Anesthesiologists handling codes??

[calmike2001]

How common is it for anesthesiologists to handle codes in inpatient hospitals? I've been told that whenever patients crash and they call "code blue" that anesthesiologists are the physicians called to handle the patient and get him stabilized. Is this true? If its true, how often are anesthesiologists doing this? Thanks for the help!

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[sandman1]

Think about it; who deals with the "ABCs" on a 'daily basis' with the greatest expertise.

How common is it for anesthesiologists to handle codes in inpatient hospitals? I've been told that whenever patients crash and they call "code blue" that anesthesiologists are the physicians called to handle the patient and get him stabilized. Is this true? If its true, how often are anesthesiologists doing this? Thanks for the help!

 

[nmehta]

Think about it; who deals with the "ABCs" on a 'daily basis' with the greatest expertise.

At the hospital I rotated at, Anesthesia residents respond to every code blue. Their job is to get the airway secure, and then only do they start to respond to real reason for the code, whether it is necessity for a line/drugs, etc.

Pretty exciting if you ask me.

 

[powermd]

At my hospital anesthesia responds to every code and does airway management. Codes are run by the ICU resident (IM), and the "code team" consists of whoever is on call (ICU/CCU residents, float resident, on-call ward resident, cardio fellow (if available)). All on-call IM residents have code pagers, but interns do not. If you are floating (only the float interns are present overnight), you respond to codes when you hear them called overhead. I'm not sure how it is at Columbia, but I'd be interested to hear.

 

[Wahoowa]

At the hospital I am at, there is a code team that runs the floors, it is a group of IM residents, however, whoever gets there first runs the code. Anesthesia always responds because the anesthesiologist is the "lines and intubation expert".

In the ICU, whoever gets there first, usually a managing service resident/attending, runs the code. However, in the OR, as we all know, the anesthesiologist runs the codes.

 

[sandman1]

The most frightening thing I have ever witnessed was a group of IM residents running a code:

One morning when I was comming off of call, the alarm sounded in the hosptial and I rushed to a room in the wards on an upper floor - it took me about four minutes to get my box and get to the pt. When I arrived, I pushed my way past a group of IM residents and found the pt to be a woman in her mid forties laying in bed (non-responsive) with zero spontaneous respirations and her head tilted to one side.

I scanned the room and to my amazement I realized that one of the IM residents was thumbing through her chart while about three others were assisting him in his "chart review;" another IM resident was attempting to put in a PIV (in the foot), and another was fumbling around with a central line kit with NO idea what he was doing.

About 10 seconds after I hit the room, an RT showed up and we were able to bag her up on 100% Os....

I have nothing against IM folks at all. They tend to be extremely cerebral and are good in areas in which they are trained. I feel that it was simply because they don't use the ABCs with any meaningful frequency that what I walked into was a complete cluster ****.

In my opinion, the best folks to have handy on a code are Anesthesiology, ER and Gsurg docs (not ortho ). A good RT is also worth his/her weight in gold.... "Practice makes perfect!"

At the hospital I am at, there is a code team that runs the floors, it is a group of IM residents, however, whoever gets there first runs the code. Anesthesia always responds because the anesthesiologist is the "lines and intubation expert".

In the ICU, whoever gets there first, usually a managing service resident/attending, runs the code. However, in the OR, as we all know, the anesthesiologist runs the codes.

 

[Wahoowa]

The most frightening thing I have ever witnessed was a group of IM residents running a code:

One morning when I was comming off of call, the alarm sounded in the hosptial and I rushed to a room in the wards on an upper floor - it took me about four minutes to get my box and get to the pt. When I arrived, I pushed my way past a group of IM residents and found the pt to be a woman in her mid forties laying in bed (non-responsive) with zero spontaneous respirations and her head tilted to one side.

I scanned the room and to my amazement I realized that one of the IM residents was thumbing through her chart while about three others were assisting him in his "chart review;" another IM resident was attempting to put in a PIV (in the foot), and another was fumbling around with a central line kit with NO idea what he was doing.

About 10 seconds after I hit the room, an RT showed up and we were able to bag her up on 100% Os....

I have nothing against IM folks at all. They tend to be extremely cerebral and are good in areas in which they are trained. I feel that it was simply because they don't use the ABCs with any meaningful frequency that what I walked into was a complete cluster ****.

In my opinion, the best folks to have handy on a code are Anesthesiology, ER and Gsurg docs (not ortho ). A good RT is also worth his/her weight in gold.... "Practice makes perfect!"

I know what you mean. I had a similar experience as a third-year medical student.

 

[Skip Intro]

I know what you mean. I had a similar experience as a third-year medical student.

Ditto. And, it was during the big "power outage" last year in the Northeast, you know, when all the electricity in NYC went out. It was surreal.

At the hospital I'm currently rotating at, it's pretty much what others have said. The Anesthesia resident carries the code beeper and shows up pretty much to secure the airway and/or start additional lines. That's about it.

We had a joke in one hospital I used to work at years ago, too. If you urgently paged a RT for a vent and he/she didn't respond after several minutes (which was usually the case), all you had to do was call the code - whether warranted or not - and you'd get 3 or 4 of them to show-up in about 15 seconds.

-Skip

 

[HomerSimpson]

A frequent occurance in the institution where I trained was showing up to manage the airway after they had bloodied it beyond belief, after numerous attempts at laryngoscopy or whatever the hell they were doing. I also have nothing against IM docs but I do know that codes are no place to learn how to intubate a patient. scary

 

[UTSouthwestern]

Not typical of my institution, but the worst code I was involved in was when a medicine patient coded and an unknown number of intubations had been attempted by 7 medicine residents. It was an RT who had finally gotten exasperated and called the code. I gave the resident with the blade one last chance to intubate with my guidance and that was it. I looked, and after clearing the posterior pharynx of copious amounts of blood, of course the airway was grade 1 when I dropped in the tube past the torn epiglottis. When we ventilated the patient, a huge gush of blood fountained up and out the ETT and the senior medicine resident smirked and tried to pull the tube out thinking I had missed. I had to forcefully hold the tube in place and push his hand away (all the while covered in blood - please wear eye protection/face shields at ALL times, guys) and when the RT confirmed placement with a stethoscope, I asked how long the code had been going on before I arrived: 30 minutes.

This guy had aspirated at least a liter of his own blood and had no access, central or otherwise, had been obtained while he bled out from varices and everyone was futzing around with the tube that we could have easily gotten had the code been properly called early in the sequence of events.

 

[HomerSimpson]

It was at your institution dude, although it was under the old chairman. So many things have changed. When I was there they actually had to change policy because they had a couple of patient deaths resulting from failed intubation, from cavalier IM residents who got in over their heads. As of 2002 at least they were required (by a change in policy)to have us at least within earshot before trying. I also have lots of stories about this subject. It is amazing to me that some of these IM residents were not interested in the care and welfare of the patient. They seemed more upset that they didn't get the procedure. Pretty sad I think. Am I bitter? yeah a little, because everytime I went up for a code I had to figuratively and sometimes literally fight for the patient's well-being. It got to the point at the end of my residency that I would move the person trying the intubation out of the way physically if necessary get the tube in and start at least one good peripheral or central line before departing. I'm sure the new chairman has been working with IM on this subject, but the old chair was a total wussy and caved to whatever they(any other service) wanted. Sorry about the rant.

 

[Eidolon6]

Anesthesia rarely responds to codes where I am. When they do, the patient is either intubated already or being bag masked succesfully so they can be transported to the ICU for definitive care where a more orderly intubation can take place. The "belief" that securing the airway in a code is sticking a tube down the patient's throat is a bit bunk. In inexperienced hands (all specialties included here) you are libel to gag the patient, have them throw up, aspirate, and if they survive the initial resuscitation, have a lengthy Mendelsohn syndrome or aspiration pneumonia to look forward to. A tight seal with a bag mask will get you a long ways. In my training program, I would trust most third year IM residents to handle the code and if driven to, intubate...the surgeons, ER docs and gassers respect this as well. My suspicion is that a number of you are speaking of singular experiences or experiences at locations with less stellar IM resident support. I can't really see any justification of the comment "The IM folks are really smart and cerebral...but don't use the ABC's enough to employ them." Baloney. You can't make that statement globally because training depth and quality varies so much from place to place. One of the failings at many residency programs in IM is that airway management and the code are not very aggressively taught parts of the curriculum. This comes from the expectation that the ICU rotation should teach all this, which is BS. Practice make perfect. I do know (as do a lot of my colleagues) how to assess and airway and if need be, call the anaesthesia on call if its beyond my skill level. That's the art of medicine...knowing when NOT to do something.

 

[Skip Intro]

A frequent occurance in the institution where I trained was showing up to manage the airway after they had bloodied it beyond belief, after numerous attempts at laryngoscopy or whatever the hell they were doing. I also have nothing against IM docs but I do know that codes are no place to learn how to intubate a patient. scary

I always hate how the IM docs at the hospital I've done most of my clerkships at just push like 4mg of Ativan (e.g., for an impending respiratory failure) and then try to jam the Mac down the patient's throat and then shove the ET in. The patient, meanwhile, is not amnestic and is gagging through the process, all while the other residents/students/nurses/whomever-is-handy are practically standing on the patient's arms to keep them from guarding. They do this routinely in the ER and on the floors because hospital policy is not to use paralytics unless you are anesthesia trained (which, I guess, makes sense). But, the patients really suffer. At least push a big, fat dose of Versed or propofol (which aren't restricted) if they aren't contraindicated (especially the latter) and you know you can bag the patient and have a reasonably good airway before you drop the tube.

-Skip

 

[trapper john]

At our hospital, medicine is supposed to run the codes. Anesthesia gets paged to every code, and our job is to secure the airway and do lines, though the surgery residents usually want to do those. I've never seen an IM resident attempt to intubate a patient without anesthesia there, agreeing to and supervising it. And even that is very rare.

Usually after the tube is in, I leave, but if it's the beginning of the year and the "supervising" IM resident is just out of internship, I may hang for a few minutes.

The worst code I ever saw was in the "mother/baby" unit. A woman who had given birth a few hours before became obtunded. A first year OB resident was in there absolutely terrified, looking like she had no idea what to do. Worse, the nurses on this unit had never had a code there before. The anesthesia resident on OB call and I had to run the code until general surgery arrived and took over. Just a nightmare. We were pretty sure it was a PE, but the patient had also been bleeding post partum. Whatever it was,the RT couldn't mask ventilate the patient, and for that matter neither could I, so I just put in a MAC 3, and luckily it was a grade one airway. We got her stabilized, and on the way to ICU, she woke up and became combative, so I don't know what the etiology was.

 

[UTSouthwestern]

HomerSimpson, check your private messages.

Johnston's 4 years have put his mark on this program in a big way. The changes in faculty also reflect his impact.

 

[Tenesma]

i think our role is and should be airway management at codes.... the IM/EM/Surgery people need to learn how to run codes, so we can't be stealing that from them. However, it is entirely appropriate for us to redirect them, guide them or take over if need be....

Eidolon: Quote: The "belief" that securing the airway in a code is sticking a tube down the patient's throat is a bit bunk... Actually, if you read the ACLS guidelines and the literature on the subject, the bag-valve-mask is considered to be on par with endotracheal intubation for "short" transport times, primarily in the field setting, due to the high rate of undetected esophageal intubations. In the hospital setting, securing the airway with a tube down the throat is bunk (a bit of tongue in cheek here), as you are supposed to secure the airway with the tube down the trachea.... Any patient receiving CPR needs to be intubated for two reasons: 1) decreases incidence of aspiration from all the pushing on the chest/abdomen 2) increases success of ventilation of patient while people are pushing on the chest.

I don't care how good your program is, I have never, ever known of any internal medicine person who considers themselves to be an expert at laryngoscopy, and therefore should not even attempt it (again the high rate of undetected esophageal intubations)... The IM folk should stick with bag-valve-masking... actually the RTs should be doing that cause the IM folk don't know how to do it properly...

When i was a resident, the IM residents would always ask if it was okay if they tried to intubated under my guidance... My response to that was to recommend to spend one of their electives in Anesthesia so that they could learn how to intubate under more ideal circumstances.... and not practice (and screw up) an airway in somebody who is on the brink of death - that is when experienced hands should come in to play (just like the ATLS recommendations say: "the most experienced laryngoscopists available is to secure the airway")

 

[UTSouthwestern]

Unfortunately, quite a few programs do not allow their IM residents to do anesthesia electives. Three IM residents this year thus far have approached us to do electives, thinking that any difficulty scheduling one was being caused by our department. A quick check with our PD showed that we have never blocked that from happening and would treat them like the general surgery residents who rotate through our program for one month in their internships, yet none have been able to get the IM department to agree to it. Hence the arrangement the chief residents are having to make to give the IM guys a learning environment for airway management.

 

[Skip Intro]

Unfortunately, quite a few programs do not allow their IM residents to do anesthesia electives. Three IM residents this year thus far have approached us to do electives, thinking that any difficulty scheduling one was being caused by our department. A quick check with our PD showed that we have never blocked that from happening and would treat them like the general surgery residents who rotate through our program for one month in their internships, yet none have been able to get the IM department to agree to it. Hence the arrangement the chief residents are having to make to give the IM guys a learning environment for airway management.

You know, this is sad. I don't know if the root cause is territorialism, a institutional political game that can run amok in hospitals, or just simply lack of interest. Even a couple of weeks would probably help, especially if they are "running" the codes on the floor.

Right now, there is a Pediatric EM fellow who happens to be with us during my current anesthesia rotation. I've found that, not only is he an awesome guy who is really open to learning (mainly about pediatric airway management), but he's also a great source of teaching for tidbits and tricks that he's picked-up along the way.

It's sad that IM residents don't get a chance to rotate through the OR with the anesthesia crew. Both services are missing out.

-Skip

 

[sandman1]

Laryngoscopy is truly an art. If those who don't do many don't believe this, they should try to tube a 400lb pt with a large neck, no chin, and a small mouth... while the pt desats (and those big ones like to) at a rate of speed that would make Jeff Gordon blush. If someone thinks "well, I can just bag-mask a crashing pt because that's easy," then they are dead wrong! Any other gas folks on here know exactly what I mean.

I'm not sure what the solution is to be honest. When I was towards the end of my CA-1 year and felt I had a 'decent' amount of intubations under my belt, I would actually seek-out any IM residents rotating on service to make sure that they got some experience in intubating. I would also do this with paramedic students. Sometimes I would get an attending on those days who was a little selfish about letting one of his/her residents give up intubations, but I knew it was for a "greater good." I knew that I would be doing these, daily, for years, and I knew that those folks rotating through needed to get the 'biggest bang for their buck' in order to make the experience meaningful and 'useful' later.

I also have been on codes where things were urgent, but perhaps not emergent, and I took pride and pleasure in walking some IM residents through an intubation and central line placement (see one, do one, teach one). This is beacause I know that there will be a time one day when they will be in a situation where they may be alone in a code. They will (hopefully) reflect on a positive experience that I was able to help facilitate, and hopefully apply what they learned.

I'm sure you all remember the first time some Gsurg resident let you put in a CT as an intern and you thought, "Wow, that resident was pretty alright." And now, although not a surgeon, you have picked up enough experience putting in CTs where you can do them with your eyes closed. Hey, surgeons aren't always in the unit when you get a hemodynamically unstable pneumo - right?

I know what some of you mean by "pushing them asside" but I'm not sure that this is always the right way to approach things - depending on the situation at hand.

"A Greater Good".... I hope you all agree.

 

[Gator05]

Tenesma,

Questions about your CPR requirements. Pretty sure ACLS mentions that it is ok to proceed with CPR via a non-secured airway as long as pauses are made between compressions for breathes. As you mentioned, with a secured airway, simultaneous compressions/breaths are allowed. Did I miss something in our ACLS courses???

Next, why not instruct the IM residents on the Combitube? Yes, it's not perfect, far from it perhaps, but was designed for poorly-trained providers.

 

[Skip Intro]

Tenesma,

Questions about your CPR requirements. Pretty sure ACLS mentions that it is ok to proceed with CPR via a non-secured airway as long as pauses are made between compressions for breathes. As you mentioned, with a secured airway, simultaneous compressions/breaths are allowed. Did I miss something in our ACLS courses???

Next, why not instruct the IM residents on the Combitube? Yes, it's not perfect, far from it perhaps, but was designed for poorly-trained providers.

This is getting WAY off topic, but last week I was working a case with the chief resident and one of the attendings. It was a 14-year-old girl who was having a congenital hernia repair. The attending is a big airway person, and she always brings in her "bag of tricks" to the OR. It's great, because as a student I get to see a lot of newer technologies that other students (and maybe even residents) don't always get to see. Anyway...

On the case, we used a King LT instead of an LMA. We discussed the relative advantages/disadvantages, etc., but the thing stayed in for the full 45 minutes that the patient was anesthetized.

Here's what it looks like:

Now, something like this could be a good compromise for code teams. Anyone?

-Skip

 

[Audrey Hepburn]

....but someone earlier wrote about the art of laryngoscopy. My question to all you anesthesiologists (especially the "smaller" ones) - does this get easier? I'm a competent student, and have attempted about 20-30 intubations as of yet, probably successful at about 50-60% I think for a while I wasn't getting the MAC down far enough, but my lord, you get a real fatty in for a gastrc bypass, or some ex-linebacker with a huge head and thick neck, and I feel like I can't "lift" the head enough to get a good view of the cords. VERY frustrating. I know some anesth. women md's develop great techniques to get around this problem - what do you all think?

Thanks,
-AH

 

[jwk]

....but someone earlier wrote about the art of laryngoscopy. My question to all you anesthesiologists (especially the "smaller" ones) - does this get easier? I'm a competent student, and have attempted about 20-30 intubations as of yet, probably successful at about 50-60% I think for a while I wasn't getting the MAC down far enough, but my lord, you get a real fatty in for a gastrc bypass, or some ex-linebacker with a huge head and thick neck, and I feel like I can't "lift" the head enough to get a good view of the cords. VERY frustrating. I know some anesth. women md's develop great techniques to get around this problem - what do you all think?

Thanks,
-AH

I think you need to get your technique down first on "normal" patients before you even attempt some difficult ones. 20-30 isn't near enough, especially if you're still missing that many.