simply calls out calm, short, simple, timely orders , “Stop compression, check for pulse, what’s the rhythm? start compressions, epi, atropine, bicarb,” and on and on in the proper ACLS order. 

If luck is with us, there will only be two or three junior residents, but often there are ten to twenty residents and med students in the room. Generally they just stand there and observe. The ICU residents often take part: starting a femoral line, or finally getting a chance to intubate. Sometimes, the code leader will spontaneously turn to the ICU resident and say, “So, Dr. Panickedlookinyoureyes, what do you want to do?

There’s usually at least a couple RTs present. They assess and maintain the patient’s airway, draw an ABG, start bagging, and set up the intubation equipment in a blink of an eye. They will monitor sats, and observe for spontaneous breaths. 

We also bring nursing attendants along. The vast majority of the time, they are responsible for administering proper CPR.

The code team always recruits the floor staff as gophers. They run back and forth, quickly and eagerly grabbing any medications or equipment needed. They are reminded to call the patient’s attending physician and family. 

Meanwhile, back in the ICU, nurses scurry around, preparing a bed for the potential new arrival. There are three outcomes of a code blue: the patient dies, the patient lives and stays on the floor (rare), or the patient lives and comes to the ICU. 

To be continued…

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*Of note, we have a rapid response team that attends any situation in which a patient is deteriorating, but death is not necessarily imminent. They try to help the patient and prevent a code blue from being called. Often we hear the rapid response team called, and then immediately following, we hear a code blue called if the situation is more dire than expected, or if the patient rapidly deteriorates.

This entry was posted on Tuesday, January 13th, 2009 at 00:14 and is filed under Musings. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.