Field Notes: A Code Blue to remember.

Why we train.

Several months ago, I was working in the ER when a “Code Blue” was called overhead that I won’t soon forget. The patient never had a chance…and, I promise you, that was okay.

What a “Code Blue” announcement really means.

They don’t actually announce a Code Blue overhead if someone dies in the ER and needs immediate CPR. If someone is that sick in the ER, we either know it when they arrive or are alerted to that fact by whoever notices a patient’s rapid deterioration—usually a nurse, technician, family member, or a blaring alarm from a patient monitor.

But when a Code Blue is called on the overhead system, it means someone needs help outside of the ER. Depending on the situation, if a Code Blue announcement might mean I need to leave the department and go to a patient. It depends on the details. That’s all been worked out in advance.

The meaning of a Code Blue also varies tremendously. It could mean someone’s heart has stopped and they need CPR. Or it could mean that a patient had an allergic reaction to intravenous contrast while getting a CT scan, and we need to administer epinephrine in the radiology suite. Alternatively, a Code Blue could merely mean that a patient fell down; in reality, they're probably perfectly fine, but because it happened in the hospital lobby, for example, the only way for the person get “official” medical attention is to activate the same emergency response system that calls in the same cavalry that would be needed to give CPR and advanced life support. It’s a strange system—the same overhead PA announcement and resources are marshaled for a death and a minor fall. So, when I leave the ER for a Code Blue, I never know what I’m going to get until I’ve reached the patient.

A brisk trip down the street.

In this case, the words over the loudspeaker were “Code Blue, Code Blue, 15 Francis Street, ED code team activated.”

ED code team. That’s me. Or was it my colleague in the other part of the ER? The workflow is always changing, so I always have to check. In this case, it was my responsibility. That meant getting over to 15 Francis Street STAT.

The ER is located at 75 Francis Street, but you can get to 15 Francis Street via a flight of stairs and a hallway that is so long (and has so many conduits and doors) that it’s literally called The Pike—named after the Massachusetts turnpike!

Getting to 15 Francis from the ER is a lot of steps. While the buildings are connected, the distance from 75 Francis to 15 Francis is the equivalent of 1/2 a city block. That meant an extra hustle to reach the patient quickly. If we moseyed at a snail’s pace, it could’ve taken many minutes. A brisk little jog was in order.

“Where’s the patient?” I asked someone in the brigade of ER responders I was walking down the Pike with.

“Someone said the bathroom.”

“Ah, hell,” I said. I figured this meant that someone, an outpatient, a visitor, or even a fellow employee, had overdosed in a single-occupancy restroom. It wouldn’t be the first time.

As I got closer to the code, I could see the typical cluster of people assembled around the action, but not doing much. I edged my way past the outer perimeter and got closer. The bathroom door was being held open. I could see one of my colleagues moving up and down—she was giving chest compressions.

“Well, I don’t think the patient is going to survive, I said”

The punchline.

The patient receiving chest compressions in the bathroom next to the lobby of 15 Francis street was a mannequin. A dummy. A bunch of plastic and cloth. Not a real person.

This was a “mock” code—a simulation designed to help us practice and to help the organizers identify weaknesses in our response system. One of my colleagues was there observing.

So, the patient wasn’t going to survive—nor had “he” ever been alive. The point of the mock code was not to see if we were good enough to bring the “patient's” heartbeat back. The point was to see how we can improve our system.

As Dr. Paul Jansson, the physician who organized the exercise, put it to me, “the point of these scenarios is to manage the unknown in an unfamiliar environment.” Most of what we learned had nothing to do with medicine and everything to do with logistics.

The medicine is “easy.” Everything else is not.

In reality, whether a person survives CPR has little to do with how brilliant the team leader or team members are. It comes down to the patient’s overall condition (do they have one problem or ten?) and how well teams perform a few simple tasks.

When I arrived, there was already a senior resident there “running” the code. She had beaten me to 15 Francis and assumed control of the situation. Technically my presence at the code superseded her command, but I wanted her to stay in charge—not a problem for this particular resident, who was both entirely competent and sufficiently confident. So I took on the role of “consultant.”

Of course the Hawthorne Effect was in play here. I knew we were being watched. So, I focused on a few critical actions. I wanted the senior resident to tell me whether we had already done some simple things that sometimes get overlooked, and which can save a life:

1. Check the patient’s glucose level with a quick pinprick test. If the glucose is too low, it’s possible that something as simple as sugar might bring the patient back.

2. Give naloxone (Narcan), the highly effective antidote that will reverse any opioid overdose, if given soon enough.

3. Minimize pauses in chest compressions to check for the return of the heartbeat. In my view, this is the most critical thing in any code. Even seasoned teams routinely take way too much time doing this and every second without chest compressions increases the risk of permanent brain damage, even if the team does manage to bring the patient’s heartbeat back. So, my focus is often on this. In fact, if we are giving good chest compressions, we have much more time to think everything else through carefully.

All of that had happened.

An old debate…

Obviously the goal of CPR is to bring the patient back from the dead. So, my goal was to minimize pauses in chest compressions and do all the advanced life support we could possibly do until the dummy either came back to life (it can “do that”) or until Dr. Jansson told us to stop the exercise. If we needed to place a breathing tube, we could do that. If we needed to give more medications, we could do that. The fact that we were located in a bathroom did not change that, in my view. My thinking was “Ignore the setting—do the simple things right, just like we would downstairs in the ER.”

The senior resident had a different perspective. I don’t know whether she knew the specific purpose of the exercise (I did not), but she was very focused on getting our patient out of that bathroom and to the ER.

This debate has a name: “Stay and play” versus “scoop and run”? Usually this debate refers to choices that emergency medical service teams (the folks who show up when you call 911) have to make.

My argument for staying was that transport can harm the patient. Getting the patient off the floor and onto a stretcher can take more than a few seconds. That “downtime” without chest compressions can be a killer. It’s also very hard to administer effective chest compressions while a patient is being rolled down a hallway.

The senior resident’s argument was that if we got the patient to the ER, he might be an ECMO candidate (a lung bypass procedure that is appropriate for some younger patients with cardiac arrest).

That was a good enough argument for me (though partly because I thought she might be correctly “gaming” the exercise. Dr. Jansson, the doc who organized this mock code, is an ICU physician who is interested in fancy things like ECMO. So maybe that was the agenda of this code, I thought.)

So, I went with the senior resident’s preference and we proceeded to transport the patient back to 75 Francis Street. I figured that once we started that trip, Dr. Jansson would announce that we could stop. He didn’t.

It wasn’t until we reached the ER that the exercise concluded and we all debriefed.

What we learned.

From the time the Code Blue was first called until we reached the ER with the “patient”, 24 minutes had elapsed. That was considered very fast, considering the distance and complexity of the situation. (I had the senior resident to thank for that. I would have “stayed and played” for longer, but for her nudge to get things moving to the ER). We learned that the point of this particular mock code had indeed been to measure how long it took us to get that body from the bathroom floor at 15 Francis to the ER, and to identify trouble spots in that process. We had done well.

Some key things were learned.

1. Sometimes things fall off of the “chuck wagon”—the pre-packed stretcher for Code Blues that has oxygen tanks, emergency medications, cardiac monitors, defibrillator pads, basic airway management tools. That slows down transport.

2. Teams are not always sure who is supposed to run these codes.

3. Not everyone knows where to go. While we are given a location overhead, and security escorts us to the code, if you miss the initial parade, you might have trouble finding the code.

4. Hospital security carries Narcan, which is something I did not know, and which is great!

The debate rages on.

In writing this, I again chatted with my colleague Dr. Paul Jansson. We briefly debated “scoop and run” versus “stay and play.” Like the senior resident who ran the show, Paul also leans towards scoop and run, in part because running a code in a bathroom seems a little, well, suboptimal. While true, I pointed out that an inconvenient locale does not inherently impede critical actions. We can give first-rate CPR and advanced life support with just a few items (which are in the chuck wagon), good leadership and well-trained teams. In this case, I’m glad the senior resident nudged me towards getting the mannequin down to the ER. In hindsight, I’m proud that we got that big hunk of plastic and polyester down to the department so quickly!

More than that, I’m glad that we did this exercise. It was very worthwhile. It identified a few places where we could do even better than we did—and which could help a real patient in the future. That’s why we train.

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Thanks to Dr. Paul Jansson for organizing a superb mock code and for reminding me of some of the details!

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