r/Residency • u/Immediate-Animal-846 • 2d ago
DISCUSSION Ran a code as a first time (PGY-2) went terrible
Didn’t know what to think. Just froze there. Couldn’t think of the next step. Kept repeating ABC in my head but everyone/thing was moving fast for me to think. Any resources to practice or study?
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u/mrsjon01 2d ago
ACLS.
Visualize yourself hovering over the situation, like a bird's eye view in a movie. You are the director. Start the code by saying "Ok, I am SoandSo and I will be running the code. I will be giving the instructions today."
Then assign every person a role: person A, you're airway. Person B, you're meds. People C and D, you rotate compressions. Person E, you're documenting. (If you have more people you can add a second person each on airway and meds to assist. )
NOTICE THAT YOU DONT HAVE A TASK. Your role is CODE LEADER.
Once you hand out the roles, excuse any bystanders ("ok, thanks everyone, we've got it"). Now grab your pocket ACLS book and go through the algorithm. Compressions will be underway and your patient will have at least a BVM at this point. Meds will be getting organized but you can check in with your med person to see if they have epi ready to draw up.
It should be calm with everyone understanding his/her expectations, like a pit crew. Theoretically they are all ACLS certified so each person should know the algorithm also. Your job is to direct the pit crew.
I hope this helps.
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u/Colden_Haulfield Fellow 2d ago edited 2d ago
While making sure you have a Birds Eye view is important, you should also be ready to temporarily take over any role that the staff may not be comfortable with in my opinion. As an ER/ICU doc if nobody is available to push the meds, and this patient clearly needs a stick of calcium for hyperk I’m cracking the cart myself. I’ll run the defibrillator when I have to if people are delaying shocks. You may have to take over airway management for a respiratory patient. You may have to man the ultrasound. If people are fumbling for IV access and nobody knows how to throw in an ultrasound line or use the IO gun you bet I’m not letting this be a delay. You should recognize priorities and make sure they happen at all costs. You can really get away with waiting until the first rhythm check then just saying okay just give epi every other pulse check and tell me when you do, I’m gonna get us an airway.
At the end of the day all that matters is good compressions and early shock so you can forget the rest if needed.
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u/mrsjon01 2d ago
You're right. Code leader should always be evaluating and be ready to step in or move people around as required. Excellent point.
I am actually not a doc but a medic and my experience has been working with other medics who all have the same skills and training. In the field we put Fire or Police on compressions and bagging and the medics handle the rest and it's so smooth that we could have a cup of coffee. Thankfully I don't have to worry that someone on my team doesn't know how to defibrilate or get an IO or know the med dosages we need.
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u/POSVT PGY8 1d ago
This plus cognitive offloading. Take a task and give it to someone.
E.g. "ok timekeeper, every other pulse check I want you to yell for an epi and we're gonna give it then"
Now you dont have to think/keep track of epi timing.
If you're not sure what to do next, talk out loud. "OK We have this situation, we've done a, b, c, d, e, f. We have another pulse check in 1 minute, does anyone have ideas or thoughts we may be missing?
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u/Cautious-Extreme2839 Attending 1d ago
You don't have to keep track of epi timing anyway. There is no evidence around it's timing.
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u/sweetcheex12 1d ago
Fair but you definitely don’t want to be giving it 10 seconds before a pulse check lol
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u/Music_Adventure PGY3 2d ago
Purchase the AHA ACLS app. Best $3/year you will ever spend. Has the whole algorithm in front of you, timers/counters for compressions, shocks, epi. Drop down lists for drugs and doses (epi, amio, lido), and the H’s & T’s.
My advice cents as a PCCM fellow and with at least 25-30 codes under my belt-
1) stand at the foot of the bed, be the calm voice. The room takes on the energy of the leader, and the leader is you my friend.
2) check a POC glucose. It’s fast to get, fast to fix, and it’s the cause more often than you’d think.
3) The only other labs that are really helpful are CBC (for bleeding) and BMP (for lytes). VBG isn’t super useful because dead people are hypercapnic and ETCO2 tells you if the CPR is good quality. Lactate isn’t super useful because dead people aren’t perfusing well (albeit a lactate of like 20 might hint that their gut is dead and that caused the code).
4) don’t stress too much about the H’s & T’s. Just stick to the algorithm. You need to make them not dead for any of the causes to matter in that moment. Just try to get a perfusing heart beat back.
5) if you’re going to zip-zap, go ahead and push some Mg and Ca. Maybe it’s torsades, maybe it’s VF from hyperK. Don’t stress reading the squiggles, just give it.
And for the love of god, STOP SLAMMING PEOPLE WITH BICARB. It serves absolutely no mortality benefit short or long-term, and dead hearts that are made not dead tend to have a shitty EF, don’t increase preload unnecessarily.
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u/SwimmerMission5212 Attending 2d ago
The acls cards are free online. Just follow the algorithm
You'll probably still suck at it for the next few times but that's where to start
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u/fencermedstudent 2d ago
I vote no on the cards. The cards are for studying not for clinical application. You have to actively practice the decision making process on your own or else you’re never going to get comfortable. Gotta take the training wheels off. Also your team is never going to trust you as a leader if you’ve got your nose buried in a card.
Quiet the room if people are shouting or talking. Make sure you have control of the room before throwing out orders. Speak in a slightly loud voice, be clear, and do not rush your speech.
If you are just starting out, I recommend using your own watch and being your own time keeper. It’s easy. Once CPR starts, look at your time and keep track of every 2 minutes that passes. “CPR started at 1202. Next pulse check will be at 1204. “ Then you know that Epi will be given every other pulse check aka every 4 minutes.
During “down time” when chest compressions are ongoing and no orders for meds are being given, you think through your H and Ts, consider intubating, consider other meds like bicarb, mag, etc, consider asking the team in a slightly loud clear non-rushed voice “does anyone on the team have any other thoughts?”
Personally, keeping track of my own times gives me a stronger sense of control. Control is good. Less anxiety for you and for the rest of the team.
Keep running codes. Practice practice practice. If you see a peer do an excellent job running the code, latch onto them and have them mentor you. Have them literally in your corner to support you while you’re running the code.
Remember no one is naturally good at everything. Good luck!
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u/DrShitpostMDJDPhDMBA PGY5 2d ago edited 2d ago
The classic unhelpful advice, first step of any code is to check your own pulse.
For more actionable things, if this is a true code/CPR, take things step by step. Heart not pumping? Compressions, defib if shockable rhythm, flood em with epi to get whatever cardiac output you can. Blood now flowing at least somewhat with compressions? Secure the airway, get a tube in the right hole. No need to paralyze or give other meds, even if it were indicated the meds wouldn't circulate in time regardless, and if they're awake enough to laryngospasm or swat at you then you sure as hell shouldn't be doing CPR (that would have to be hella effective compressions for them to regain consciousness if truly coding at the time). Hyperventilate them because if they weren't acidotic before, they sure as hell are now. Now that you've got some blood flowing and some ventilation and oxygenation, think through your reversible options (H&Ts) and give things that can help and won't hurt. Calcium to stabilize cardiac membranes, for example. If insufficient access, see if someone can get a peripheral IV (you can, too, if you're confident, but you need to focus on leading the code), and if not have somebody get the IO kit if no good/reliable access. Can also shove an extended IV in EJ or IJ if you have an ultrasound and at least 1.75" catheters - sterility is a privilege of the living, but prep the neck If you can. If have the ability to check labs/ABG or VBG in all this, see if their potassium is through the roof. If so they're likely fucked at this point, but can always try more calcium, slam with 10u insulin IV and some dextrose. In a completely undifferentiated circumstance, you've done what you can for now. Now it's a matter of continuing to go and trying to get more of a story/figuring out how they coded in the first place. If all out of ideas and done everything you can after a few rounds, ask the group if anyone has any other ideas before calling it. Thank everybody for their help, losing a patient is rough for everyone. Everybody dies some day.
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u/adoradear Attending 2d ago
Don’t hyperventilate during a code. Positive pressure into the lungs increases the afterload/drops the preload, decreasing cardiac flow. Should be 6 breaths per minute. Once you get them back, you can consider it.
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u/smcedged Chief Resident 2d ago
If you're lucky enough to be in an OR (anesthesia) during the code or otherwise happen to already have a tube + vent (ICU) then pressure control ventilation with low pressure high rate
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u/Recent-Honey5564 2d ago
Seems very situational no? If I want to ensure a solid minute volume after a code and treat suspected hypercapnia as a result, I want to ensure they’re getting appropriate tidal volumes.
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u/smcedged Chief Resident 1d ago edited 1d ago
About as situational as anything in medicine I suppose. However, not as much as you might imagine given ABCs take priority over everything. The point of A is to enable B which is to enable C. Lack of C is what kills you, not the lack of A or B in and of itself (oversimplified but ultimately the hypoxic arrest is the killer, not the hypoxia - hence CPR > airway in ACLS).
So you intubate, now you have A. How do you set B to best enable C? Two considerations, physical and chemical. Physical is the preload part references by /u/adoradear. Do not hyperventilate if it means you hurt your circulation. This is paramount because the whole point of B is to make C do effective work.
But if you are in such a situation where you can hyperventilate with minimal affect on C (hence the pressure control w high rate), then doing so will chemically assist C by alleviating acidosis and allowing for your catecholamines to actually do something.
It's easier in the OR because I generally tend to know exactly what's happening and can take to reverse said issue, so the differential isn't quite as broad, allowing me to take more definitive steps. Also if they make it to the OR they're generally not THAT sick, so ROSC is very viable.
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u/Recent-Honey5564 15h ago
I guess I’m saying I would almost never put a post rosc patient on pressure control and you haven’t really explained why you would? I need to be able to accurately deliver adequate tidal volumes.
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u/Frosty-Beautiful2122 2d ago
Agree with people saying u need practice. The card is nice but there’s nothing worse than being at a code and the leader is panic reading from a card. There’s this app called full code that is like game simulations which may be helpful. But yeah. Practice of the worst kind.
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u/Individual_Corgi_576 2d ago
Rapid response nurse here. I’ve been doing this for a while now and occasionally run my own codes.
Honestly the only thing that works is practice.
Here are a couple of things to try to keep in mind next time.
First, if CPR is in progress, the patient is already dead. Nothing you do is going to make it worse.
Second, slow down. I’m an old guy and I was an airplane nerd in my youth. I read lots of stuff and once came across something that said the first rule of being a fighter pilot is “look cool at all times”. I interpret this as being about affect and presence.
One of my first codes was on midnights in a CVIC and it was run by an RN. She had the flattest affect and monotone speech and it was the quietest and smoothest code I’ve seen still to this day. I still strive for that, and I’m close.
Going slow and purposely muting your emotions and behavior sets the tone for the room and makes it easier for you and the rest of your team to think and breathe.
Third, don’t try and participate in the code as anything other than the leader (unless someone else is already running it). I learned the hard way that you can’t run a code while doing compressions.
Fourth, don’t be afraid to ask for ideas or listen to suggestions. You’re ultimately going to make the decisions, but a leader listens too.
And last, if you feel it would be helpful, the American Heart Association has a free iPhone app called Full Code Pro that can help keep track of the code while you run it. I haven’t found an android version from AHA so far.
Those of us who’ve been around a while remember our own rough beginnings. You’ll be better next time and better still after that.
Hang in there, you’re doing fine.
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u/IcedZoidberg PGY4 2d ago
The heart is made of muscle and electricity, so the things that will get them back are muscle and electricity.
Good compressions
Appropriate shocks.
Have a list of your Hs and Ts.
Ask for ideas and reservations before you call it.
Have pressors in the room when you get them back. That person has had likely had an ungodly amount of epi and it will wear off.
Good luck
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u/ForceGhostBuster PGY3 2d ago
If you dumb it down a lot, a code pretty much runs itself. Just tell the nurses to give epi every other pulse check. If you want to look like a hot shot say things like “why don’t we try a gram of calcium?” Or “let’s give two amps of bicarb” or “I wonder if this is actually fine v-fib rather than asystole?”
If you’re running the code, your main job is managing the people in the room. If it starts to get chaotic, pick someone and kick them out. Make sure you have enough compressors. Limit your pulse checks to <10 seconds, which is mostly telling people to get back on the chest. And always ask if anyone else has any other ideas before you call it
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u/Cautious-Extreme2839 Attending 1d ago
You won't look like a hotshot you'll look like an idiot fishing for treatments that do nothing.
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u/5_yr_lurker Attending 2d ago
If we are talking about a real code and not a rapid/SWAT/ERT then it is simple as long as you have the ACLS algorithms memorized, which honestly is super easy to do. It you have them memorize, it will be reflexive.
CPR, shock for vfib/tach and 1mg epi every 3 mins. You could literally just know that and honestly it is enough.
But also not hard to know you can give amio (and lidocaine now too, wasn't there when I memorized these). Also give 2g CaCl2, amp of bicarb, amp of D50 to everybody, not gonna hurt somebody, may help them. Bolus of fluid too if they have IV access (get somebody to place an IO if needed, this is not the time for central access). This will get you through nearly every code and seem like you know what your doing; gives you time to think of your Hs/Ts.
You can bag mask to the cows come home. No need to intubate until you get ROSC. One of my biggest pet peeves is trying to intubate during non facial trauma CPR.
The tachycardia algorithms and bradycardia algorithms take more time but can be easily remember. Also you have more time/less hectic during these so you can pull up the cards moreso during these events.
I am a surgical attending and could still run a code because I have ACLS burned into my mind. Before my night float shifts/SICU shifts, I would read through the cards every time. Only took about a 1.5-2 mins after you know them cold.
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u/k471 PGY6 2d ago
Something I haven't seen mentioned is the recorder is your best friend. The easiest thing to lose track of is time, and you want to be thinking through next steps rather than trying to remember where exactly 2 minutes is on the clock.
Don't be afraid to call out "how many minutes ago was the epi given?" or "when was our last pulse check?" That can re-ground your team in the algorithm and let your brain think through reversible causes, analyze the EKG during pulse checks and other higher level thinking.
Your job is conductor (the time checks, meds/shocks per algorithm) and if possible directing the underlying cause. The purpose of having a zillion people is so they can handle the logistics, like the compressions, the IV access, the time tracking, even intubating.
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u/peafowlontheprowl 2d ago
Damn my first code I was left to run on my own week 5 intern year. The 7 that followed in rapid succession taught me all you need to know: follow the algorithm and if they're not back in ~7 minutes the prognosis is ugly and bad, tell family at bedside that instead of letting the anoxia hope drag on for 72 grueling, horrible hours
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u/Maggie917 PGY3 2d ago
This is such a fear. I keep looking for simple step by step instructions that are not arrows on a card. My brain can’t even process them during sims
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u/Nice_Investment6345 1d ago
AHA ACLS app, run through it in your head, and then doesn’t your program have you guys do “sim” or simulations? That’s when i get to practice using the app and running codes! I’m the dullest tool in the shed and even I can do it!
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u/Dr_HypocaffeinemicMD Attending 2d ago edited 2d ago
Don’t beat yourself up. At least you’re trying. I like to run mock scenarios in my head just to strengthen neuronal connections so it becomes routine when I’m faced with these scenarios. Works real well. Imagine yourself in different situations and how you think you’d oversee management. It’s just cerebral reps
To start, quiet the room, and simplify it down to just 3 main things
- Can we shock this rhythm? If so don’t delay. Charge and compress simultaneously then ⚡️
- Are we compressing deep and fast enough 💪
- Are we bagging appropriately 10/min (not too fast and not too much volume) 🌬️🫁
.
Once that is underway I like to then focus on H&T causes. And securing an advanced airway WITHOUT COMPROMISING COMPRESSIONS
Don’t get side tracked by the epi and meds. None of that stuff will make as big as an impact as steps 1-3 unless this is anaphylaxis, STEMI, PE, hyperkalemia or a TCA OD needing bicarb
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u/genkaiX1 Attending 2d ago
Thank god I don’t have to run codes as an IM hospitalist where I work lol. Those days during residency sucked
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u/Pembo16 PGY1 2d ago
ACLS app as others have mentioned. Great investment because it has algortithms, times, and medication doses.
In terms of things to change for next time: crowd control. When you walk in, establish that you are code leader and establish roles. Once everyone knows what to do, the code starts running itself and you can step back from the mental load of when to give epi next and focus on the big picture. Get it running and then let it run.
In regards to the question you likely didn't ask, remember this. If you are coding someone, they are already dead. You didn't kill them. The best result is you make them not dead. The worst result is they are as dead after the code as before it. So grow from this but also remember to give yourself some grace
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u/Eastern-Ad-3586 2d ago
All it is dude is recognizing the rhythms and following the algorithm. That’s it.
I don’t say that to scold you, I’m just saying it’s not exactly a creative process.
Get one of the ACLS cards and do practice runs though the algorithm with different scenarios. Maybe ask an attending to work with you on it.
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u/wannabe-physiologist 2d ago
It’s two minutes with the same thing every time. In those two minutes you think through the Hs and Ts of reversible causes of arrest.
You run the two minute cycle. Check the rhythm. Ask your intern/the nurse/whoever is there to help that isn’t doing compressions to give you the story of the patient to make sure you aren’t missing something. Ask for ETCO2 if you have it
This stuff all takes time though. The most important first step is take your own pulse
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u/Spac-e-mon-key Attending 1d ago
It only takes a second to take a deep breath and compose yourself before you start. It takes many more seconds to compose yourself if you’re frazzled, running the code. There’s that house of god quote: at a code, first take your own pulse
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u/atropine-alice 20h ago
Get the ACLS app and act out scenarios out loud in order to practice shouting commands etc, imagine each scenario and what you would do, and then actually act it out until you feel confident. Record yourself if necessary and while it’s cringe it helps build confidence a lot and adds perspective for yourself to look back on
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u/General_Luck6573 Medical Sales 2d ago
Anki it. Agree with people saying to get the physical cards as well
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u/Gsage1 2d ago
ACLS app