3 C’s Of Code Blues – Calmly Communicating With Confidence

Code blues requiring advanced cardiovascular life support (ACLS) can be anxiety-ridden for anyone. This post will not discuss the actual algorithms but rather what I call the “3 Cs” of running a good code – calm, confident communication.

As an intensivist and cardiac anesthesiologist, I’m accustomed to running codes in the ICU and OR. The first step is to take order, clearly identify yourself as the code leader within the chaos, and delegate tasks to the individuals assembling at the bedside (timekeeper, access, medication administration, airway, etc.) Cognitive unloading is essential for the code leader. It provides everyone with a singular task to focus on – the most important being high-quality chest compressions and/or early defibrillation based on the initial rhythm.

Second, the room should be silent except for the code leader and those announcing a task has been completed (“18 gauge IV in the left arm!”) or milestone has been achieved (“end-tidal CO2 increased!”). Extra people should gather OUTSIDE of the room. I’m a firm believer in this and will (politely) ask others to leave as I feel this is a prevalent barrier against streamlined communication.

Next, I’ll verbally go through the differential (“H’s and T’s”) in addition to doing a subcostal cardiac ultrasound assessing for reversible pathologies (hypovolemia, tamponade, etc.). I try to get this done in the first two minutes to start addressing potential triggers immediately. Confidence comes from a combination of experience and preparation, so constantly staying up to date with guidelines and mentally rehearsing hypothetical scenarios is helpful.

Regardless of the outcome, I’ll conclude a code with a moment of silence if appropriate and an opportunity to debrief. The code team will openly identify barriers to completing their respective tasks and provide other feedback regarding the overall workflow. Finally, I’ll acknowledge the efforts of each team member and proceed to update family members/caretakers. This debriefing is often neglected but provides an opportunity for the entire team to reflect and often comfort each other when patients we have all cared for succumb to their illness.

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