Episode 62: Running a cardiac arrest

Hey everyone, I'm Brandon Odo. And I'm Brian Bowling. And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling and expert guests to impact how critical care is practiced in the real world. Welcome back everyone. It is Brandon Odo back with Brian Bowling. Hey everybody. And we've got a case for you today, no guest. And I swear it's because we wanted to get back to basics and not because we had a guest reschedule on us. That is as far as you know the truth. But it's worth I think, you know, we don't need a guest for this topic, which is good old. Cardiac arrest. We were just talking, we're like, have we ever really just done a cardiac arrest case? And I think we've hinted around it in the context of other things, but we haven't really tackled this. And I think it's worth doing because while the nuts and bolts of ACLS is something we all kind of sit through and re-servations every year or two, everyone actually does it differently. Which is reasonable, it's down to logistics and practicalities and workflows. And it's worth taking a close look at because the way I do it and the way Brian does it are going to be different and it's going to be different from how you do it. And we can all probably learn a little bit from each other. So Brian's got a case for me and we're going to chat about it and we'll see what we can take out of this. Yeah, I think the other big take home from this is people who do resuscitation on a regular basis, right? The ER guys do this a lot. People in the ICU, depending on type of ICU, you probably run codes more often than others. But those people who do it regularly don't always stick to the script of ACLS, right? Because that's not really what ACLS is designed for. It's not designed to be the end on the be all of cardiac arrest resuscitation or any kind of resuscitation. It's really designed more for a framework so that when suddenly everything goes off the rails, you lose a pulse, you have a V-tack, V-fibre rest, a patient goes down in the hallway or on the floor, et cetera, that people can just sort of without thinking start doing stuff because we know that doing stuff is better than not doing stuff and the faster you do stuff, the better the outcomes are. Yeah, ultimately ACLS is not only some people call it an introductory or basic approach to cardiac arrest. There might be some truth to that, but it also just doesn't say much about a lot of things. They continue to make it more stripped down so that it's more accessible, but also I think respecting the evidence more in the areas where there's not much data, they increasingly say we have no opinion on this, which leaves room for us to do things different ways. So there is practice variation and it's all permissible because just no one has done a study showing that it matters. So everyone's got a different approach. All right, Brandon, so you are in the ICU. You have, you're coming on for a night shift, you're settling in, you've sort of gotten signed off from the day team, you've decided what to order for dinner. You've got all the stuff sort of squared away, you're getting ready to go, kind of walk around and see how things are going, and suddenly the coat alarm goes off, right, so you can hear overhead that alarm going off and people are running down the hallway. So you get to the room and you find a 75-year-old gentleman who originally came in earlier this afternoon with some sepsis, came in from outside hospital, sepsis of an unknown source at this point, but just that he was starting to look shocky at the outside hospital, was intubated there and packed up and sent to you. You don't know a lot about this guy because he kind of just got there, but the sign that you got was that he sort of had the basic workup started since he got there. He came with some things that they had started at the outside hospital, he's on some antibiotics. He is not so far required, vasopressors, that may change. He's been relatively stable despite being intubated and sedated, okay. So you get to the room, sort of what's your first thing when you approach a situation like this, what do you start with? So my approach to a cardiac arrest, much like to any kind of crashing, really sick patient, in particularly one where you're kind of coming into it fresh, like you haven't been, you haven't known the patient much, you haven't really been doing stuff, you know, the classic one would be a coat on the floor or something, but it could be one of your patients to like this where you just kind of came in. You got to figure out what the deal is and that means, you know, understanding what's happening and what you have to do about it. So look, all the context we have is that it's this vaguely septic patient who didn't seem wildly unstable although they were sick enough to be intubated and now reportedly has no pulse. So I'm walking in there. The benefit we have is that it's an ICU patient already. So there is a lot of resources in control we have that we wouldn't have in another setting. So if you go to a code outside of the unit for instance, then you're not going to have as much monitoring available. The staff of course may or may not have the same familiarity with this sort of thing and just a lot of the tools you're used to having, you're going to have to scramble to get. But we're on better footing here because they're probably already on the monitors and in this case they already have an airway. So that's all great stuff because some of the first questions I try to ask with a fresh crisis like this is on the one hand your ABCs. So we have an airway already and we can decide how their breathing and circulation is. And then on the practical side, do we have enough access? Do we have enough monitoring? Do we need some other resources here? So I'll ask you, as patients in the ICU on the monitor, I'm going to look up what's the rhythm that I see. You're in VTAC. Okay. So VTAC is one of the somewhat easier rhythms to recognize. Of course, sometimes they still trick you and it's something like an SVT with a barren conduction or whatever. I assume there's a nurse or a couple of nurses around. Yeah. So you're the upsides and downsides, right? It's shift change. So you've got lots of people around. The downside is that you've got people who are trying to leave and the people who coming on don't really know this guy. But you've got lots of help right now. Okay. And then as far as my world, are there other providers floating around? Yeah. Because you're changing over too. So the day team is still there, you're coming on. That's pretty much it, right? You're in the regular ICU, medical ICU. But yeah, lots of people. Sure. When codes and just resuscitation is typically taught, one of the things people will teach is in order to maintain a controlled, smooth workflow and make sure things get done, you really want to have kind of one person who's clearly running it, a leader for the team. And straightforward, well-defined roles for everyone else. You're doing this. You're doing that. Communication, when you want something done, who's doing what? And that all sounds great in theory. But I tend to find that it is hard to do in practice when you have not drilled this stuff in advance. We talked, you know, when we spoke about cardiac arrest with the emergency mine guy, Dan Dorkis about team management and stuff. I really think that those types of things, you can't make up at the code. You have to learn and train those things ahead of time. So if our team and our unit has drilled these sorts of things, what are the roles in a cardiac arrest? Who's going to run it? How are we going to manage responsibilities and that sort of thing? Then great. This is a time to use it. If not, we're not going to build that structure on the fly. So you end up with sometimes who's running it as a little flexible and who's in what role and doing the specific tasks ends up being flexible as well. And I think that can be okay as long as people are used to doing it in an effective way. So yes, ideally, a walk in the room and either somebody is clearly running this team or I'll say that I am. If there's a couple of us, whatever, you know, you can kind of decide on the fly how important it is based on how much of a vacuum of leadership there is, if that makes sense. And then the people in the room as well, am I going to say you are doing compressions, you are recording, you know, you are pushing meds, probably not. And partly because I don't know who's best equipped to do all those things. So what do you do instead? Well, when you want something done, you spell it out clearly to the room and then you just make sure that someone says they're going to do that thing, assuming that they're going to be a person who's well equipped to do that. Now, as we talked about with Dan, I would love a lot of these things to actually be managed by the nursing team internally. And that may mean having someone kind of running their side of it and tasking things out to the right people and following up on them so that I don't even have to worry about it. But that's again something you usually have to work out ahead of time. So that's as far as how we're organizing the team here. As far as practicalities, we have a rhythm. We should confirm that there is no pulse because VTAC electrically is a rhythm that could have a pulse or could not. So someone should be feeling a pulse or I am, you know, can we appreciate any pulse at all? And you have no pulse now. Okay. And is there an A-line? No, no, yet. Okay. That's an important thing for monitoring, you know, for any critically ill patient. But I think a huge help in a cardiac arrest because questions like this, is there a pulse which when you're going by a palpation can become almost like a vibe-based decision? I mean, how sensitive are your fingers and where are they? It's much easier to just look up at the monitor. But we don't have one right now. Sometimes the pulse ox can tell you some of that. Now, if you have a clear plethe on the pulse ox, I'm pretty confident there is a pulse. And if someone is like, hang on, I'm not sure. But okay, we seem to have a pulse this VTAC. So ACLS and, you know, at this point, everybody in their mother understands that's something you have to defibrillate. So next question is, do we have pads on, and if not, let's put them on. Yeah. So the team's getting pads on. They've got the coat card in the room. They're hooking everything up. The other important thing obviously is doing chest compressions. If somebody called a code, they probably have started doing that, although that's certainly not a guarantee. But if not, they should be. But I think one of the real threads throughout this whole process, when you look at cardiac arrest from the evidence-based side is understanding which interventions definitely have an effect on outcomes. And this is a real simple thing because there's not that many. What clearly affects survival to discharge from the hospital with good neurologic outcomes, which is what we actually want, good chest compressions, good meaning started right away, interrupted as little as possible for as little time as possible, deep with very good recoil, and defibrillating early, and that's kind of it. Everything else is maybe helpful, unclear, maybe affects surrogate outcomes, probably certain patients that helps. But honestly, if that's all you did, you'd be on pretty decent footing. And that's why in outpatient settings, that's often all we ask by standards to do. You'll push on the chest, you could do that well, you're doing a lot of what you need to do. So we should remember that because we're going to start thinking of doing a lot of other stuff, which is fine, but it should not interrupt that stuff. If you're having like deep thoughts, and it means you're interrupting chest compressions, I think you're probably doing it wrong. Yeah, fair points. And I think that when you have someone running these teams, that's one of the important roles. And you could delegate this to someone, but really making sure that those basics are getting done. Yes, someone's doing compressions, but are they doing effective compressions at high quality? And some teams will even assign someone to just watch compressions and ensure the quality is good and coach them and say, hey, you know, you're going a little fast now or you're starting to lean someone who can use like a metronome or have a stopwatch and just track those things, a very reasonable thing to have. And the more, you know, something like me is not busy, maybe I'm not running it or everything is going smoothly, I'll totally do those things. But on a metronome coach, the compressions, that kind of thing. We talked about PAS, we talked about pulses, we're getting them set up to defibrillate. How is our IV access? You've got some pretty solid peripherals, nothing central. You know, when you got signed out tonight, the team was saying, sorry, hey, things got really busy. I was going to put a central line in this guy. I was going to put a line in this guy, haven't gotten to it yet because he hasn't needed pressers, but probably worth considering tonight, but nobody's actually done it yet. Yeah. So if there was no access for tenuous access, probably the first line should be an I.O. In this day and age, if you haven't readily available. In the old days, we would stick a lot of central lines in in these settings, especially is that they have no access and you're just crashing in these non-stairer lines. And it's a lot of fun and you feel cool. But I don't know if it was particularly safe and they just ended up having to come out a little later because they were never sterile. So except in rare cases, I think an I.O. is fine. But if you have good peripherals, that's totally fine too. Just keep an eye on them because even seemingly good ones come out and you lose them. And we are going to want to be giving meds. So someone could probably start drawing up something like Epi, although technically we don't need to give it quite yet, but it'll take time to draw up and all of that. The good news is, of course, we already have an airway. The question is, I assume on the vent, typically we would take them off and bag them. I don't think you absolutely have to. They're going to have alarms on the vent and you can adjust the vent and turn the pressure alarms way up and stuff like that. But in most settings, people are happier to just bag the patient. And I think that's fine. The other question I would ask in a monitor setting like this is, what the hell happened? So yes, this patient is in VTEC, but did something lead up to this? Was there some sort of pro-dram where they were coming more unstable, hypotensive? Maybe we just do something, like give a med or change something, or is this truly out of the blue? This patient was just chilling, being stable, and then they're now in an arrhythmia. Yeah, that's a good question. So the problem is that because this was during a handover, nobody was really paying that close of attention to him. Right? I mean, he was being monitored. I don't want to make it sound like people were being negligent, but nobody was staying there watching him. And he doesn't have an a-line. So you can't go back and look at the flimetry and say, oh, he was getting more and more hypotensive. If you go back and look at the last couple of hours of trends, this blood pressure is trending down. Nothing really significant from the telemetry from the cardiac monitor, except that you do notice that he's slightly getting slightly more attack at cardiac as the day goes on. Sure. Yeah, people who like to do quality improvement and stuff like to say things like, no cardiac arrest is truly anticipated. People don't suddenly crash that we just suddenly notice it. In real life, though, it's certainly the case that some things do seem to come out of the blue. And you do what you can. That seems like the case here, although we can dig more into it. But in the first minute or two, we, of course, have to focus on simple things, which in this case is getting them hooked up and shocking them. So if we have pads on and are ready to go, I would charge it a fibrillator. That's an unsynchronized defibrillation. And frankly, I'll usually just go to the max amperage on the thing, juulage, and then shock them. And what I'll ideally usually try to do is coach the person doing compressions that we're going to charge the thing. Don't freak out and don't stop. So we can charge while they're compressing. And then give them a little bit of a countdown. Like, you know, tell them on three, we're going to get ready to shock and clear them. But everyone else to clear first, so you don't spend five seconds saying, you clear? You clear? I'm clear. He's clear. We're all clear. And then as soon as they're clearly off with shock and just ask them to get right back on the chest immediately after. And it's a good time to change compressors as well. I like to see two or three people who are kind of established as the compressors to rotate through. So we know who is who is up. You can get a little congeline going. But plan to just compress right after your shock and then just keep kind of working through this. I, again, if it all possible, once this is kind of situated, we have things under control, maybe you got a first shock in, I'd love for someone else to manage this. Keep the time. Keep track of where we're at. You know, we're basically giving epi every two rounds, you know, every couple of minutes that's around, we're going to check the rhythm slash pulse if needed and then maybe shock. That's kind of it. Maybe Amio, the kind of next round in if they're continuing to be in an arrhythmia. But I don't want to have to give too much thought to that stuff because anyone could do that. Everyone's done ACLS there. And if I'm sitting here holding a stopwatch, I can't do anything else and I'd kind of like to do other things. One of those other things, again, kind of quality assurance. So making sure the important stuff is getting done, like great chest compressions, assessed by looking at them, but maybe obsessed by other markers. So if you do have an A-line, you can watch those blood pressures. I would love to have entitled CO2. That is, you know, been a strong recommendation for cardiac arrest for many, many, many years now. And our uptake in a lot of ICUs has been kind of so, so on it. Some places use it for all the vented patients and then it's already there. But if not, a lot of people are not necessarily doing it. They're not like putting it on their bags when they're bagging. They're not doing it in a non-invasive way, a patient who doesn't have an airway. But I think we should because it tells you a lot. If someone is, you know, prognostically, if the end title is pretty high, 30, 40, I'm feeling really good that we're going to get this patient back. If it's like 10, not so much. And also, again, monitoring compressions. If someone is demonstrated we can get that end title to 25 or something and then the next person comes up or they've been on for a few minutes and now it's like 15, maybe we're just not getting it, but maybe the compressions are worse. And we could all point at it and say, Jim got 25. I want you to get 25 or you're fired. Why aren't you as good as Jim? Yeah, you can make a game out of it or I'll get up and I say, you got to beat me. I'm older in my back hurts. It's just nice to have a marker, you know, you know, things like getting a backboard under the patient. And then, you know, as we're shocking, a shockable rhythm means we're, we've got, we're in the game here. You know, something like a sisterly and yeah, you could get this person back, but it does kind of feel like your, the writing may be on the wall. But a shockable rhythm to me, like that's a heart that wants to get going again. And if it's not, then we can all ask what we did wrong. So VTAC, we shocked it a couple of minutes later, I'm going to want to see what's our rhythm now. All right. So you shock and you're still in VTAC. Okay. So this is again, it's just a kind of straightforward, monomorphic VTAC. Yeah. I will kind of do a quality check to see, is there something we could be doing better? So if we can put more charge through it, then I'll do that. I will check the pads in many cases. And you may see that your pads are coming off. You may be that your pads are not very well positioned. People just slap them on usually kind of anterior and lateral. But sometimes they're like so anterior that I'm not confident. A lot of that charge is getting through the myocardium and then I'll reposition them, go straight to like anterior posterior or at least more posterior. And if you're having trouble with contact, you can just try to fix them. Sometimes I will do things like apply pressure to them, get a towel or something. Make sure you have glove hands and kind of lean in on them and make sure you're getting really good contact. And then think about medical things as well. And once things are kind of situated and I can take a breather, this is a great time to or delegate someone to pop open the chart and see what's going on. So what do we know about this patient's history, for instance? I want to go back real quick to talk about something because you mentioned applying pressure to the pads with the towel on and just want to make sure that we clarify it for people that they understand. Talking about applying pressure while the shock is delivered. Yeah, so the issue here is that the worst the contact between your sticky pad and the patient's skin, the more impedance there will be to electrical flow. And impedance is the resistance to an electrical circuit. And while the defibrillator will try to measure impedance in a gest is current to account for that, it is still a barrier. So if you have a lot of air in your circuit, that could be the difference between successful cardioversion and not. So this will come up sometimes with refractory A-fibs and stuff like that, but could it be a cause for not breaking a V-tack? Yeah, maybe. So it's just something to think about, especially if you're like a very diaphoretic patient or some kind of just skin factors where you're really having trouble with pads. And you could do what you have to do. Both they're hairy, try to shave them, maybe use some kind of a skin prep like benzoin, but there is just good old pressure if necessary. You do want to make sure you're not going to shock yourself, of course. There was some literature suggesting that even shocking during chest compressions is safe-ish, but it's only-ish. People do feel it sometimes and I don't want to recommend it to anyone. So something like a towel or just additional padding, it may be a good idea. Yeah, so I just want to clarify that though because I think that this comes up sometimes if you've never seen this and they kind of freak out like, well, I can't shock because you're just touching the patient. And so yeah, I just want to clear up that it is okay to- this is the sort of the exception to the, I'm clear, your clear-or-all-clear rule, right, is that if you have some padding like the towel and you're applying downward pressure on the chest, it's okay to go ahead and shock. Yeah. As long as you're doing it in a thoughtful way and you just didn't- it's not somebody forgetting that there- Right, right. Yeah, you want to make sure that it's not accidental, right? That you're not just saying they're just like, I'm going to try to get this stick here. You definitely want to make sure that it's intentional. Okay, so yeah, so you're going along, you're doing the ACLS thing, you're still in VTAC and you say, what do we know about this guy? Well, so he is a- he's a guy, past medical history of coronary artery disease. He's had a couple of MIs in the past. He had- he had PCI last- last year. He said PCI a couple of times now. So he doesn't have a great heart to start with. He also has some beginning stages of chronic kidney disease. He is not on dialysis at home. He does not have dialysis access, but he does have some chronic kidney disease. And then he's got the usual, you know, stuff that comes with all that, right? He's hypertensive, he's got some hyperlipidemia. He's got some pre-diabetes, whatever that means, you know, the gist of stuff. Okay. So, you know, some of this history is probably not informative. Things like diabetes and hypertension increase your risk of pretty much everything, so I can't do much with that. But some of it could be some more suggestive. So he has a history of a Schemic cardiac disease. So of course, that may predispose him to arrhythmias, but in a more actionable way, it may predispose him to more ischemia. So maybe he had an MI. Nothing I'm necessarily going to do with that right now. The very old days we would sometimes empirically give thrombolytics if you were very suspicious of MI and arrest, but not so much anymore, but certainly in post-arrest. And then kidney disease. And the main things there are easy hypercytlemic, which is a very reversible cause of arrest. And potentially some other things like he could have a paracardiophusion, which can happen uremia, and that can cause tamponod. But of course, we have more information too. So does he have labs or imaging that we've had, which are informative at all? He doesn't have anything yet unless you want to send some stuff now. Yeah. Of course, depends on the patient, right? This guy just arrived. I'm sure he had something done in his other center. Hopefully there's nothing too exciting that anyone knew about. Like they found a dissecting aorta and they didn't mention it or something like that. But we have what we have. So typically we will send kind of some broad labs. I don't find them wildly useful in cases like this, partly because it's going to take a while to come back. And partly because there's not that high of a yield. If you have point of care testing of some kind, that may be a little quicker. But generally, what's it going to show? Grassodotic, everything's a little weird, they're lactate tie, that kind of thing. A potassium could be useful, but what I'm probably going to do, if there's any possibility of hypochylemia, is just treat it empirically with calcium, which has a very rapid and salutery effect on hypochylemic cardiac instability. So I'll typically give a gram of calcium chloride. They'd say you don't necessarily need to do this routinely for all arrests anymore, which I think is probably true. But if there's any hint of possibility of hypochylemia, I would usually do that. And then for other kind of, and now we're getting into what you would call, you know, reversible causes and people talking Hs and Ts and stuff like that, I don't necessarily use that framework. But I do think that looking for things to reverse is probably the most important thing. Once things get into the flow of ACLS that I can be doing, because again, they don't need my help. Tell them when to push epi, I don't really care if I get it a minute off or something anyway. Like I said, the evidence is not that amazing for it to begin with. But I don't want to miss the hypochylemic and not treat that. So the other thing that I'm in almost all cases is going to be doing is putting on an echo probe. Again, kind of mixed evidence on the benefit here. But I would like to get a probe on every arrest at least once and just make sure there's not some really readily, readily fixable thing that I could be addressing. So what does this look like? Again, the most important thing is not to screw up our basics. So I'm not going to interrupt compressions. But you got a machine there. And if I'm off the floor, I have a little portable butterfly I'll sometimes use. But ideally we have a unit around. Get it situated, probably get on the patient's right side, put gel on the probe and put it on the skin or almost about on the skin in a sub-cost or a sub-siphoid view. And you can try to get a view while compressions are ongoing. But it's tough. It's like trying to hit a target with a rifle from the back of a kangaroo. It keeps bouncing. It keeps bouncing. I will workshop that one. Anyway. So realistically, you're probably going to be waiting until the next pause. And the benefit of going from a sub-costal window like this is you're kind of out of the wave of everything else. So you're ready to go. You got your probe on. As soon as they stop, you're going to try to require that view. And your goal is not to interpret it, it's just to get a clip. So I want to save a view of the heart and then get out of there. Get the probe off and ideally have a towel there and wipe the gel off. As long as you're not using a para-sternal window, the gel may not at the end of the world. If your para-sternal is going to really irritate the compressors because they're going to be sliding around, but it's probably a good idea to wipe off anyway. And then just get out of there. And then at your leisure, you can look at your clip and see what's going on. And what are the useful things to look for? The first thing that will jump out at you is what the heart is doing. And that may correspond to your understanding based on the rhythm. So if it's in V-tack, you'll see the ventricles being tagging cartic. And if there's no pulse, probably contracting very little. But sometimes it's surprising. For instance, you could think that there was a systole. And in fact, you see an organized rhythm with just a very weak heart. And that may say, make you say, hey, maybe I should try to shock this or maybe it looks like the heart is fibrillating. And that's a shockable thing. So it kind of adds information. There's not good evidence for like treating these eco-graphic findings versus the clinical or just electrical findings. But I think it makes sense to a lot of us. But again, the most important thing is reversible causes. So is there any effusion that makes me think there could be tamponade? And if there is in this setting, you could call for help, but I would probably try to drain it immediately. I mean, by the time anyone else gets there, you're going to be so far down the rabbit hole that it doesn't matter what cause the arrest that you might not get them back. And then other things, you know, if there's an extremely flat IVC, I might wonder about hypovalemia, but typically in arrest, you're going to see a plethora of IVC, the venous side is just blowing up anyway. You could look for other weird stuff. Our V dilation is not going to be that helpful to me. I used to think that was suggestive of PE, but again, by and large, most RVs are big and cardiac arrest. So I wouldn't really go much from that unless you see something like a clot and trans it in the right heart. Now if you had clinical suspicion for PE before, then maybe you could maybe do something like look at the legs, look for a DVT. And then if you do see a big right heart, you see a DVT in a sudden arrest. All right, maybe that's a guy who coded from his PE and then it might make sense to give thrombolytics because there is very good outcomes if you give it early from a PE induced arrest. I might look in the belly for free fluid if I really did think there could be bleeding. And I might look at the chest for pneumothorax, looking for bilateral lung sliding. I probably should do that more often. I wouldn't say I do it in most or all arrests, but that is right in that category of reversible things that you don't want to miss. Yeah, all right. So I think even I have both done the recessed the recessed PE course. Yeah. Did you do PE in your practice? No, I have not been in a setting that hasn't available. I would like to and you know, I think I would use it in much the same way. The benefit there is you can watch the heart throughout the whole CPR cycle. The compressions are not such a problem and get a great view and even do things like use it to guide the compressions. They have a lot of reports of people who could see that you're compressing over a point which is not draining and decompressing the LV. It's actually obstructing it. You're pressing over the LVOT and you're making a choke point. So you could tell them, hey, move an inch to the left and you try that and then kind of monitor quality that way. It's really interesting stuff. But I think most of us don't have TE probes hanging next to our other probes on our porn and care ultrasound machines. I love it if we got to that point. Yeah. I agree with you. I think it's super useful but I think it's not something that most people are going to have access to. I bring it up less for, hey, let's talk about how you can use TE and teach people how to do this. And more for, let's put that out there. In case people aren't aware that this is a thing that you can do in the ICU and that has a lot of benefits and that hopefully this will move the needle a little bit, right? We'll get to the point where we can do that routinely because I think you're right. I think it could be very helpful. Yeah. And in a patient where you can't get surface windows, then all the more useful. But even for those you can, it's just that much better of a monitoring tool. It's like having that a line. You just park it in there and have a really good look at literally what the heart is doing the whole time instead of having to use these surrogate markers like can I feel a pulse or is there some kind of pressure or what's the rhythm? All of which are relevant, but seeing the heart is hugely helpful too. Yeah. So speaking of a lines, so this guy does not have an a line. Do you at any point consider just throwing one in, throwing a femme a line in or is it more trouble than it's worth? So I love to have them. I think it's one of the more useful things in an arrest. Am I frequently putting it in during the arrest? I think it comes down to bandwidth. If it's just me, probably not because I think it's more important than I have a big picture of you of what's going on. If we do have extra hands, like you said, it was shift change. Here's a two or three of us, then yeah, I or delegate to someone, that's a great thing to have done. And assuming again, you have nurses to get it set up and all of that side as well. But is it so important that I would prioritize that over other important things? Maybe not. A lot of this comes down to how fluidly you can make it happen. I mean, I'm not going to like turn it into a federal case where everyone has to get sterile and like it's getting in the way of chest compressions and stuff like that. But and I would do a femme, generally speaking, and I would generally use ultrasound, I mean, I could do it blind, but it's in my hands just going to be probably quicker and certainly safer. Well, especially I think when you're talking about somebody who's getting chest compressions, right? Well, hopefully you're having an easy time feeling the pulse because you're getting good chest compressions, but it's got a very more than if you had a person who had like a normal pulse. Yeah, I really, I mean, it's fun to do blind sticks for lines and stuff. But I think a lot of the reason people think that they're really quick and safe at getting them is because everything's happening under the skin. If you had like, if you lived under the skin and you watched this needle coming in, you would probably think you were under attack by aliens. I mean, there's a lot of harpooning going on that is just a not visible on the surface. I mean, we talked about it with Scott talking about ECPR and stuff. The femme is a good site, but it's a great to have ultrasound. And now if I'm in there anyway, might I throw in a central line, maybe, now if we have great peripherals, maybe not, but if there's anything questionable about them and again, I'm there already. I already have like a kit open, which has most of the equipment, then there's a good chance I will. And just again, it's probably not going to be sterile, but that's okay. Yeah. I feel like I find more often than not, we are, we get a central line by accident, right? We're going for going for the a line and you get blood. It comes back up and you check and it's not pulsatile and it's a very great, well, throw, throw a central line in that and then go next to it for the a line. Yeah, but yeah, I'm with you. If you've got good access, I think I always the way to go. If you don't, and then the need for a central line in during a code, I think is pretty low. Again, it's it's fun, right? Everybody likes those crash lines, but there's a lot of downsides to them and I don't know that they outweigh the upsides most of the time. Yeah, the main time I would really want one is if it was something like a massive hemorrhage and then I do like to have large bore central access, I don't really trust peripherals, but for just meds and stuff, not a big deal. But again, if I'm there anyway, and if there's difficulty with other access, Josh Farcus calls it the dirty double, just take a couple of femelines in, take them out later one of the patient's stable, it's not a huge deal. All right. So you get a look with the probe and you don't really see much of an effusion. You don't really see a whole lot that's all that helpful to be honest. You can see that the heart is, you know, tachycardic. How much do you think in your opinion, how much do you think you're able to see? Things like regional wall motion abnormality at this point. For, well, in the context of arrest, I don't think you're going to see much of anything. Yeah. Unless, I mean, yeah, we said v-tach. If it was a little less v-tachy and, you know, it's contracting a little slower and more organized, maybe, but in my hands, not much at all. I am not a guy who is typically looking at a regional wall motion abnormalities because it's just not in my wheelhouse. The EM guys cardiology, they're good at this. But having a really strong sense of the anatomy and how it maps out is a skill which requires some nuance. And I'm not doing it enough. I mean, how often am I diagnosing an MI, you know, a true type one occlusion acutely, not very often. I mean, I'll take care of them after they were diagnosed and treated in the ER or something. So what we see is demand sorts of stuff, which is not anatomic. So it's just not something I deal with a lot. But again, even if I were, I think in this case, it would be something to tackle after you get a pulse and get the patient resuscitated and then we're starting to ask questions like, what's next? So you get some labs back. Your potassium is a little high. It's 5.8. You've already given some calcium. So I don't know that there's much more to worry about there. What else did you send? I'd probably give more calcium if it's actually high, I just lean into that and why not. Sure. Okay. Would you do any sort of hypercalemia protocol for that for 5.9? In the context of an arrest, I mean, you got a guy in codex. It might push me maybe to give bicarb. Okay. I'm not, I'm not routine to do in bicarb interests. But if I really think that could be it, maybe. But insulin and stuff like that, I don't think any of that stuff works acutely enough, especially in a patient with almost no perfusion that is going to matter much. The key thing really is the calcium because that does work right away and will effectively stabilize the heart if there's any room for that. Okay. All right. So maybe we'll give some bicarb. We're going to give some more calcium. Any other lights that you're curious about or any other labs? Probably not. I mean, again, I expect it to all be a little bit deranged, yeah. But as far as actionable things, the only other kind of like testing stuff, you know, you could think about it a chest x-ray, but I probably wouldn't because it's going to disrupt our compressions and stuff. And the main question really would just be, are there pneumothorax, thermothoroses? And I would probably use the ultrasound for that. If there's questions about the airway, then we can have to tackle that. But most of that's going to come down to, are they bagging effectively? Are we getting good end title? And usually you have some kind of an oxygenation on your pulse ox, but that's the main thing. Now if the story was that this patient got increasingly hypoxic and that seemed to be the cause of arrest, then we're kind of going a different way here and we have to deal with that. But even then we still have to get a pulse back before it's going to be very relevant. All right. So you've given some calcium. You've given some bicarb. You're doing the ACLS thing. Immediately reversible that you can see on the echo. What's next? So it's going to be more of the same. And this may include things like, you know, looking in that chart, making sure there's not something salient in the story or the patient's history, which bears upon what we're doing, making sure that we're doing things with all the best vigor and quality we can, like chest compressions and our access is working and our meds are going in and we're shocking as effectively as possible. It is reasonable if we get two or three shocks in to try to involve someone like cardiology. I don't think they're typically going to have a great deal more to add acutely. But you know, intractable VTAC is, again, it's not quite like a systole or PEA in that it's a little less associated with a patient who was just already more abundant in dying. It's a little more likely to be due to primary cardiac sort of cause. So it is possible they could advise. And the main thing they might offer suggests would be other aneurysmics. We would usually give AMEO. We used to do light-acane, which they took out of ACLS, but not because it was bad. It was just didn't have great evidence. So that would be a reasonable thing to introduce. And occasionally people will consider other aneurysmics like Procane-Amide or Flukelyne or Weird Stuff, which is not in my wheelhouse. So I would usually rely on someone like CARDS to make a recommendation on those sorts of things. People will talk about doing other Weird Stuff more often for refractory V-Fib, which you just can't seem to break. Things like double sequential defibrillation where you use two sets of pads. Things like beta blockade, which sounds crazy, but some of this is driven by sympathetic tones or like an ismalol drip. A lot of this is kind of experimental. I have done double sequential defibrillation and there actually was a study a little while ago suggesting maybe it does help. So sometimes I would try that. V-Tack I think is a kind of weaker indication though. You really, typically, you either break V-Tack or it deteriorates into V-Fib. You know, it's not a stable long-term rhythm because it is organized. And people don't die with an organized rhythm. You kind of go one way or the other. So what kind of evolve that way? And of course, the other thing that at some point we should think about is notifying this person's family or whoever is their responsible party is just going on. I think people are different on how early they do this. I find that some people, it's like the first thing they do. I kind of think that for some like residents and learners, that's because it's something they like know how to do. Like, you know, it's in their capacity and I'm going to go notify someone, which is fine. But I wait a little for a lot of these things because first of all, I'm probably busy. But also, I don't really know what to tell someone yet and let to get a coherent story here. And like if someone codes and then five minutes later, we get a pulse back, that's a good time to let someone know what happened. If they're like coded two minutes ago, you're sort of still in the thick of it. But if we've been here for 20 minutes, then I think it's a good idea to let someone know because we have a decreasing chance that this is going to go well and I would rather set them up for that than dropping it on them, like, sorry, your husband died. I think it's better to be like, listen, this bad thing happened. They have no pulse or heart stuff. We're trying to get them back. It's a good chance. We're not going to be able to do our best for let you know that kind of thing. And then following up later, that's certainly something you can delegate to someone. Sure. Yeah. So speaking of that, how long would you continue this resuscitation if things don't improve before you say, all right, we're kind of out of options here. Yeah. That's a great question. I think a lot of it comes down to the details, how salvageable do you think this patient is? When you have that code that is in the setting of multi-organ failure, you know, maybe an older, sicker person, but they've been here for a day and a half and they've been circling the drain. I think most of us, and I think reasonably, will do a shorter code because the prognosis as soon as they lose a pulse is already very poor. And when you get a few minutes in and they haven't bounced back, then it's even worse. So you don't need to go very far until it's like, diminimous. But in most cases, I would probably do 30, 40 minutes. And that flies by. I mean, you might not think it's been long, but you turn around and you're getting close to that. I will try to do longer in patients who seem to have a better baseline chance. The younger patient, the one that really is kind of out of the blue like this, like they didn't seem that sick before. And of course, you know, they're in the ICU. So it was witnessed right away. We're doing excellent chest compressions and all the right care. And then, you know, other prognostic markers, potentially things like that in title, maybe helpful. And then also, again, the rhythm. Are we still seeing rhythms like V-Tech? Do we get a pulse back? Let me lost it. We got it. We lost it. Or was it like 30, 40 minutes of acistually? If it's still shockable rhythms, I'm going to be more inclined to push this farther. And you know, there is an increasing amount of evidence that in some patients, people have really long arrests and have good outcomes, 40 minutes, 50 minutes, an hour, it happens. And I would hate to be the one who just cut them off because I was tired or I was just so in the habit of assuming nobody survives that I was the reason for it. That being said, you know, 56, 60 plus minutes, if we're not having any other luck and there's nothing else to try, that's probably when we might call things off. Again, unless there's another move, you know, you have ECMO available, like we talked about with Scott. And then we should probably think about it much earlier than that. But reasonable stuff to do or some other Hail Mary's from cardiology or whatever. Okay. All right. So this guy, you mentioned Amy, but I didn't really do Amy, so let's give him some Amy out of her own. How much are you going to give him? So I would do that by like the third-ish round of CPR if we still have a shockable rhythm that hasn't been given. Yeah, he's still in V-Tack, so how much you want to give him? So usually with bolus, 300 milligrams, people get mixed up sometimes because in non-coding patients, we bolus 150 over 10 minutes. But they have no pulse, so you need a higher concentration probably. And you bolus, a realist could we just push it? Yeah. So you get 300 on board. Would I ever repeat Amio? Yeah, you could repeat it at least once. At some point, if they haven't had a response, I don't know if they're going to. That's what I might think about other R&U rhythmics. All right. Like Lydakin, you're thinking, or I think most often, if there's a second line, that would be it. Yes, you talk to cars, and they have some other bright idea based on something. The other exception to bear in mind probably would be Torsads. So we said this is a monomorph of V-Tack. If this was a, it looked more polymorphic, and kind of was twisting and stuff, and you know, someone could dig up on the telly what it looked like before and the QT was long and that kind of thing, you should give Mag. And you know, very reasonable to do empirically, in a intractable V-Tack anyway. But I'd push two, four grams of magnesium, and I might even repeat it if we kept getting V-Tack. Okay. All right. So you give some amiodarone, and we'll go ahead and give four grams of Mag too. I'm a big fan of Mag as well. So we give some Mag and we give some amiodarone. And your next pulse check, you have a sinus rhythm sinus tack with a weak pulse. Where do you go from here? Okay. Well, first we all applaud, pat ourselves on the back, pat each other on the back. What a great moment. But try to cut that down to two to three seconds, because the next thing that's going to happen is the next code. So he has a pulse, so now we are in the realm of just sick patients, and then the question has to be what's his blood pressure. So if we don't have an A-line, then we should cycle a blood pressure and see where we're at with that. It's either going to be very high, because he got a lot of epi, or not that high, in which case, he probably needs more epi. Yeah. All right. So yeah, it's not that high, right? Because he's like a map of, we'll just do maps for easy math, he's a map of like 55, 56. Sure. Which is at least in kind of like a physiologic realm. If it was like 30, then my thought would be like, obviously it's low, but I don't really trust that number anyway. If we don't have an A-line, I want an A-line now. Okay. Because it was really low, and probably very lay-byel pressures, I a thousand percent don't trust that we're going to be able to track it with non-invasive. So this really is a time for that, I think. But we should think about what we're doing, and that means a pressure drip. I think epi, in many cases, is reasonable after a rest to support the heart, but also something like Norepinephrine is completely reasonable, and a patient who was having arrhythmias like VTAC, maybe I would lean that way, a little less beta, because I don't really want to stimulate his heart too much. I'd probably throw the Echo Pro back on and see what we're looking at here. Is it a severely depressed EF, or not too bad? And now I can start to ask some of those other questions like, how does RV look, and is there something crazy going on with the valves or things like that? But hang some kind of a drip, probably try to get an A-line, make sure things like the oxygenation are working out as well, and an EKG. Because now we have to ask those questions like, why did this happen? So we should get a 12 lead while we're able, and ask, does this look ischemic, and not just in a diffused, demanding sort of way, but something anatomic that makes me think, it's got a plaque rupture causing an MI, and that caused this, and he's be cathed now. Yeah. Okay, yeah, so your echo, your echo doesn't look awful, I mean, your EF is depressed for sure. And how much of that is just my cardio stunning, for the fact that he just got a couple of rounds of ACLS versus he has a true kind of heart failure, cardiogenic shock picture. Your EKG does show some ST elevation, looks like inferior wall mostly. It's not crazy, but it's noticeable. And so you start a little bit of epinephrine for the guy, and he gets more tacky, not surprising me, but his blood pressure does come up some, and he's looking less unstable. I'm not going to say he's stable yet, but he's less unstable than he was before. Okay, so if he seems to respond to EPI and is not having crazy arrhythmias, that's fine. But given that he had all these arrhythmias, I would probably want to keep an arrhythmic on board. And if he responded to AMIO, that should be AMIO. So we would start the drip with a low threshold to rebolas if need be, but certainly having that drip running. I'd probably do things like send labs at this point, and he's probably going to be a candidate for targeted temperature management. Now this has been an area of controversy. And I would not drive to do this right, right away, only because it's kind of logistically a thing. And I don't want people focusing on that instead of important stuff, like you could wait a few minutes. Frankly, you could probably wait and just wait for fevers and manage those. That's in that realm of controversy. If we do it, I'll usually go to 36 degrees, and I'd first see, is he waking up if not? If he's following commands, no sweat. But before we get bogged down in those things, or even sending labs, we talked in cardiology and being like, it's guy coded, we got a pulse back, but now his EKG has what looks like inferior MI. And they should be the ones to look at it and decide if they're going to manage. Because, like, prima facia, a patient who has a cardiac arrest is already high risk of having an intervenable coronary lesion. So if you have a slam dunk looking EKG, great. If you have an iffy kind of a scheme looking EKG, you have to be much quicker to calf that patient than, you know, a patient who came into the clinic for an ankle fracture. You know, your pre-test probability is really high. We used to say maybe all arrests should go straight to the cath lab. I think we're not quite there anymore. But if there are signs suggestive of ischemia, they really need to consider it. And unless they have a strong argument why they shouldn't, I think they probably should calf them. Yeah. All right. So you call cards and they look and they go, yeah, I think he probably needs to come to the cath lab. He doesn't really need to come, he doesn't need to bump stuff out of the way. We've got a bunch of cases going, but as soon as the table is open, we're going to take him. So we anticipate within the next 30 minutes. So luckily, it's evening, but the cath lab is still busy. And so everybody's still here, they're not calling in people from home. So you're looking at probably 30, 45 minutes or so until they can get him down there. You're going to keep him stable to then, let's talk about cooling him again. So you had mentioned considering this that I think he is a prime candidate for it. You mentioned 36, right? This is the object of some controversy. Is it 33? Is it 34? Is it 36? Is it just not 38? Right. Do we just say anything less than 37 or 37 itself is okay? We're going to pick 36. If need be, how are you going to go about cooling him? Yeah, I'm using my marker is, are they following commands? That gives you a straightforward tool because sometimes people will be like kind of moving and doing stuff. And then there is sometimes a gray area where they seem kind of there, but they're technically not following commands, but by and large, that's my cutoff. However, again, the value has not been as clear in recent studies. So I rarely go to 33 anymore. I would often go to 36 and you could argue the most important thing is just not having fevers, which you could be reactive about. Everywhere that I've worked, the main tool has been the Arctic Sun, which is external cooling pads in a closed circuit system that watches their temp and then cools them in a reactive way. It works pretty well. You do have pads all over which can get in the way, but you can move them out of the way if you need. It is not the same as just a regular cooling blanket or ice bags or other devices, which are on one hand not as effective, but on the other hand, not reactive enough. These temperatures fluctuate. And the whole argument for doing this proactively would be that you're really minimizing the amount of time they have any fevers. So if you're going to do that, I think you need something like an actual device, even though the pads are a little expensive. There are other ways. There's cooling catheters that are invasive and stuff like that. You could put ice water in the stomach and stuff like that, but I think most people are finding devices like the Arctic Sun to be a good balance of logistics and efficacy. So I appreciate that they give us an estimate for time because that really helps us plan our next little while. So with 30, 40 minutes, I would probably put pads on and cool to 36 if he's not following commands. I would if he doesn't have a airline and probably a central line, try to get those in. If he has really good peripheral access, I might hold on the central line only because if I could get in a fully sterile line in this time without holding anything up then fine, I probably wouldn't put in like a non sterile one if he has other access because it's not that important right now. But I really would like to have an airline and that should be no problem and just kind of getting any other ducts in a row. So yes, getting some labs off, seeing how he responds to whatever pressures we have him on, seeing how he's doing arrhythmia-wise, we need to do more there, how he's doing on the vent and of course, updating family, hey, they have a pulse back, they're still very, very sick, their cardiologists are going to go and see if there's a blockage in his heart, they can open up, you know, we'll keep you posted. All right, yeah, I think all that's very reasonable, I agree with you about the central line. If you're, especially if you're on epi, I think you probably need a central line, but I would not delay getting to the cath lab to get one and I wouldn't put one in dirty at this point if you've got a solid peripheral. Yeah, that's the key. I mean, this comes about the time. Something is playing, which is the most important thing, surgery or procedure or something. You have stuff to do, but kind of timing so you do not, the worst thing is like the patient who's bleeding is to go to a surgery and you're like fudzing around in the middle of a, like a central line or something, right? Like, don't be that guy. Right. Right. Okay, so we've got him all situated, we're going to kind of cool him slash at least to keep him from getting hot, throw an a line in, you manage through a central line in, they're going to take him to the cath lab. Well done. I don't know that there's much more to say because, I mean, we could keep going, right? He's going to come back from the cath lab and you can do all that stuff. You can talk about rewarming from TTM, but that sort of, that sort of gets out of what we originally said out to do, which was running the code. So the code's done. Let's talk about a couple of things real quick, some variations on this. So you mentioned, we mentioned how it was really fortunate that this guy was already in the ICU. He's already intubated. Let's talk about logistics of calling a code. Do you call a code if your patient is already in the ICU? Now, you're saying notify the hospital operator. Yeah, let's call it a page it overhead or set it out over the code page or whatever to the code team if patients are already in the ICU or do you just run it yourself? Yeah. I think this usually should be a policy. Most places I've been, they would. One thing it does is just get your local staff there so you don't have to like call down the hallways. Right. You need help. But it potentially gets you other resources too. Just having enough manpower, especially like with off hours, to do your chest compressions. Maybe you need help with the airway or other things. A lot of what comes you might not need and you can get them out of there. But I think it's usually reasonable initially. Now, if they keep like recoding or something, I don't know if you need to keep calling it again. Sure. But it's something that can be a matter of policy certainly. Right. Yeah. It's reasonable. Right. I think the biggest problem you have when you call code is you get too much help sometimes. But then I think that's, that's good where you can designate someone here and listen. You are, you know, your job is to stand here and you're the bouncer. Right. Nobody gets in. Who doesn't have a job? You got to keep the noise down, et cetera. But I think you're right. You get resources that you might not have. Because I think we forget that. Right. We're like, well, I'm in the ICU. My team's here. My nurses are here. But, you know, what about maybe you have a rapid response team who comes and they have a point of care machine that they can run labs for you if nothing else, right? Or they have somebody who is free to, to record. You know, maybe you're lucky. You have an EICU that you can hit that button and there's an EICU nurse that'll pop up and will record stuff and just let you know when it's time to do, you know, like all those quality improvement things that you mentioned, right? When it's time to do a pulse check, when it's time to give more FB, et cetera. Yeah. Or, you know, other teams who know the patient may materialize. The cardiologist may show up if they knew the patient, the primary service. People that I don't want to have to track down, but if they just materialize, it could be a big help. Yeah. So now, crowd management is definitely a topic that is worth some talk, I think. Yes, it is always true. You end up with more people squeezing into these rooms than fit there. And how to deal with that is a challenge. I feel that... How do I put this? Yes, there's usually too many people and yes, the amount of energy in the room, the amount of noise and like fast movement in chaos is usually too high. And that one of the most important things to do is to kind of tamp that down. This is worse when you're outside the ICU because it's like already chaotic, but that being said, I think a lot of people assume the answer to those things is to like assert authority and start like yelling and being like, all right, you know, I'm in charge here, everyone shut up. If you don't need to be here, get out of here and that kind of thing. And I don't think that really works. First of all, it kind of fights fire with fire and it kind of inflames things more. Second of all, we talked about having clearly to find roles and stuff and usually that's not the case as Dan described, these are like swarm teams, people just kind of accumulate, you know, to know where they haven't trained together. So it's not clear who needs to be there. People are just kind of helping out. Now what you may be able to do is clear out people who know they don't need to be there, they're just watching like a student or something like that. And they're like, all right, I'm in the way now. But by and large, you have people who came to help out and they may or may not be able to. If you just start yelling at them, it's just kind of rude. They're like, they're there to help and you're like, piss off. So, and then what do you have left? Maybe like three people. So I think the better approach is to, you know, bring down the amount of energy by example. If there are specific things you could do, like, you know, hey, could we turn that auction off? It's kind of loud. Or, you know, put on a mechanical compression device because it just kind of cools things down. And then, you know, if you may have to say something like it's getting a little crowded in here, let's see if we can make some space in this room here. If you're not doing anything right now, maybe you can be in the hall, that kind of thing, then I think that's best. This kind of thing is more nuanced than it sounds. It's more like settling a argument with your spouse than it is like being the general of an army. You know, everyone is here kind of to help out. It's confusing. It's complicated. You have to try to make order by demonstrating order than by fiat. That makes sense. Yeah, no. I think it does. And I think the noise thing especially is something that if you're not careful, we'll creep up on you. And then suddenly you realize, I can't hear anything because it's insanely loud in here. And that's when that's when the temptation is to just scream, hey, it's too loud. Everybody shut up and get out of here, right? As opposed to along the way, you know, one thing that's good is if you've got an audible codelarm, right? A lot of places you have a little button you can hit on the wall. It's an audible alarm to call people who are in the hallway, right? Turn that off. That's just going to play her and make noise. You know, as the tempo of things starts to ramp up and the conversations get more and more and more and more, you know, start to say, hey, if you're not actively involved in a resuscitation, can you step out in the hall? Because I think a lot of times you have cross conversations, right? So while you're sitting here running the code, these guys over here are talking about, do we need to get more channels for the pumps? Do we need to get more supplies, et cetera, et cetera? That's a conversation that needs to happen, but it doesn't need to happen right here. So can you guys step out in the hall and have that conversation? And then, you know, when the code goes on for a certain amount of time, people, I don't want to say people lose interest, but, you know, you're standing around not actively doing stuff. You might start talking about things that are completely unrelated, right? Hopefully they're still somewhat related, right? You're talking about how, you know, the guy down the hall needs somebody to go do this or that, not just, you know, how about dem bears, but, you know, some of that stuff and people forget that, and I think sometimes too, you overmodulate without realizing it, right? So you're talking in what you think is a normal tone, but it's actually pretty loud because the room is getting loud. And so you're talking louder and then the room gets louder and so I think you're right, yelling get out is not the answer. Yeah. And it's easy to get frustrated with how crowded it is and how busy and stuff, but not realize that the reason you're able to get things done is because there is all his resources there. And a lot of stuff going on in parallel that if it all came through like a central command and you had to deal with it all, it would be too much. You don't want to deal with the, how many channels are on the IV, you know? So there's a balance between, you know, things being too chaotic and just not having resources because you don't want to have only three people there and then you have to do all kinds of stuff on your own because you don't have enough hands. Right. Right. I mean, I was in a code one time where, you know, it's getting like that and at one point looked over to the code cart and asked for some drugs and there was no one there. And I was like, there was a pharmacist here a second ago. What happened to the pharmacist? Yeah. And that'll happen in the longer ones, right? People start to filter out because they're like, oh, you guys seem good or something. And then before long, there's like, it's just you. Yeah. The best situation I think in terms of crowd control is when you have a team that's not just people, right? All the code and not just like a bunch of people come because they heard a code, but there's an actual team, right? And you have a responsibility, right? You're the airway person, right? So you're the ER resident or the anesthesia resident or the ICU person or what you're the person that you know that when a code goes off, you're going to go to the airway stuff. You show up, patients are already intubated. We can go, hey, they're already intubated and they're like, cool, I'm out then. I'm going to go back to whatever it is that I'm supposed to be doing. As opposed to people show up and you go, we've got enough people, some of you leave, then what happens is everybody leaves because everybody thinks I'm, I'm some of them, right? And so when you have, when you have less delegated roles, designated roles rather, you need to be specific about who you're sending away. Yeah. And it's always ideal to have a pre-built team like we talked about with Dan who trained together. They know their roles. It's just not always possible. It's not how everyone is staffed. The other thing that we should probably talk about is, what do you do when it's all over? Either you, you called it and you didn't get them back or you did, you know, something like here where they're going to the cath lab. Do we all just wander off or do we have some kind of conclusion? I could certainly be more evolved about this. We talked about it a little bit with Dan, but what I always try to do is have at least a quick debrief with the people in the room, which for me, just bare-bone stuff consists of, if they died, I try to give them a, it's a quick moment of silence, which I think is kind of helps us unwind from the action phase and just kind of remember what we're doing here. And then I try to just summarize what happened to everyone in the room because it's easy to forget big picture and a lot of people may not realize, especially if it was complicated. And my internal timeline and big picture about what's happened would be helpful for others. And others may have a different one, so this is how we can reconcile it because a lot of people may think something else is going on and then ask the room to questions. Do you have any questions about what happened here? This is the type of people to clarify, why did we do that? Why didn't we do that? Something confusing. And do you think there's anything we could have done better? Was there, was there an error made? Was something that got crazed that didn't need to, whatever. Just give some opportunity for this kind of thing and it really only takes a few minutes. Ask people, look, I know we're all busy, if you could just give me five minutes in the room here and you get back to whatever you're doing, it doesn't take longer than that. And it really kind of brings some closure, I think. Now, in a long code, people will have come and gone, it will have mixed up a little bit. But you can capture most of the room, again, it does not take long. And if you really had something crazy, that may be psychologically distressing. It may be reasonable to circle back and do more of a cold debrief at a later time, like the next day or something in a more organized way. But just something real quick and hot, I think is helpful to do. And it's easy to forget, but I think there's a lot of value. Yeah, I agree. I think there is. And I think we forget more often than we don't. Right? I think we tend to say, all right, I got to move on to other things or good job, everybody. Thanks and walk away. But I think you're right, it is worth doing. And I think the other thing to remember is you need to be open to hearing that you didn't do something well. And you need to remember that that's not always bad. I mean, it's not good to do something not well. But just because you could have been better and there's a bad outcome that happens does not mean that you screwed up and killed someone, right? Things happen. That's how you get better. You need to be open to hear it with when this is a time. Yeah. A patient died or had something bad happen to give you this lesson. Yeah. Don't waste it. Right. I mean, the worst thing would be to not learn the lesson because the bad thing already happened. Right. And I think the two potentially bad ways to handle that are one, I'm not even going to be open to the idea that I did something wrong or that I could have been better at something. And two, the opposite extreme, if somebody says this and this and this, you kind of missed this and, you know, that was a bad thing or whatever, then to just go, I'm awful and beat yourself up about it the rest of the day. And then you can't function. Yeah, assume there's going to be things you could do better. You know, if that kind of reaction sort of implies that perfection isn't the expectation and anything else is a breach. Yeah. That's just not the real world. These are crazy situations. All right. Well, fortunately, this gentleman is off to the cath lab now. Where they're going to do some cath lab things for him. And he'll come back. I'm sure. Still sick. He still has sepsis. Right. We still didn't figure that out. But there'll be other things to do, but that's for another day. So any closing thoughts before we wrap this up? No. I think, you know, cardiac arrest is such a classic scenario in critical medicine. It's gotten simpler and simpler as far as the specific interventions, but that almost just makes it a better and better case study of these team dynamics and kind of managing workflows and everything is so compressed in a time way that it's a good way to train yourself and your teams to do resuscitation well for other things too. Because if you can have a cardiac arrest where it is so smooth and quiet and controlled and everything is working together like cogs on a wheel, I think you can do most things well. It's not just about the specific situation. It's about the people and how they work. Yeah. I think a good code should look as different from medical TV as you could possibly get. Right. When you watch, you know, grazing out of me or ER or any of those things, they all tend to be screenfests and chaotic and a really good code should be none of those things. Because like you said, it is fairly algorithmic with some thinking thrown in to figure out reversible causes, but it should go fairly smooth. Yeah. Things are exciting when they're getting out of control, right? That's not the goal. Right. Boring is good. We won't boring. All right. Well, good case, good topic, and I guess we'll talk to these guys next time. Thanks, everybody. Thanks. Bye. Bye.