Getting better in codes?

CX_EDRN · Jul 8, 2017

Honestly, I think time and experience is the best remedy. I stay pretty calm but if I feel myself getting anxious I always make myself stop whatever I'm doing and take a deep, conscious breath. That seems to be enough to steady me. If you're having trouble placing an IV during CPR, try and go to the opposite side and have someone else grab the arm and hold it down for you. There is never a lack of extra hands in a code, although that can sometimes be a detriment as well. Work out what it is that you're struggling with and find a solution for one thing at a time. Confidence is everything. :)

Guest374845 · Jul 9, 2017

Now that you've been in a bunch of codes, try stepping back to the foot of the bed with the leader for the next one (when there's obviously plenty of help to allow for this). It will look different to you now that you know the roles and the algorithms. It will help time slow down because you're not fixated on a fine motor skill. Take it all in and use that experience the next time it's on you to get a line started in extremis.

Or just walk up to the head of the bed and drill their humerus like a boss. :cool:

Editorial Team / Moderator · Jul 9, 2017

Or just walk up to the head of the bed and drill their humerus like a boss.

That was my first thought! Grab the drill!!!

Julius Seizure · Jul 9, 2017

OP, I was a nurse for years before my hands stopped shaking every time I was in a code. I've seen nurses with 20+ years of experience, leaders on the unit....and then in a code they are shaking so badly that they cannot draw up medications. I think stepping back and watching the code as a whole is a good idea to help slow things down in your mind - as long as you have a good leader managing the code. A well-run code should not be chaotic. As time goes on, I think your abilities in codes will get better. But don't be too hard on yourself. Codes are stressful for everyone. And starting an IV on a moving target is hard, too!

JKL33 · Jul 9, 2017

A well-run code should not be chaotic.

Very true. Are things fairly calm at your place, OP? If voices are too loud/improper tone, equipment crashing around more than necessary and trash is being thrown everywhere, this has an overall effect on participants. I'm not saying none of these things can ever happen, just that they contribute to the atmosphere.

Another way we can mentally encourage ourselves to stay calm is to recognize that (being very literal for a second) the situation is already as bad as it can get - and remaining calm enough to perform precisely and efficiently is the only thing that gives us a chance to reverse what has already happened.

akulahawkRN, ADN, RN, EMT-P · Jul 10, 2017

I worked for a few years as a Paramedic and got used to running codes as the team leader. Back then I was usually the only advanced provider so I'd take airway (HOB) and direct everything either from there or nearby until I got the tube. Then I'd secure the tube and hand off ventilation to another person on scene. That position is also very good for starting an EJ line. Usually I'd go for the right EJ and once that's in and secured, that's my drug route. (This was in the time before drilling an IO was an option.) Next on my list is the tube...

Now that I'm an ED RN, having that experience of being the team leader, it's difficult sometimes to step back and just concentrate on a single task. Regardless it's a good thing to remember a few things when you find yourself caught up in a code:

Slow down. Slow is smooth. Smooth is fast.
It's not your emergency. Do not take personal ownership of it. You help people through theirs, but that's it!
Focus on your single task (unless you're team lead) and remember the above. Do that task as well as you can. Once done, you can move on to another task.
Multitasking under stress is nearly impossible. We serial-task well so capitalize on that. One task at a time.

When its all over, whether or not the patient survives, step back and ask yourself if there was anything you could do better next time.

And once again: Yes, there have been times when I've been tempted to bump a doc out of the way when it was clear he or she was completely intimidated by intubation. While I'd have gotten the tube, I would also have gotten fired...

Gary Mendoza · Jul 10, 2017

I've been a RN for over 10 years. My first year I was very nervous about codes and just about going to work in the ED in general, but when I started working trauma and worked multiple codes daily I became calloused to the codes. Everyone was calm and collected because they had done it so much. It's like most things in life, practice makes it easier.

I notice when I travel to small rural hospitals the nurses tend to get very excited during codes, I've been pulled into the directors office a few times because the other nurses thought I was acting like I didn't care, but it was not that at all; I just don't get excited during codes anymore, just like gun shots and knife stabbings don't excite me anymore either. I give top notch care, but I don't get hyped up like the new grads or the inexperienced nurses.

akulahawkRN, ADN, RN, EMT-P · Jul 10, 2017

I've been a RN for over 10 years. My first year I was very nervous about codes and just about going to work in the ED in general, but when I started working trauma and worked multiple codes daily I became calloused to the codes. Everyone was calm and collected because they had done it so much. It's like most things in life, practice makes it easier.
I notice when I travel to small rural hospitals the nurses tend to get very excited during codes, I've been pulled into the directors office a few times because the other nurses thought I was acting like I didn't care, but it was that at all; I just don't get excited during codes anymore, just like gun shots and knife stabbings don't excite me anymore either. I give top notch care, but I don't get hyped up like the new grads of the inexperienced nurses.

Very similar... except I've only been working as an RN for about 2.5 years now, all of it in the ED... with 6-7 years working on the EMS side of things. Smaller/rural hospital EDs are typically going to have lower daily volumes and therefore also lower numbers of codes so those nurses aren't going to have quite the experience that a nurse from a larger urban ED will have.

elijahvegas, ASN, RN, EMT-P · Jul 11, 2017

its the grimmest but most crucial piece of advice ive ever received during my EMT and paramedic training that stays with me during each code

"they're already dead. you're not going to kill them any worse"

the basic idea is breathe--brush up on your skills any chance you get, and most importantly dont try to tackle something over your head. its one

thing to try to progress and expand your skills, but in a lot of these situations there isn't really a whole lot of time to teach. the best thing you can

do is grab an easy task that you can bang out quickly, and observe what everyone else is doing. once you've mastered your one task, move on to

another duty and keep observing. when i first started off, i jumped immediately on EKG and pad placement while watching everyone else do their thing.

then i moved onto being the iv/io guy. then once i had acls drilled into my head, i volunteered to administer meds. then once you can figure out procredures for A-line setups and central lines move onto that. if you can get your hands on a level 1 pressure infuser be that person.

no one can man a code all on their own, its a team effort. leech all the knowledge from everyone else who can do the things you cant and use that to progress

AZQuik · Jul 11, 2017

A lot of good advice here, but the bottom line is, the more codes you work (not practice), will make them more mundane, and settle your adrenaline a bit.

Until then master the skill. Start iv's the same way every time. Pretty soon the muscle memory off tkit, clean, poke will become so ingrained it will be automatic.

Often the tube goes in during a stop in CPR, time it so that's the poke. Also, don't be afraid of the i/o. Much easier in general, and during compressions much easier than hitting a vein.

LostPenaprilQ1H · Sep 20, 2017

What I did (and still do as a new grad ED RN with 10 months experience) is try to present for as many codes as I can get to. I have pretty much always gone straight to the crash cart to draw up meds/administer meds/operate defibrilator. The more I've assumed this role the more confident I feel performing it. Jumping in and pushing yourself is a great way to become proficient and more confident.

I still get shaky during codes. I honestly feel that I'll always be shaky during codes and I've come to accept that I likely SHOULD be shaky during codes as it is an intense situation that causes an adrenaline rush, increase in heart rate, etc... I find I get more shaky/flustered if the person is young or actually has a witnessed arrest, immediate BLS, with minimal downtime. I feel more responsibility in these codes as these are the patient's I know have higher than average chance at ROSC with chances for good quality of life afterwords.

Starting IVs during compressions can be very difficult and shouldn't consume too much time or interrupt compressions. In my ED we'll typically attempt access utilizing two people trying simultaneously on both arms. If both are unsuccessful we go straight to IO.

I also find that being a part of the "cleaning up" afterwords offers closure for me. It gives me time to digest what just happened and make the room and patient as presentable as I can for the family.

Just some food for thought. Everyone is different but I've found this routine has worked for me and made me a better resource during codes!