Own the code
“Time of death, 2:18”
As a young intern, I watched my senior residents with envy as they commanded the code room. “Equal breath sounds,” they would announce after sliding the endotracheal tube effortlessly through the cords. I reflected on those early days briefly before delivering the bad news to anxious family members. Walking back to my desk I placed my hand on my colleagues more experienced shoulder with a halfhearted grin, “Who knew the medicine would be the easiest part of our job?” He laughed, “Always learning my friend.”
The intubations, chest tubes, and central lines become routine after a while. And if you’re not careful, codes become routine as well. But it’s one of the most important things we do. Not the procedures, not the medicine, but rather the finesse, the details, the subjective and unquantifiable aspects of the job. It’s a separation of our specialty from others. It's the dignity of human life. It’s important to preserve.
“The intubations, chest tubes, and central lines become routine after a while. And if you’re not careful, codes become routine as well..”
So how do you own the code room? How would you like to be viewed as a leader and general human being? Start with a moral compass, and let it guide a set of principles.
1.) Preparation.
It’s a word used so often, it may come across as contrived, but it’s anything but. It’s essential to establish a set of standards in your room before the code arrives. The pharmacist and med nurse will work in tandem to keep on schedule for medications. They will keep time and announce that the medication was given for the room and request your assistance only if needed. The timekeeper will make the announcement for pulse check. No one else will make that announcement. Techs and nurses doing compressions, kindly assemble a line.
“RT, you’re with me, I like a Mac 4, bougie, and 8.0 tube prepped. Suction and BVM of course. I’ll let you know when. Medics, Place the largest IVs you can. If the patient does not have access, place an IO. I trust you with this task and will assume it’s handled unless you request assistance. You do not need to ask me for permission to get access.”
2.) Quiet is confident.
A loud code room is a sign of disorganization or personal insecurity (Or worse, both). Quiet leadership commands a room. I tell the team that the noise level of the room reflects directly on our team, and if an inpatient team is passing by, I want them to see how we do it down here.
3.) Report comes first.
EMS report is given before I take over the management of the code. Never interrupt. You can ask questions after. It’s the only chance you have to get essential data. EMS will know to continue compressions while giving report. If they inadvertently pause compressions, instruct them to resume compressions while giving report.
4.) Teamwork.
No code will be called before every team member is individually given the opportunity to make a suggestion or offer an objection.
5.) Time of death.
In the final moments of a person's life, no chatter. Pin drop silence please. When time of death is called, the person's name is read aloud (if available), and the room takes a moment of silence to honor the dignity of human life.
6.) Family conversations.
Even if that means you’re an hour over shift. No questions left unanswered or unaddressed.
7.) Team debrief.
What did we do well, and where did we mess up?
8.) Self-reflection.
Find a way to feel connected, every single time. Don’t let it become routine. Find a way to connect even if momentarily.
9.) The process of release.
When you have completed the first seven steps, take a deep breath, exhale, and release. You have done all you can do. You have provided comfort to the family. You were there for humanity in someone's worst moments. But after that exhale, you release it. You have to return to your own life. We will all grieve at some point in our lives, but today's grief does not belong to us. Today's grief is borrowed, not owned. And when the exhale is done, the lease has ended. Never walk directly into your home after a shift. Sit in the car for ten minutes, go for a walk. Exhale every last bit of mental fatigue. Read, listen to music, open a window. When you walk into your home, your scrubs come off. Both physically and metaphorically.
“When you walk into your home, your scrubs come off. Both physically and metaphorically.”
I’ll leave you with one of my favorite poems to read before I walk into my home.
'No Man is an Island'
No man is an island entire of itself; every man
is a piece of the continent, a part of the main;
if a clod be washed away by the sea, Europe
is the less, as well as if a promontory were, as
well as any manner of thy friends or of thine
own were; any man's death diminishes me,
because I am involved in mankind.
And therefore never send to know for whom the bell tolls; it tolls for thee.
MEDITATION XVIIDevotions upon Emergent OccasionsJohn Donne Welcome to humanity, young interns. It’s a good place to be.
about the author
Adam Barnathan, DO, is a 2019 graduate of USF Emergency Medicine. Dr. Barnathan enjoys working as a community ER physician and giving back to the EM Community at USF by sharing his unique perspective and teachings regularly as an invited guest at our conferences.
Post edited by Enola Okonkwo, MD.