Decoding the Code

My first patient coded from a respiratory arrest when I was six months out of school. Code Blue. No amount of BLS training can actually prepare you for your first patient arresting before your eyes. You think to yourself, or maybe you even scream it out loud, "I need some help in here!" Then you realize, "Wait, I am the help", and your stomach drops into the floor.

New-grads experiencing their first code

I was called to the room because the patient was having an "anxiety attack." She was breathing 30-40 times a minute, I felt her pulse pounding at over 200 beats per minute. Then, no pulse. I was in disbelief, readjusting my fingers along her wrist thinking I had misplaced them. The only pulse I felt was mine, pounding through my fingertips. My coworker called the code and an onslaught of doctors, nurses, pharmacists and respiratory therapists flooded the room. Somebody shoved suction equipment into my hands, and I stared helplessly at it; any knowledge of this equipment that I previously held was no longer there, my mind was frozen.

Experience has shown me that an efficient code runs like an orchestra playing an exquisite piece. Everyone knows their part, and plays it effortlessly. This is the part that BLS doesn't teach you. A near-perfect code should go something like this:

The primary nurse calls the code, lays the bed flat, and begins chest compressions. Second, floor nurses should bring the code cart to the room, and set up oxygen to the bag-valve mask to begin bagging the patient. Usually by this time, the code team arrives. As soon as the code team arrives, the primary nurse should delegate chest compressions to someone else. This way she can communicate patient history and SBAR to the doctor running the code. Respiratory Therapy will exclusively manage the airway from this point. and a backboard will be placed under the patient in between rounds of chest compressions. Duties need to be assigned by either the MD running the code, the Supervisor or the Charge Nurse. Someone documents interventions, someone pushes medicines, and people need to form a line to relieve the person doing chest compressions. In reality, people usually assign themselves by calling out, "I'm writing!" or "I'm next to the IV!" A pharmacist and a Critical Care nurse manage the code cart.

Inevitably, there are too many people in a room during a code. Not having enough help will never be a problem in the acute care setting. People will be standing around hoping to get in on the action, reminding me of this vulgar Dane Cook sketch that was popular while I was in college. At some point you will have to ask people to step out for lack of space!

The biggest mistake many new-grads (and experienced nurses!) make is focusing on the wrong data. Many times you spend precious time frantically asking yourself, "what did I miss?" instead of asking yourself, "what do I do now?". There is a lot of anxiety surrounding codes. Many experienced nurses feel out of practice, and many new-grads feel totally unprepared. My approach is to know what you will personally do in a code before a patient ever arrests. For example, I like to document or "write" during a code. If that is already taken, I jump in line for chest compressions. If that's taken, I get out of the way.

What are your experience with codes? What advice do you have for the new RN or the out-of-practice nurse?