Tuesday, March 27, 2012

Code Blue In Real Life

As I previously mentioned, I am currently studying for my recertification in ACLS. Once again the algorithms have been slightly altered from my last test two years ago so that retaking the test is a necessity. But luckily, the good folks at the American Heart Association have been paying attention and have simplified the steps we have to memorize to pass the tests. Gone are the maddening anti-arrhythmic drugs such as procainamide and bretyllium that we used to have to regurgitate to the tester in order to pass the Megacode section. Those steps were impressed in our craniums just deep enough to get our certificate then promptly forgotten within forty-eight hours. Now the AHA has shortened the algorithms so that the only drugs left to remember are epinephrine and vasopressin. Even the old standby, atropine, has fallen from favor.

In real life, resuscitations were never that complicated.  When a code blue was activated, the team would race to the patient's bedside. The anesthesiologist would intubate the patient. Somebody would wheel in the external defibrillator and hook up the monitor. One of the medical students or the intern would start chest compressions. After a couple of minutes, the code leader would ask for a pulse check. If none was detected and the rhythm appropriate, the patient would get shocked and chest compressions would begin anew. Every few minutes the leader would call for a bolus of epinephrine. Intermittently, somebody will get the idea to give some calcium or bicarb. Once the patient deteriorated to slow agonal or asystolic rhythms, atropine would be added. Only once did somebody actually order procainamide to be started. I think it was by a third year Medicine resident who wanted to prove his acumen in running codes. I'm not sure it was ever started. I don't think anybody even knew where to get the procainamide. And I'm sure I have never seen bretyllium requested at a code blue.

I'm glad the AHA has realized that simple is best. Previously the algorithms were so complex that it was rarely followed as prescribed. They printed up little pocket cards that doctors could carry so that they had something to read off of during a code. But in reality, nobody had those cards in their wallets or pockets when conducting a code so resuscitations were always carried out by memory of a test possibly taken years prior. And the only thing people remembered was shock, epi, shock, epi... Now the AHA has come to the same conclusion.

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