When the er falls apart on a code

[VentMedic]

Ten o'clock in the morning in the ER, were doing clinicals. Call comes in over the radio, rescue is coming in with a cardiac arrest eta 2 mins. We start heading to the room to get everything ready, the rescue shows up and their coming towards the room bagging the pt and doing compressions. We get him over to the table where I continue compressions.

At this point I watch as the biggest jumble of people unfolds in the room.

Everyone is supposed to have a job to do, but at some point everyone except the paramedic students (us) forgot what they were supposed to be doing.

The dr is calling out " who is getting the drugs ready" and you hear " I was but now im trying to get a iv established" No one is doing anything in any order, people are just jumping around the Dr is calling for meds and people are literally bumping into each other.

When it was all said and done the Dr pronounced the pt.

It just amazes me how a ER of trained nurses and a Dr could fall apart like that.

Ive worked codes in 2 other hospitals in town during clinicals, and while on duty, and they all went perfect, or as perfect as you can go. Everyone had a job, and the Dr knew what was going on at all times. So where does the blame fall, on the Dr for not controlling the scene, the nurses and techs for not keeping to their jobs, or the hospital for not doing frequent training to prevent things like this from happening?

Let's recap:

3 Paramedics bring a pt to the ED with a King airway, no IV and CPR in progress.

You are doing compressions.

Doctor thinks ("assumes") there is IV access and yells for meds.

Nurse realizes no IV access and proceeds to attempt access.

Doctor thinks ("assumes") he has an ETT for meds but realizes he now has to reintubate where he could have been establishing a central line if needed.

Now who from the people mentioned wasn't doing his/her job with what had to be done first with access for meds and a stable airway?

Possibly the biggest fault I find here is the doctor "assuming" too much from the ambulance crew. He was ready to take over from the Paramedics by continuing with the meds, as it should be when an ALS crew brings in a patient, when his nursing staff realized NOT.

[Mateo_1387]

I am curious. How many people were in the room working the code?

Just from what I have read, I think the problem with the code is leadership. One person should be on top of everything. This person is the doctor. Being that the OP's area obviously carries all their codes to the hospital, the ER staff should be capable of working them smoothly. Codes are so ....."cookbook"........ So, it is my opinion that leadership would have been the problem.

Even if the hospital may have expected more treatments, the commander should realize in the first thirty seconds what is done. When they first walk in they can visibly see if and IV is established, the person is intubated, the monitor is applied. When these things are not done then that is the time for the doctor to start dictating what is to be done. What I am saying is that instead of saying something like "I need and IV, epinephrine, Intubation" say " Terri, get an IV established, Josh, get the epinephrine ready...." and so on and so forth. This way everyone will know their job.

[VentMedic]

Even if the hospital may have expected more treatments, the commander should realize in the first thirty seconds what is done. When they first walk in they can visibly see if and IV is established, the person is intubated, the monitor is applied. When these things are not done then that is the time for the doctor to start dictating what is to be done.

And you too are assuming. Just because there is a visible IV does not mean it is functional. There was a tube sticking out of the patient's face but not the most appropriate airway. The doctor was dictating but with the wrong assumptions. So yes, he was making the wrong assumptions.

Each ED has its own culture and takes a life of its own depending on management. I have a different set of responsibilities in every hospital ED I moonlight at. Add a rent-a-doc and my shift can be very good or really bad. There are alot of factors that go into determining the success of an ED and even on the best of days they can vary. For the most part I will say the majority of the EDs in my area function very well.

The doctor may have been a rent-a-doc and did not know who anyone was in that ED. The other staff may have been PRN or floats. Unless you are going to work in the ED environment, there may be little you can do to change that or even understand it. Some days things run smooth as silk and then there are times when things just don't click. This may have been a very off day for whatever reason. It seems that it was a very off day for the 3 Paramedics in the back of that truck.

Now, as prehospital providers, what options did the 3 paramedics have that could have enhanced their treatment of the patient? If you are a paramedic student, you should be looking closely at this type of patient if his size was a problem. Did you notice any other sites for an IV? What are the defining anatomical features that can help determine if ETI is going to be successful before you do too many attempts? Did you notice how the doctor intubated to gain an insight on a difficult airway? There is so much to learn as a Paramedic student even in perceived chaos.

If the ED is falling apart, plan your own strategy in your mind for this patient for future reference. If you have a useful suggestion during a code, then respectfully offer it. If you are the first to notice there is not an IV or a patent one, then announce it. If you see it is a King and not an ETT, point it out. Different airways may not be readily recognizable since some hospitals use several different ETTs and some hospital staff may not be familiar with the many different tubes besides the ETT.

[firedoc5]

Bummers! Some of our partners have been together longer than their marriages.

THAT I can testify to. What size of ER was it? Do they get a lot of codes? We had code in the field that we revived. Got to the ER and the pt. crashes. The main ER staff were busy on a critical MVA pt. that got there about 5 minutes before we did. So it was a few ICU nurses and some floor nurses. Here I am doing compressions (great for the abs.) and no Doc. in site at that time. My partner and I ran the code. Since I was an ACLS Inst. I was "elected in charge" until either the DON or Doc showed up. So do I'm doing compression and giving out orders. No one else there had ever defib'd. a pt. other than my partner so he was watching the monitor, ready at the paddles. Finally one of the docs making his rounds shows up asking if we needed help. I whispered loudly "Help'. He took over and got on the phone for more help. Evidently all the floor nurses were LPN's. Guess that's why so many were very timid on doing stuff. And the RN's (two I believe), one would do nothing but adm. drugs and the other was just making sure everything the LPN's were doing things right. They wound up putting in a pacer and got him up to ICU. That was a save for us. Even under normal circumstances we don't call it a "save" until the get to ICU. If they didn't make while still in the ER we didn't call it a save. They eventually flew him out so we didn't know how he turned out.

Fortunately at the next ACLS class practically every one of those nurses were in that class.

On the note of long term partnerships, when you are with the same service, sometimes at first there is a lot of trial and error. I learned how each EMT and Medic did their "own stuff" and quirks and I could adjust myself to where we met in the middle.

There is just one time that stands out in my mind of a "fumble". Had a taxi driver coded. He was laying on the road way under the opened door of the taxi. We moved him to where we thought we had enough room to work with. I just got the guy tubed and I turned to move the monitor so I could see the screen better in the sunlight. At that time Jimmy was flushing a epi needle. And wham, I got jabbed to the bone in my finger. Rookies take note We came to the conclusion that we faulted by not making enough room, Be sure to have more than enough room to work. Should of had the monitor already where it could be seen. And don't have a needle up where it can be hit. It's just little stuff like that can not be overlooked. Even though Jimmy is now Fire Chief we still tease each other about it. We just said that he zigged when I zagged.

[Doczilla]

I agree with the other statements about it possibly being a locum doc, or someone moonlighting in that facility, or new to that facility, etc. Having a good charge nurse in the code is a Godsend. I prefer them to be recording (though they often want to be "doing") because they can keep another set of eyes on the room and catch things that get missed. The doc is looking at the big picture. Having an experienced nurse alongside can help avoid issues like ordering drugs when there is no IV access, or changing assignments, etc.

Another thing that I tell students rotating through the ED is this: codes/traumas where a lot of things are going on appear to be chaotic. You have to look past the noise and the movement to see what is truly going on, what issues are being addressed, etc. It is possible that although it looked like a cluster, things were happening more smoothly than apparent. It's easy to say that a code is going well once the airway and IV are established and everything is happening consecutively rather than simultaneously. When you have multiple staff doing multiple things at once, this is where it can be overwhelming to people not used to it, or inexperienced providers. This is what truly separates emergency medicine from all other specialties.

A good paramedic or physician is looking past the immediate interventions and anticipating the next. "give 1mg epi" is easy enough at the provider level. "Draw up the amiodarone" and "order blood up here" are looking one step beyond what is going on. It's possible that the physician was asking for the next drug in anticipation of the IV being established shortly. Or not. Difficult to say when I wasn't there.

Let's not forget the importance of a good prehospital report on arrival at the ED. Maybe one wasn't given, or the doc wasn't listening, but the IV and airway issue should be known on arrival with a good report. "Down time...yada yada yada... attempted intubation unsuccessfully, so placed a King airway... attempted IV unsuccessfully.... put a 20g IV in on this side but I'm not sure if it's working....summary of drugs that have been given...last drug given....time since last epi..." These things will set the priorities for the physician and let him know what to address immediately and where we are in the ACLS protocols.

First things out of my mouth to the ED staff:

"How's the tube?" (to the Respiratory Terrorist)

"How's the IV access?" (to the nurses)

I will recheck these periodically. This is ensuring the ABCs are addressed and rechecked.

The King Airway, like adult IO, is one of those things that really started out in EMS, so they aren't as well known in the hospital setting. King airways are still pretty much relegated to EMS, so ED staff aren't familiar with it. IOs are known in the ED, but they are unknown in the rest of the hospital (with the exception of pediatrics).

'zilla

[firedoc5]

Let's not forget the importance of a good prehospital report on arrival at the ED. Maybe one wasn't given, or the doc wasn't listening, but the IV and airway issue should be known on arrival with a good report. "Down time...yada yada yada... attempted intubation unsuccessfully, so placed a King airway... attempted IV unsuccessfully.... put a 20g IV in on this side but I'm not sure if it's working....summary of drugs that have been given...last drug given....time since last epi..." These things will set the priorities for the physician and let him know what to address immediately and where we are in the ACLS protocols.

First things out of my mouth to the ED staff:

"How's the tube?" (to the Respiratory Terrorist)

"How's the IV access?" (to the nurses)

I will recheck these periodically. This is ensuring the ABCs are addressed and rechecked.

'zilla

Exactly, a good accurate report essential, with the unsuccessful and screwups included. Good or bad you have to be accurate.

I too check the tube before and after getting out of the rig. Get inside and tell the RT to check the tube immediately. One night brought in a code and did the usual. But moving from the cot to the table they must have moved the tube. When the RT checked the tube it got pulled back a bit. And the doc just rolled his eyes. Now this doc was our new Medical Director. So I didn't know how he would react. But after all was over I pulled him to side and I told him that if I bring a tubed patient in, it will be correct or they won't be tubed, EOA then. He sort of glared at me at first and started laughing saying he knew it was placed right until they moved the guy. He was tentative enough to notice the tube move. He was real cool. But we became the best of friends after that. He ran a program on his own for doctors getting ready to take specialty boards. When there was a seminar for ER docs he had me give the "what's out there" and what we put up with, and sometimes it's not pretty. Even after I was done I stayed for the whole seminar and picked up a lot info. And I was a "gopher" too. It was a lot of fun.

[Mateo_1387]

And you too are assuming. Just because there is a visible IV does not mean it is functional. There was a tube sticking out of the patient's face but not the most appropriate airway. The doctor was dictating but with the wrong assumptions. So yes, he was making the wrong assumptions.

I Kind of have to assume without actually being there to see it. I see what you mean by it being there but maybe not functional. My idea of 30 seconds may be a bit off, but it does not take long at all to figure these things out.

The doctor may have been a rent-a-doc and did not know who anyone was in that ED. The other staff may have been PRN or floats. Unless you are going to work in the ED environment, there may be little you can do to change that or even understand it. Some days things run smooth as silk and then there are times when things just don't click. This may have been a very off day for whatever reason. It seems that it was a very off day for the 3 Paramedics in the back of that truck.

This is no excuse to me. In my system there are multiple agencies that respond to codes, you have a chance of getting two trucks from six different EMS agencies, 1 of five supervisors, and 1 Fire truck from 22 different fire departments. So there is a large degree of not knowing who you will respond with. Yet in every cardiac arrest there is an established code commander, and the cardiac arrest always run smoothly. In the cases reviewed where mistakes were made, there was not code commander present.

We boast high resuscitation rates. Everyone knows there place on a call. Same should be the case for hospital staff.

Let's not forget the importance of a good prehospital report on arrival at the ED. Maybe one wasn't given, or the doc wasn't listening, but the IV and airway issue should be known on arrival with a good report. "Down time...yada yada yada... attempted intubation unsuccessfully, so placed a King airway... attempted IV unsuccessfully.... put a 20g IV in on this side but I'm not sure if it's working....summary of drugs that have been given...last drug given....time since last epi..." These things will set the priorities for the physician and let him know what to address immediately and where we are in the ACLS protocols.

I have a different view on this. Say you get a good review from the medic. If they are 10 minutes out things quite possibly will change. The last drug given, tube placement, anything. When that patient comes through the door, you are going to check that the tube is in the right spot, weather they told you before hand or not. If you expected it to be in place when they came in and it was not placed properly, then you should be prepared to fix it.

In my opinion the radio report should consist of "we are en route to your facility, full code, eta 10 min." That way you know to have a team ready to do anything you need to have done. If things are done before they enter your facility, kudos to them, otherwise be prepared. I think it is bad to have tunnel vision before the patient arrives and be thinking one direction, when the patient arrives just to be slammed and have to change up. At least if you a left in the dark, you will not be surprised, and can give appropriate care in an organized manner.

[Doczilla]

I have a different view on this. Say you get a good review from the medic. If they are 10 minutes out things quite possibly will change. The last drug given, tube placement, anything. When that patient comes through the door, you are going to check that the tube is in the right spot, weather they told you before hand or not. If you expected it to be in place when they came in and it was not placed properly, then you should be prepared to fix it.

In my opinion the radio report should consist of "we are en route to your facility, full code, eta 10 min." That way you know to have a team ready to do anything you need to have done. If things are done before they enter your facility, kudos to them, otherwise be prepared. I think it is bad to have tunnel vision before the patient arrives and be thinking one direction, when the patient arrives just to be slammed and have to change up. At least if you a left in the dark, you will not be surprised, and can give appropriate care in an organized manner.

You misunderstand me. I meant the report on arrival in the ED.

'zilla

[Mateo_1387]

You misunderstand me. I meant the report on arrival in the ED.

'zilla

Oops, my bad, I totally missed it :oops:

[VentMedic]

This is no excuse to me. In my system there are multiple agencies that respond to codes, you have a chance of getting two trucks from six different EMS agencies, 1 of five supervisors, and 1 Fire truck from 22 different fire departments. So there is a large degree of not knowing who you will respond with. Yet in every cardiac arrest there is an established code commander, and the cardiac arrest always run smoothly. In the cases reviewed where mistakes were made, there was not code commander present.

Are you in a truck by yourself? No partner? And how many others show up? Does the code commander come separate?

We like to call it organized chaos in the ED. Things usually get done even if you don't always know their co-workers' names. Experienced people can usually fit in once they get started.

Did you ever think that one ED has to put up with the mess of EMS you just described with 6 different EMS people crowding into the ED with one patient? Now, multiply that by 50 - 100 times per shift minimum for some EDs. Add a 100 or so walkins to that. You have ONE patient with at least 2 - 6 EMS providers. The RN as 2 - 6 patients and some of those pts may not be very stable either.

We boast high resuscitation rates. Everyone knows there place on a call. Same should be the case for hospital staff.

Obviously the 3 paramedics on this truck don't share the same success rates as you if the best they could do on this call was a King tube and no IV. Maybe your perfect system could give them some pointers.

Again, who didn't not know their place in this situation?

Nurse starting IV.

Doctor intubating. (probably an RT somewhere around there also)

Student doing compressions.

Things were definitely getting done.

There wasn't a lot of info given here for the other players who may have also been in their place. As a student, the OP may not have known who all the players were and what their functions actually are. As I stated before my job description changes with every ED I work in.

I think it is bad to have tunnel vision before the patient arrives and be thinking one direction, when the patient arrives just to be slammed and have to change up. At least if you a left in the dark, you will not be surprised

You are probably right. A hospital shouldn't expect much from Paramedics.