Code Blue I

The truth is, most "codes" called in a hospital turn out to be false alarms. All medical staff are instructed to call a code if we even think about it; it's the quickest way to get help in the hospital. No one can be reprimanded for calling one; even if it turns out to be benign, better safe than sorry. When a code is called, a ton of staff come out of the woodwork. Not only do you get an ICU fellow, a code team, a host of nearby doctors, nurses, pharmacists, and respiratory therapists, but depending on the hospital, you also get security, a chaplain, and a runner (someone to go find supplies you need). Sometimes it is better to call a code even if you have multiple doctors in the room simply because we'll need someone to get a bipap machine or mix up a drip or place another IV.

The truth is, I have only been at a handful of codes and none that have been incredibly acute. Recently though, in the CCU, one of our patients coded and we were there from the very start. In fact, it happened on rounds; the resident was first called away, then he pulled the fellow in, and then a minute later they poked their heads out and asked for more help. The attending strode in and started directing the code. Although running a code tends to be the job of a senior resident or fellow, it was entirely appropriate in this case and I immediately saw why. The patient had an uncertain diagnosis and the attending's mind worked so quickly. He not only went through ACLS by rote - another round of epinephrine, continue chest compressions, charge to 100 Joules - but talked aloud, allowing us some insight into his rapid and complex thought process. He immediately laid out the differential diagnosis, described the rhythm he saw on telemetry, and proceeded to complex therapies way beyond ACLS (we even tried inhaled nitrous oxide). He remained coolheaded throughout, asking for ideas, maintaining absolute control of this situation. A CCU patient crashing is terrifying because these patients have no reserve; there's no higher level of care; there's no room before they die. But at least in the CCU, the staff is trained for this level of complexity, the patient had abundant access, and he was already on drips we could titrate. He didn't make it, but that's something for the next post.