Barbados Butterfly wrote some eleven or twelve posts on advice for interns (incidentally way more valuable than mine, since she wrote from a few years’ seniority, rather than only ten months, like me). If I could remember more of them, I’d try to reprise them a little more precisely. But the one that sticks in my mind most vividly contained her song, “Call A Code.” The words went something like this: “if the patient looks blue, call a code. . . if you can’t find a pulse, call a code. . . if you think you need help, call a code. . .” only much more poetically. (Does anyone else remember the words better?)
The basic point was that the intern should not hesitate to call for help, even as dramatically as calling a code, if they have any suspicion that it’s needed, or if they’re at all uncomfortable with the situation.
Many hospitals in the US are developing pre-code teams, which everyone is encouraged to activate if they feel the patient is unstable but not absolutely in cardiac or respiratory arrest. At least in my hospital, there seems to be a little stigma among the surgery residents associated with calling one of these. And for the senior residents, that’s probably reasonable. What these teams do is guarantee that xray, blood draws, ekg, and chest xray will be rapidly available. A confident resident (that means me in two months – hmmm) should be able to handle a patient who’s still breathing and has something resembling a blood pressure by stat paging these services independently, and getting one or two extra floor nurses to help bring medications. Of course, the other thing that these teams bring with them is a hospitalist attendings, who will take charge of the situation. Which is the real reason the surgery chiefs hate these teams: they don’t want to relinquish control of their patient, no matter what the problem is. (And they always have anecdotes of MICU patients on pressors through a peripheral iv, with no a-line in place, to back up their concerns. [This is bad because if vasoactive agents extravasate from a peripheral iv, they can cause severe skin necrosis; and if your patient's blood pressure is bad enough to need pharmacological support, a cuff isn't accurate enough to be measuring it by; not to mention that cuffs get more inaccurate as the pressure gets lower.] )
Anyway, my point is: if you feel the least bit uncomfortable with your patient’s status, call for help of some kind immediately. Try for a senior resident first, if that’s how your team is arranged, but if not, or if that’s taking too long, don’t put saving face above your patient’s welfare.
May 15, 2008 at 6:45 pm
Here we have “precode codes” or MET calls (Medical Emergency Team). There are specific criteria for this (we get little laminated cards attached with our ID cards for the code categories and MET call criteria). There is also a criteria (well, at hospitals I have been at) for “anything which the clinician feels requires MET attention”. It hopefully prevents a number of progressions to full code (and the poor outcomes that follow), and facilitates the transfer of the patient to the ICU or to the acute care they need. Or at least support for the clinician on the ground.
They typically consist of around 5 people, including an anaesthetist/ICU specialist and a medical registrar, a radiologist with a portable XR etc. They seem to work really well with both medical and surgical staff.
Incidentally, I called a code blue last year on a public holiday when I found a man who got lost on the way to the emergency department who was having 20/10 chest pain and seemed on the verge of expiring. I apologised to the code team if it was a wrong code, but they were very quick to tell me that there is No Wrong Code.
May 16, 2008 at 8:11 am
Sounds like a good call on your part. My hospital, too, has the ER tucked away in an obscure corner, from the inside, with dozens of turns and branches, and I frequently have to direct distressed-looking people. None as bad as yours, though. At least he got moved to the front of the triage line.
May 17, 2008 at 1:51 pm
You should never be afraid to use the code team. It is much better to be wrong, and not need them, than need them and wait too long to call them.
As for the stigma? Screw the rest of them, you want to keep your patients alive, do what is best for them, not what the other interns think.
May 20, 2008 at 9:12 am
Hi Dr. Alice,
I love reading your blog and sharing in your growth from medical student to surgeon.
Do you have any advice for the upcoming crop of 3rd year medical students who will be starting clinical rotations soon? Specifically, how to do well on the surgical service–what do you expect/like to see in the students? Any tips for learning a lot without becoming annoying and getting underfoot? (Just a little anxiety here, as surgery will be my very first rotation and I want to do a good job