Code Blue: Information for Writers with Sarah Clark

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A CODE BLUE is defined a cardiac or respiratory arrest.

Here to help us understand what

happens during a CODE BLUE is Sarah Clark. 

Sarah spent 29 years as a nurse. Her positions included: ICU, Emergency Department, Med/Surg, telephone triage, long-term acute care, and teaching at the nursing school. For the last 3 ½ years, she has been the simulation coordinator for hospitals.

If you are writing a crisis that begins outside of the hospital, most likely the patient will be arriving in an ambulance.

Prior to arriving at the hospital the EMS will have sent a bullet-ed report to the CHARGE NURSE. 3-5 minutes before arriving they will encode – this is the report/notification.

At the beginning of the shift, the charge nurse will have assigned rooms within the Emergency Department. Emergency is now called E.D. not E.R. by hospital staff. 
* Your lay person would probably still call it the E.R. 
* It would be a mistake to have the doctors and nurses call it that
   now. 
The charge nurse is on the radio and manages the room flow. The charge nurse will assign the case to a room. 

When the EMS unit brings the patient in, they go straight to their room/nurse.

If they coded on the scene or in the ambulance, several things are already in place for the hospital staff.
· The patient will have pads already in place (often, one on back
   and one on front) for performing shocks and be on a backboard,
   facilitating CPR compressions. 

· The patient will be intubated
· The patient will (when available in that locale) have a LUCAS
   unit in place. A LUCAS will perform chest compressions for 
   CPR, leaving the health providers hands free for other things. If
   the LUCAS is in place, they will most likely leave it at the
   hospital until the patient is no longer in need. It has a battery and
   can operate for around three hours without be connected to a
   power source. It can be plugged in and many ambulances have
   electrical plugs. 

· The patient will have an I.V. line in place.

If the patient comes in with vital signs, then as a writer, you need to decide which of the above you would like to have in place.

Let’s pretend for a moment that a patient presented at the E.D. with signs of a cardiac event. While in the E.D., he codes. Immediately the team goes into action.

Here are the players:

· Medication R.N.
· Airway Manager
· Person Performing Chest Compressions
· Code Cart Manager
· BLS Team Leader - this is the PROVIDER. They no longer call

  the person making the decisions “doctor” with the lack of 

  physicians the provider could be a physician, physician's assistant,
 or nurse practitioner
· Documenter
· Family Guide 

MEDICAL RN stands on the right hand side of the patient. 

· Check for IV access, patency (the quality of being unblocked)
· Establish IV if none present.
· Prime tubing with 1 liter NS (normal saline)
· Administer ordered meds
· Communicate when med has been administered
· Protect the IV site. This is IMPERATIVE. That IV is the patients

   life line in an emergency. If the nurse can not find a vein they

   will place the line in the bone with an IO or intraosseus line. T
   The nurse will say “Drill ’em.” This method is fast and relatively
    safe. 

   VIDEO QUICK STUDY Trigger alert. Graphic. (12:00)
* The IV line is most at risk when the patient is being moved from
   one stretcher to another. GURNEY is a term that is no longer in
   use.

Ambu Bag

The AIRWAY MANAGER :

stands at the top of the stretcher and is usually a respiratory therapist. This is NOT a nurse. A respiratory therapist has an associates degree – a two-year degree in providing respiratory aid.

· Open airway
· Ventilate with Ambu bag 

· Requests suction setup 
· 2 People: 1 to seal the airway and 1 to squeeze the
  bag 

  * An Ambu bag is 100% oxygen. 

  * During a code the patient is manually ventilated. 

· This person will often stand on the left, or if need be, they can get

    right up on the gurney with the patient. This person needs to get

    the chest compressed a full 2” or it is ineffectual. Most people

    will wear out after two minutes and need to be replaced. 

· Any qualified person can do the compressions. 

· They monitor/check for pulse 

· If the patient did not come in with EMS then they will place a

   back board and a Zoll pad (for shocks) there are 2 pads – one on
   the back and one on the front. They can cause fire (chest hair)
   They no longer use paddles.

· Two people can rotate responsibilities to give the person giving

   compressions a chance to rest. They must monitor the quality of 

   the compression.

· Stands next to the cart –  everything they will need during a

  code is in the cart. She will hand people things as they are 

  needed. 

· They must be a nurse, and it is best if they are familiar with the

   layout of the code cart
· They hand in:

  * Back board 

  * Zoll Pads

  * Set up for suction
  * IV tubing with one liter of NS 
· Prepare the Empinepherine 
· Hands in meds as ordered
· Operates Zoll defibrillator
· Communicates with the runner for needed supplies

So for example:
The provider will say, “Give an amp of Epi.”
Code cart manager replies, “Epi.” As she hands it to the medication

                       nurse.
The medication nurse says, “Epi.” Then administers the meds and

                       says, “Epi’s in.” 

BLS TEAM LEADER
· This is the provider (doctor/physician's assistant/nurse practioner)
· Stands at the end of the bed and does not do anything hands on to

   prevent tunnel vision. 

· Needs to be able to see everything
· Makes all decisions about the patient 

THE DOCULMENTER
· Ideally, this is the patient’s nurse – in reality it will be a newer 

  nurse. The documenter stands next to the provider.
· Charting – documenting everything that takes place
· Ensure participants sign the code sheet
· Timer – is UBER IMPORTANT!

“It’s been two minutes. Time for a rhythm check.”

EVERY TWO MINUTES:
· Check the rhythm on the heart monitor
· Check pulse in the femoral area of the groin. That would be here:

· Change out the compressor if they are human. 
· Decide if you are at a shockable rhythm
· Shock them.

“It’s been three minutes do you want another epi?”

EVERY THREE MINUTES:

· Epinephrine helps vaso constrict to shunt the blood to the heart 

  effectively – it is the first line drug to use in a code, and it can be

  administered every three minutes. 

FAMILY GUIDE
· Determines if the family wishes to stay
· Positions the family near the exit
· Answers questions briefly and honestly
· Reminds the team the family is present (tendency towards gallows

   humor to break the stress)
· Escort the family out if needed


In every hospital there is a RAPID RESPONSE TEAM. This is a pre-code team that includes an experienced nurse and a respiratory therapist. They identify the patient’s risk of coding and move him to ICU.

NURSES SAY “CRAP.”

When do they stop?

1) The patient is stabilized
2) The patient is declared deceased
    · Typically, they will call it if the efforts have not worked and 

       the patient flat lined for over twenty minutes.
    · If they were brought in with a flat line, it’s usually called – 

       because of the length of time they were down. 

    · If the spouse/parent is on the way, for example, they 

      will try to continue efforts until the spouse has arrived. 

    · Often it’s the family that asks the team to stop 
    · Sometimes they continue for longer than they normally would

       have to give the family time to come to the conclusion on their

       own. This helps with the grief process. 

And there you have it. 

A huge thank you to Sarah Clark  for her expertise.

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