Code Blue: What Should I Do?

Bridgid Joseph, BSN, MSN, APRN, CNS

Code Blue (cardiac/respiratory arrest) events in-hospital can be really scary, especially if you work in the Medical-Surgical or procedural areas because they are so unexpected (most often, I should say.) I remember my first code quite clearly: a coworker and I were in a double room, helping to admit a relatively healthy (by transplant unit standards) patient, and as we were walking out to finish up the admission paperwork, we saw the patient in the first bed take his last breath. This man was not well, but we did not expect him to go into cardiac arrest!

So what did we do?

We both froze for probably 5 seconds, but it felt like forever, and another nurse walking by saw the scene, called out for help and ran to get the code cart, shouting at us to start compressions. She knew what to do and got us all doing what we needed to for the patient, and then we worked as a team. The code team showed up and took over leading the code within a few minutes and it was as if our hesitation didn't matter (it ultimately had no negative effects on the outcome of the patient), but it did matter to me. I have never felt so horrible about not knowing what to do like that very day, and I vowed that I would never let a patient down because of my own fears again, and I haven't. I have overcome my fear, I actually love responding to codes, and I now train others in how to respond to codes...and hopefully take the fear out of it for them too!

I know that fear of the coding patient, but I also know that while you don't have to be an adrenaline junky like me, you can train yourself to work through that fear you have the first few minutes because you can start to think of a code like changing a dressing over a wound: there are certain steps that need to be completed in order. Sounds to simple? I promise, it's not. And, if you have Advanced Cardiac Life Saving certification along with Basic Life Saving, that's great, but we all have that same adrenaline rush (or 'fear') for the first few minutes, no matter how many certifications we all have, we are still humans and responding to the unexpected life or death situation, right?

Breaking down codes into roles, and having situational awareness of it all will help you to feel confident in your skills during a code event. Based on the American Heart Association's guidelines, the roles of responders can be clear, concise, and very simple:

1st Responder (the person first on scene at an arrest):

Call for help
Drop the head of the bed so the patient is flat
Check a carotid pulse (if you aren't sure if it's yours, theirs, or if there is one at all go to step 4)
Start compressions (see above: if someone has a pulse and you just can't feel it, trust me, they will wake up and tell you to get off of their chest- compressions are NOT comfortable)

2nd Responder:

Bring emergency equipment to the site of the emergency
Help to get a backboard under the patient (if they are not on a hard surface)
Manage the airway (using an Ambu bag or a pocket mask with a one-way valve)

*switch roles with the compressor every 2 minutes

3rd Responder:

Turn on the AED/Defibrillator you have available and USE it (if the patient is pulseless)!

*It sounds silly, but a lot of people turn it on and feel that their job is done....it does need some human interaction and critical thinking skills, like not defibrillating a patient with a pulse.

4th Responder:

Assist in obtaining an IV and getting fluids ready, get emergency medications prepped and ready for the team (if you are comfortable), make sure emergency airway equipment is available, if needed.

5th Responder:

Document the event (this is important for Quality Improvement and Medical/Legal reasons)

Anyone else?

Assist as runners to obtain items that may be needed outside of the room, make any phone calls that may be necessary/requested, and help the code team find the room!

For the first few minutes of a code, this is all you need. You are helping the patient to circulate blood, you are maintaining their airway, and trying to restore circulation through defibrillation (if necessary). When ACLS trained staff/the emergency response team arrives, medications may need to be given, so the patient's primary nurse should stay with the code team leader to give vital information about the patient so they can figure out why this happened and how best to treat it.

How to overcome your fear?

Practicing emergency events on your unit can help you immensely; the more you practice, the less you have to think about what you are doing as it becomes second nature (talk to your Manager/CNS/Educator about doing mock codes).
Get in the room, and take on a role, in every emergency that you can...if you can't practice with mock codes, the real thing is the best experience!
When you respond to an emergency, if you need a moment to take a breath before you get into action, take it, it will help you to use your adrenaline to focus on what needs to be done.
Debrief: talk to the other responders after real/mock code events and speak honestly about what you felt about the response, including what went really well, and what could be improved for next time. It will make you feel better and realize that everyone has fears and stresses about codes.

What should you try to avoid?

Running away: I understand the whole fight or flight response, but don't fly....please? You need to be there for your patient; fight through it!

Switching roles without communicating: If you need to switch roles for some reason, communicate with someone else in the room to make sure they are taking over your role (maybe you don't feel comfortable with the AED, or someone needs you to take over compressions, so communicate clearly that they need to cover your role).

Yelling: You can communicate best by speaking, and people respond best to clear and concise communication, as opposed to yelling.

When you walk into an emergency situation, think of the roles of responders, and as each action as a task that needs to be completed, just like any other routine care of a patient, and you will slowly but surely overcome your fears. You have the skills and you can put them into action, so be confident in your competence and keep saving lives!

Learn more in Part II of this topic!