Code Blue: What You Won’t Learn From TV

Each July brings new residents – recent graduates from medical schools – to the inpatient wards of major teaching hospitals across the United States. Among the many new responsibilities these young doctors will be taking on is one of the oldest and most critical – their role on Code Blue teams, or groups of caregivers who respond to cardiac arrests. Proper verbal communication and information sharing are essential for teamwork in high intensity situations like code team responses. 

In Hollywood, Code Blue teams are often portrayed like a NAVY Seal team – a group of seasoned professionals responding immediately with stunning coordination to deploy heroic interventions with amazing success in these fictitious environments. In theory, this is what we also want in the real world since survival in cardiac arrest patients depends upon prompt care. Yet, at many hospitals, the reality may be far different given the challenges with having such expertise readily available at all times. Many times it is pure, primordial chaos. Usually on arrival to a code, physicians are hit with numerous sounds first. Bed alarms, blood pressure alarms, and heart rate alarms blare insistently, a Greek chorus to the unfolding drama. An unanswered, continuous string of questions hangs in the air like a heavy fog. “Can someone page anesthesia?” “Who is the primary team?” “Do we need access?” “Where’s the EKG?” “Where’s the cards fellow?” “Chest X-ray stat!” “Who spoke to the family?” “Is this guy DNR?” “What are his labs?” “What’s his history?” “Am I in charge?” “Wait, when does the cafeteria close?” But the truth is, the most important thing is to just “BREATHE!” and gather one’s wits.

Learning how to be proficient at this skill may seem like a major burden. One might even ask, “Why should I bother if I am not part of a code team or am training in a field like radiology or psychology where there is a lower risk of seeing a code?” It is because in the United States, an estimated 370,000 to 750,000 patients have a cardiac arrest annually and undergo attempted resuscitation during hospitalization. Of those patients, less than 15% survive.1This establishes cardiac arrest as one of the most lethal public health problems in the United States, claiming more lives than colorectal cancer, breast cancer, prostate cancer, influenza, pneumonia, auto accidents, HIV, firearms, and house fires combined.2In my experience, I have witnessed these arrests all over the hospital from the ICU, the general floors, all the way to the MRI table and even in elevators. The arrests happen all over the hospital, making it important for all staff members of a hospital to be effective in managing cardiac arrests. 

Despite the inception of Advanced Cardiovascular Life Support (ACLS) more than 50 years ago,3,4the fundamentals of cardiopulmonary resuscitation have remained unchanged, but survival rate remains low. Why? Studies have reported deficiencies with in-hospital cardiac arrest care, with 23% of chest compressions being delivered too slow, 36% of chest compressions too shallow and defibrillation delayed beyond 2 minutes in 30.1% of in-hospital ventricular fibrillation/ventricular tachycardia arrests5. What explains such performance variability? Resuscitation of the cardiac arrest patient is a complex task with highly time-sensitive actions requiring coordination among diverse care providers. It is therefore not surprising that technical and human factors play a large role in determining resuscitation outcomes. These commonly relate to leadership and procedural skills. In hospital settings, especially teaching hospitals, there are frequently too many health professionals at the resuscitation scene, resulting in disorder and diffusion of responsibility. 

Communication failures contribute frequently to errors occurring during a code team response. I remember in my intern year, witnessing my first code and being surprised at the chaos surrounding the room due to the sheer inability to gain control of the room. As I came to gain experience in my residency, I discovered the key to running an effective “Code Blue” is the team leader. A team leader should calmly, clearly, and directly give an assignment, then confirm that the message was heard. Team members should confirm that they heard the assignment, then inform the leader when the task is completed. However, there can be several factors associated with communication failures, such as: (1) physicians, nurses, and other medical professionals have been trained to communicate differently; (2) health care system hierarchies that frequently inhibit people from speaking up about issues and concerns; and (3) a lack of standardized communication and procedures in different areas of health care.6In my experience, though, these skills are not learned on the fly; instead, they are best taught through simulation training and continued education with the use of a high-fidelity mannequin.7

In our residency program, we have utilized a mannequin through controlled simulations. To ensure a smooth experience for the learners, the team involved conducts a dry run of the scenario using the mannequin. Targeted learning objectives for this scenario focus on the recognition of the deteriorating patient, team approach to care, timely and appropriate Code Blue response initiation, effective patient care, and clear communication techniques. Checklists based on the current guidelines were developed and are used during the scenario to provide an overall assessment of trainee competency. Also, the mannequin is able to provide feedback on the quality of compressions and ventilation. The high-fidelity curriculum coordinator along with pastoral care facilitate the scenario and participate in the subsequent debriefing. Since implementation, numerous positive evaluations have been received from participants. Also, some of those who have witnessed a code since participating in this scenario have stated that they were able to successfully put learned actions into practice. 

Despite its importance, the key to being an effective leader is not just about constructive communication. A lot of times, it’s having to fight the doubt that creeps into team leaders’ minds regarding when to stop cardiac resuscitation or even knowing when not to start. Claude Beck, one of the inventors of defibrillation, coined the phrase “hearts too good to die”; however, with the power of modern technology and pharmacologic therapy, we can sometimes bring people back to life with “hearts too bad to live,” leading to continued suffering in the hospital and prolongation of the process of dying. Prolonging resuscitation efforts beyond 30 minutes without a return of spontaneous circulation is usually futile, unless the cardiac arrest is compounded by hypothermia, submersion in cold water, drug overdose, other identified and treatable conditions, or intermittent ventricular fibrillation or ventricular tachycardia.8So it is reasonable to stop resuscitation after a patient has been in asystole for more than 10 minutes if there is no readily identified and reversible cause. In the hospital, patients with unwitnessed arrest, rhythms other than ventricular fibrillation or ventricular tachycardia, and no pulse after 10 minutes of resuscitation do not survive.9

In conclusion, act like George Washington, and the resuscitation attempt is sure to go smoothly. Act like Napoleon, and… well, you get the picture. The powerful tools and techniques of cardiac resuscitation can benefit thousands of people in the community and hospital setting. Conversely, when inappropriately applied, cardiac resuscitation may prolong human suffering. When charged with this herculean task in the face of odds stacked against you, what is needed, of course, at all times is a balance of judgment and clear communication, to navigate these emergency situations. Death is, after all, inevitable. Only unexpected or sudden death is the enemy. 

1)  Marc Reeson, Kwadwo Kyeremanteng, Gianni D'Egidio. (2018) Defibrillator Design and Usability May Be Impeding Timely Defibrillation. The Joint Commission Journal on Quality and Patient Safety44:9, 536-544. 
2)  Centers for Disease Control and Prevention. National Vital Statistics Reports, December 29, 2011. Accessed October 31, 2012.Google Scholar
3)  Brandon Giberson, Amy Uber, David F. Gaieski, Joseph B. Miller, Charles Wira, Katherine Berg, Tyler Giberson, Michael N. Cocchi, Benjamin S. Abella, Michael W. Donnino. (2016) When to Stop CPR and When to Perform Rhythm Analysis. Journal of Intensive Care Medicine31:8, 537-543. 
4)  Jukka Kortelainen, Eero Vayrynen, Usko Huuskonen, Jouko Laurila, Juha Koskenkari, Janne T. Backman, Seppo Alahuhta, Tapio Seppanen, Tero Ala-Kokko. (2016) Using Hilbert-Huang Transform to assess EEG slow wave activity during anesthesia in post-cardiac arrest patients. 2016 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC), 1850-1853. 
5)  Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. J Am Med Assoc 2005; 293:299–304
6)Sarwani N, Tappouni R, Flemming D. Use of a simulation laboratory to train radiology residents in the management of acute radiologic emergencies. Am J Radiology 2012;199: 244–251. 
7)Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD, Marsch S. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol 2011;57:2381–2388.
8)Morrison LJ, Kierzek G, Diekema DS et al. Part 3: ethics: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation.2010; 122: S665-S675
9)Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med. 2001;344:1304–13.
Posted by Sandeep Tummala on Apr 27, 2019 8:08 AM America/New_York