Monday, May 26, 2008

Resuscitation docs..

This is kind of for only the docs here and those who stumble upon us. Just an observation. As you all know I started in medicine, oh, before Penicillin or so.

Yesterday, old lady, 89, arrests in ED, and I unfortunately bring here back. Call ICU doc to come admit. He comes down, writes orders and before he leaves, she codes again. He turns to me to run the code again and doesn't want to have anything to do with it. This, it seems has become the norm. No one else in medicine can run a cardiac or trauma code anymore but US!

I mean, you can have 3 cardiologist's standing around with their heads up their butt's if an EM doc is present at a code situation. Everyone just assumes we are the only docs who are qualified to run the situation. Kind of a compliment, but also a major PIA.

Is this what you folks out there are seeing, too? Is it because they have no balls or have we become the only docs willing to take care of the situation? If so, why? Malpractice concerns, scared, or what? Thoughts?


  1. all the time. every day. just like you say. we are, increasingly, the only docs who do "sick". we are, in one respects, victims of our own success, but also, victims of outside circumstances. in this particular instance i think most docs are scared of liability. let's face it, even though codes aren't usually successful, if you don't do them, you don't want to do them. and when that goofball ER doc is in the hospital hell, just call him!

  2. (Old Fogie Voice)I'm with ya old fart. In my day medical students searched out potential codes. Where else could you yell "Clear"! and "1 Amp Epi 1 Amp bicarb"! just like Dr. Noah Drake on General Hospital? Now the cardiologists come in like Bruce Sutter to get that one batter out and then they're gone.

  3. it all depends on the time of day at my joint.

    During the day, our Crit. Care guys will go to the house codes, etc on the floors (although there aren't a ton now since we started with rapid response, etc). Rarely do they have any codes in the ICU because they're pretty good about communication with the families and usually by the time a code would happen, a proper course of action is decided upon.

    The ER guys run all the arrests in the ED. House docs cover the arrests after hours on the floors, but us EM residents are supposed to go to any code that gets called to provide airway support and be the team leader.

  4. I've noticed that many of the doctors who do not work directly in the ED or who are not working hospitalist do not have ACLS, PALS, etc. and many don't know HOW to run an arrest. Do you find this in your area?

  5. Would you really want them running the code? I noticed a huge, huge difference in how codes were run in the ER compared to the floor. It was way better in the ER.

    The more you do something, the better you become at it. Would you want an ER nurse scrubing in on your crash C-section? Do the OB's even want a scrub tech from the OR? Do you want the aesthesiologist to intubate your baby or the NIcu Doctor. My vote would be with the Nicu Doctor. We have become very specialized. Yes, we are victims of our own success. But look at the results. The results are better when you do it all the time. We did a C-section tonight decision to baby out in 7 minutes! We would not be able to do that if we were not specialized.

    The patient probably does much better if you are coding them instead of the Cardiac Doctor who has not run a code since God knows when.

  6. pinky,
    yes, but no. running a code should be second nature to everyone having completed either a surgical or medicine residency.

    having the ER docs do them all is an ideal, but there are times when i can't leave the ER because i'm coding someone there, OR, worse, i'm about to code someone.

    at my particular facility we even code the critical care doc's patients. this is just crazy. our first responsibility is to patients in the ER. other docs should be able to run a code and competent in doing so because one day i will not be able to come or oldfart or 'cat or erdoc85 or lofty. this is a situation ready to snap.

  7. I have been reading this blog for a few months. I agree with much of what you guys have to say, but I really do not appreciate the tone of this post. As an Ob/Gyn in a teaching hospital...I get called frequently for complaints such as the ever popular "vaginal bleeding" and "pelvic pain"... and I continue to be amazed at how the ED just automatically dumps these patients on us without even doing a full evaluation. Their usual response to my question of "Why didn't you do a pelvic exam or transvaginal ultrasound?" is: well, I figured you would just do it. Granted these typically are not true emergencies and probably should never have been seen in the ED anyway, but regardless, they are your patients. So..I just go about my job and do the pelvic and transvaginal ultrasound (which is probably best for the patient)- at the same time trying to teach the ED physician what to look for (unless they get called to be the 30th person in the trauma bay when a trauma roles in - leaving the rest of the ED looking like a ghost town). My point is...before you tout yourselves as the gurus of the medical world and ridicule other specialties for not doing what you can or being "scared" or having "no balls"...make sure you can do it all. Otherwise, admit that you may be clearly deficient in other aspects of medicine that some find trivial and easy...and appreciate your consultants.

  8. As an outsider (scribe/all around scut runner) I have personally witnessed this.
    Cardiologist wouldnt even attempt to intubate a pt that coded on the tele floor, said he wanted to wait for the "code team" to get there.(btw that guy was sued and hasn't shown his face around here since the patient was a family member of a prominent nurse and did not make it.)
    Had an oncologist walk right off the damn floor while saying, pt in room 3 is about to code. WTF.
    Since when is it OK for a doctor to NOT be able to amply run a code.
    So far the only docs I have seen run codes are ER, Hospitalist and Pulmonary.
    As a future doctor it sickens me to see how lazy (for lack of a better word) medicine has gotten, and at what price?

  9. dear anonymous,
    screw you. no one here is claiming to be a guru of anything, merely that over the last ten years somehow the job of running codes has been left to us. you do sound like an academic stuffed-shirt though who sees the folks in the ER as 'triage docs'. seriously, go fuck yourself you freaking doucebag. how's that for tone? clear?

  10. As an addendum to my above post...I am extremely grateful that ED physicians are confident and more than capable of running a code...both for personal and professional reasons. The times that I have been associated with a code (fortunately, not many) I am amazed by the ability of the "code team." I continue to try to better myself in this area, but what I read in books is no substitute to the real deal...those that practice the code in real time will obviously be more proficient, which is why I believe many physicians stray from this...especially if a more experienced ED, CCM, Anesth. physician is present. That being Dr. Wannabe observed... every physician should really be capable of running a code in the event that it is necessary and they are the only ones there.

  11. 911doc.
    Sorry my original comment was a little harsh...had a few bad call nights lately. Didnt mean to offend. As for me...I will continue to click on the JCAHO Accreditation ads on your blog to help contribute...

  12. Hello. Anonymous Ghetto Medic again.

    I'm not qualified to speak to the subject of ER docs running codes. For me, it's much simpler than that.

    Why the fuck am I called to family practice office for "chest pain" calls? As far as I know, the 1400 hours of training I have pales in comparision to the multi-year degree of doctors. Apparently, none of these silly fucks has read "Emergencies in the Outpatient Setting" in the Medical Clinics of North America. How is calling me a Higher Level of Care? If I'm your patient, and paying you an office visit copay, don't get all chicken shit and call an ambulance because I'm not paying for that too.

    And further, when I arrive on scene with my shit and my protocols, why do these fuckers insist in trying to tell me how to run the call? "Are you going to start a line? Why are using LR? You need a 16 gauge or bigger! You're giving him nitrates? How do you know it's not a right ventricular infarct?" Don't tell me you're "looking for the delta wave indicative of WPW" I know you just remembered that from some crash 12-lead course. It's not convincing.

    I want to say, "Bitch, if you're such a fucking expert, why did you call 911?"

    Picked up a guy out of a LTAC facility the other day. Nurse was like, Yeah, his sats aren't so good. He's 84% on room air, so the physician wrote orders for him to be on a non rebreather at 6 LPM.

    I gave up arguing about this long ago. I feel like just throwing a plastic bag on their head any saying, "Here's a simulation of what it feels like to to have a mask on your face with too little oxygen!" I can't roll into an ER with a non rebreather at 6 LPM. You know how stupid I would look?

    When did people become idiots about which oxygen delivery device is appropriate for a particular flow rate?

    Codes at an LTAC. There's a hospital in my town. Big hospital. Long term care place. 112 beds. Physicans on staff, RTs on staff, 24/7 physician coverage. Nurses, LPNS, the whole slew. And they call 911 to run a code. These silly bitches have VENT PATIENTS. They do surgeries at this place. Intubate people here. And you call a fucking ambulance to run a code at your "hospital?" Where are your nuts? Where is your pride? Have you no shame? Christ almighty.

    I have done a fair number of codes. Here's my abbreviated wisdom for any physician who feels lost. First, grow a pair of balls. They're dead. If you are doing CPR on them, they're dead. Whatever the fuck you do, short of pissing on them, is an improvement.

    Second, thankfully, you have "allied staff" who is equally panicked and fear stricken since they too forgot rule number one. All you have to do is pretend like you know what you're doing and things will be fine.

    Third, AHA makes little cards to follow. Get one and keep in on your cart.

    Here's what the AHA videos suggest. First, you need a denim shirt. Then, when you find some gorked patient you scream, "YOU! CALL A CODE. GET THE CRASH CART. BEGIN COMPRESSIONS. 1, 2, 3, 4, 5...."

    Please, don't count compressions out loud. Forgive my arrogance, I really am a humble person, but what the fuck difference does it make it you don't hit spot on 30? 28-35 works okay.

    I don't think there's any magic to codes. They're very formulaic. Very simple. Very predictable. I don't have nurses and techs to do my bidding. I have an EMT who hands me drugs and firemen who do CPR. That leaves me to shock, intubate, IV, push drugs, suction airway, call nearest hospital, deliver report, monitor patient condition and change drugs or plan as rhythm and condition changes, and ensure nothing gets seriously fucked while dragging the patient down two sets of stairs into the ambulance for a ride to the hospital.

    If I can run a code in a strip club bathroom (which I've done), anyone with a little training should be able to run a code in the hospital. I think hospitals have gotten so fucking worthless in the diffusion of responsibility.

    The reality is that you don't get better at it by passing the buck. Get your feet wet and do it. They're dead. What's the worst that will happen? They remain dead?

    Codes are simple. Don't make them complex. There's only two rhythms anyway - asystole/PEA, pulseless v-fib/v-tach. That's it.

    I'm not going to pretend I know anything about keeping some poor bastard alive after ROSC, because that's not my training or my job. I have no clue what to do next. But the issue is the code itself. And those are easy.

  13. Got called to a code as an anesthesia resident, someone had already tried intubating, unsuccessfully, didn't really matter as you said, since his BP was "0"("Planes, Trains, and Automobiles" reference) ICU fellow told me to go get a fiberoptic scope. Kept sticking tubes down the patients throat till one went in. Patient looked like a sword swallower. And the end tidal CO2 indicator often will be negative in a code patient, since you need to have a cardiac output to have end tidal CO2.

  14. At our facility, The ED docs respond to all codes. In the 19 years at this hospital, first as an RRT and now as an RN, I have seen non-ED docs run maybe 2% of codes. Most recently, it was a Cardiologist...but he showed up after the ED doc intubated.

  15. Just wanted to chime in about oxygen gripes, Anonymous Ghetto Medic. I'm a RN in the ER & the other day I am caring for a patient with COPD and pneumonia on a VM. The admitting resident wants to lower the 02 flow (even though I had already clearly charted that I had tried it and the patient wasn't able to support it). Instead of finding me to do it or reading my nursing note (which of course I just write for my own entertainment), he turns just it down to 4L. So Mr. COPD, how does it feel to have a 40% VM on with 4L of 02 flowing rather than 8L? With sats dropping steadily, the family freaks out and comes to find me while I'm hanging meds for a non-STEMI getting ready for the ICU. I pause for a moment to not-so-kindly remind him that if you are trying to lower the O2 on a VM you have to change the appliance with it...So generally, the rule of thumb is...if you don't know what the hell you're doing, don't pretend you do and make my life more difficult. Stick to writing the orders and communicating with the nurses, Dumb Ass.

  16. Holy shit, fartie, this scares the bejabbers out of me. Note to self: do not get sick. Ever.

  17. Well, I've watched a few interventional card's at work. I am not sure about the shock factor an EM practitioner is accustomed to.. But most interventional folks are pretty up on their toes, especially if you get hold of a good one.

    It takes balls to do EM, doc. I admit, but let's be fair here. :)

  18. Even scarier is seeing what happens when a major emergency happens out in the "real world", without the back-up you have inside the hospital.

    At 35,000 feet, when the flight attendant asks for a doctor and those who respond find out that an ER doctor was silly enough to stand up, the rest just melt away back into the crowd. You can't even find them to be extra hands for doing something, much less making decisions.

  19. don't get me wrong. i'm not saying we are the only one's who CAN run codes nor am i saying we are the only ones who SHOULD, i am merely lamenting the fact that as it turns out here and at my previous facility the codes all fell the the ER doc. i think it's wrong and dangerous.

    and as to the speculation re the authors here i will add this clue, four of us were medical school classmates, i then met the others. we self selected in that regard and sound a lot alike because we were also lovers.

  20. i have doctored on two airline flights. the kits the airlines carry, at least 5 years ago, are shit. then the pilot asks you if he has to land. not a small thing... 40,000 to the airline for an emergency landing in the cont. us. one peanut in the nose, and one hypoxic patient who got better with O2. no macgyver'ed trachs yet.

  21. The funny thing about codes is that the only thing that has been shown to lead to better survival - leaving the hospital with a functioning brain - is good CPR and defibrillation.

    No drugs.

    No tubes.

    No IVs.

    Almost anyone can do this well.

    Part of the problem with codes, both in the hospital and out of the hospital, is too much focus on the "advanced" procedures, and not enough on the basics.

    Perhaps what should be done by the ED doctors is, make sure the doctor covering the floor stays and runs the code (assuming they are there, if not that could be addressed with the hospital administration), make it clear that you are just observing and offering advice when the doctor strays from the recommended treatment. Perhaps you could hand them a card with the appropriate algorithm on it.

    If they learn to punt everything to you, things will not change. If they are made to realize that they can do this, they should depend on the ED less.

  22. During my Navy time I was tasked to grade the Dental Clinics cardiac arrest drills. I walk in, throw Resussi-Annie on the waiting room floor, what do the dentists do? Call 911, cause "thats what we always do". Annie didn't get her pulse back either.

  23. I am an ER nurse. Used to be on the "code team" too. Whenever we got called to a code, because I worked at night, usually the only doc there was an ER physician. Now I work during the daylight hours, we have a patient come in who is coding, even id their own physician is there he usually defers to the ER doc. I mean we are the ones who HAVE to be ACLS certified. If I thought someone could do the job better I would defer to him/her too.

    Now if we could just keep stupid stuff from cramming up the ER. This Memorial Day Weekend has been a killer!!! Some of the staff members lives have been threatened... don't theses folks know that it's a felony to mess with a hospital employee while they're at work?? Dumbasses!

  24. Anonymous,

    The ED doctors do not necessarily have to be ACLS certified. ACEP has been trying to discourage ACLS requirements. The requirements for EM board certification go beyond what comes with an ACLS completion card.

    But, yes, they are supposed to be the experts.

  25. Holey Shitt People!! I didn't mean for that to be so rough! I'd rather have 911 fudge packing my ass than start another argument!!
    So my comments:

    Anon OB, I didn't tout myself as a "guru" of anything! And I'm talking about an INTENSIVIST walking away from a pt he'd written admitting orders on! Just asking if everyone else had the same experiences with SUPPOSEDLY competent docs NOT running codes and backing out the door when we showed up!
    For your OB/Gyn comment. Do have any idea how many vag bleeders we see and dispense with that you
    don't? Fuck Wad! And another "for instance" This weekend, female, bleeding/pain/palbable suprapubic mass/I do US and CT and call our guys who say thanks send her up to me I want to do my own US!!And, yes it's a teaching institution and is in the top 10 in deliveries/yr in the nation, so I think they're pretty good. I was not offended that he wanted his machine/hands/etc. It's pretty much my experience that OB's want to do their OWN US! So Fuck off and climb down from whatever mountain you're on!

    Ghetto Medic: Chill, go to med school and come be one of my EM Residents.
    And doctors out of the hospital are like fish out of water, we flop around alot and can't accomplish shit. We depend on you pre-hospital guys to "do that thing you do"..Rock on!

    Julie: Don't ever let a doctor screw around with equipment! We generally don't know what those little lines on the green thingy mean..

    Rogue: Preachin' to the choir here, Bubba

    Drackman: That slays me!! Annie didn't get her pulse back!!!

    To All of you: Our blog is a great coping mechanism for us 6 sick phucks! We can say all the shit we think during a shift, meeting, or lecture. We really aren't here for your education or to criticise others, altho it may seem that way at times I'm sure. We're just trying to "enlighten" a few of you as to what we deal with everyday, some sad, some tragic, some so laughable you guys don't believe us, but every event we've written about is true altho the names have been changed to protect Dr Peel.....So, HTFU!!!

  26. uh, oldfart, i didn't know! it can be arranged for a nominal fee.

  27. Hey, I'm just sitting here learning. Watching ya'll duke it out and watching the dust settle.

    Rock on Oldfart. But be careful, with that personal info, you're getting easier for Debbie Peel to ID.

  28. Old Fart.
    Like I said previously...I apologize for my original comment...just had a few bad call nights lately and had to vent. It was a bit harsh...and did not intend for it to come across how it did. Anyways..keep up the interesting and always entertaining posting.
    -Anon OB

  29. anon,
    i likewise must apologize for similar reasons. as you may or may not know i am desperate to, i don't know, go work at a hot dog stand or something. we are in a hell of a mess in podunkville and, if nothing else, i'm trying to tell as many people as i can that we really face a crisis of immense proportions in medicine... one that, i believe, is not so hard to fix as people would imagine, but, one that, if 'fixed' by any form of centralization, will break us. thanks doc.

  30. Anon OB, gracious statement, no problem. Keep reading us, we are really prety funny most of the time. Maybe we'll need an OB/GYN consultant to the blog.

    911, U R such a cheap Ho'..

  31. oldfart,
    glass houses etc...

  32. Hey Oldfart, when did they take open chest cardiac massage out of the ACLS protocalls? Or was it just "LS" back then? That must have been a blast.

  33. I work part time nights (on the side) at a small community hospital, on the inpatient side. I run my own codes and do all my own intubations.
    Irony is not dead.

  34. Hmmm.. To be honest I suppose I would probably run the code in my ED more because I know all my people and we are used to it as a group. Were the code in the ICU for example and I happened to be up there following up on a guy I admitted I would fully expect the intesivist to take it over.

    I understand your argument that this is now his patient given that she is admitted, but I wonder if it was unwillingness or not wanting to step on your toes in your turf(though that seems unlikely given my experience, but maybe he's a nice guy).

  35. "Here's what the AHA videos suggest. First, you need a denim shirt."

    Ghetto Medic, you crack me up. Please guest post at my blog!!!

  36. Drack..I posted this a few days ago but it never showed..

    Open chest cardiac massasge was done on every arrest in my EM residency. I got VERY good at cracking a chest..

    Guess what?? They stayed dead!! Big surprise..See medic above..