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.