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As an ICU attending, I’ve led hundreds of codes, & as a sim instructor, I designed a sim focused on the intangibles.
Here are 10 essential elements of code & rapid response leadership (in no particular order) that are not taught enough yet help control the chaos.
🧵
Here are 10 essential elements of code & rapid response leadership (in no particular order) that are not taught enough yet help control the chaos.
🧵
1/ Be a calm & clear leader
ACLS 101.
This isn’t about ego. It’s about your patient.
Don’t be mean or yell.
Calmly stand at foot of the bed, raise your hand, & say, “I’m going to run this.”
Reset the room.
Attendings, support your trainees, “I’m right here. You got this.”
ACLS 101.
This isn’t about ego. It’s about your patient.
Don’t be mean or yell.
Calmly stand at foot of the bed, raise your hand, & say, “I’m going to run this.”
Reset the room.
Attendings, support your trainees, “I’m right here. You got this.”
2/ Turn down the noise
Chaos loves 20 people in a cramped hospital room yelling at each other.
Ask everyone to try to be quieter & for non-essential personnel to step out.
In our MICU, codes are quiet. We strive to control the chaos like an orchestra.
Chaos loves 20 people in a cramped hospital room yelling at each other.
Ask everyone to try to be quieter & for non-essential personnel to step out.
In our MICU, codes are quiet. We strive to control the chaos like an orchestra.
3/ Clearly define roles
Chaos loves too many cooks in the kitchen.
Instead, point to people & identify these essential roles:
- Recorder & timer
- Chest compressions (with backup)
- Pulse checker
- AED person
- Airway person/RT
- Family updater
- Pharmacist
Others?
Chaos loves too many cooks in the kitchen.
Instead, point to people & identify these essential roles:
- Recorder & timer
- Chest compressions (with backup)
- Pulse checker
- AED person
- Airway person/RT
- Family updater
- Pharmacist
Others?
4/ Close the loops
Don’t yell into the ether.
Close the loops.
- Point to someone, “I need a fluid bolus off pump & pressure bagged.”
- Hear them acknowledge, “Fluid bolus off pump & pressure bagged. On it!”
- Await loop closure, “Fluid bolus going!”
aha.org/center/project…
Don’t yell into the ether.
Close the loops.
- Point to someone, “I need a fluid bolus off pump & pressure bagged.”
- Hear them acknowledge, “Fluid bolus off pump & pressure bagged. On it!”
- Await loop closure, “Fluid bolus going!”
aha.org/center/project…
5/ Prioritize orders
Related to #4, don’t expect an exhaustive list to be magically done, “I need an ABG, BMP, X-ray, fluid bolus, Levo, EKG…!”
Nope, that doesn’t work.
What is most important?
Prioritize the most essential & timely.
Utilize an iStat (2 min) & POCUS.
Related to #4, don’t expect an exhaustive list to be magically done, “I need an ABG, BMP, X-ray, fluid bolus, Levo, EKG…!”
Nope, that doesn’t work.
What is most important?
Prioritize the most essential & timely.
Utilize an iStat (2 min) & POCUS.
6/ Don’t miss the intangibles
Observe the room & catch these intangibles:
- No backboard!
- Bag mask oxygen not cranked up (you’ll know when you don’t hear that high-pitch or NRB mask not inflated)
- No suction ready
- Fluid bolus not off pump & not pressure bagged
Others?
Observe the room & catch these intangibles:
- No backboard!
- Bag mask oxygen not cranked up (you’ll know when you don’t hear that high-pitch or NRB mask not inflated)
- No suction ready
- Fluid bolus not off pump & not pressure bagged
Others?
7/ Find family & update often
Identify & acknowledge family.
They’re often pushed into the corner.
This is stressful. Don’t make it more stressful by neglecting them.
Identify a team member to stay at their side & update them often.
#pallipulm @pallipulm
Identify & acknowledge family.
They’re often pushed into the corner.
This is stressful. Don’t make it more stressful by neglecting them.
Identify a team member to stay at their side & update them often.
#pallipulm @pallipulm
8/ Don’t anchor
Be open minded & don’t anchor to a single diagnosis.
Is it just septic shock causing their hypotension, or could it be a pneumothorax or hemorrhage?
Utilize all the tools in your #ShockToolkit: POCUS, iSTAT, history, exam.
Be open minded & don’t anchor to a single diagnosis.
Is it just septic shock causing their hypotension, or could it be a pneumothorax or hemorrhage?
Utilize all the tools in your #ShockToolkit: POCUS, iSTAT, history, exam.
9/ Engage your whole team
When I run a code, I make it clear that I need everyone’s help.
We are all part of a team trying to save a life.
Utilize the collective brain. Ask questions of the room: “What happened here? Any other ideas? What am I missing?”
When I run a code, I make it clear that I need everyone’s help.
We are all part of a team trying to save a life.
Utilize the collective brain. Ask questions of the room: “What happened here? Any other ideas? What am I missing?”
10/ Debrief
We don’t debrief enough, if ever.
Taking a cue from @Atul_Gawande, I seek feedback often to improve. Debriefing helps that.
Create a safe space with time to pause, express emotions, learn, regain composure, & get water, food, & coffee before continuing rounds.
We don’t debrief enough, if ever.
Taking a cue from @Atul_Gawande, I seek feedback often to improve. Debriefing helps that.
Create a safe space with time to pause, express emotions, learn, regain composure, & get water, food, & coffee before continuing rounds.
11/ This is not meant to be a complete list.
I’m sure my pulmonary & critical care colleagues have skills they’ve honed to lead codes well.
What are other intangibles you see which are often missed & ways that you control the chaos when leading a code or rapid response event?
I’m sure my pulmonary & critical care colleagues have skills they’ve honed to lead codes well.
What are other intangibles you see which are often missed & ways that you control the chaos when leading a code or rapid response event?
@Dr_Oubre Ask and ye shall receive. Thanks for the nudge.
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