James A. Haley Veterans’ Hospital - Tampa, Florida

Hillsborough Community College Respiratory Therapy student Ted Cooke and JAHVH Internal Medicine Chief Resident Dr. Nikesh Kapadia practice CPR on a mannequin during a recent Code Blue training session.

If you’ve ever visited the James A. Haley Veterans’ Hospital, chances are you’ve heard the code calls over the public address system.

“Code Blue, building one, valet parking area,” or “Code MRT, Seven North.”  While the average visitor or administrative staff member may not pay much attention to the announcements, for some clinicians it’s a call to respond as fast as they can because a life may be on the line.

Two of the code calls – yellow and orange – are used to report a missing or wandering patient and a disruptive patient respectively.  The other calls commonly heard in the hospital – Blue, MRT, STEMI and Stroke, are used to summon rapid response teams of medical professionals to assist patients experiencing what could be life threatening emergent health issues.

Code Blues, when called from an inpatient area, are usually used to initiate cardiopulmonary resuscitation (CPR).  When called from an outpatient area, like valet parking, it could mean almost anything else.  Code MRT, (Medical Response Team) is used strictly in the hospital’s inpatient setting for patients who are experiencing a change in their medical status.  Code STEMI (S-T Elevation Myocardial Infarction) is called when a patient may be experiencing a heart attack, just as a Code Stroke is called for a possible stroke patient.

“In the hospital where you have a physician assigned to you, they’re going to be calling Code Blues usually when the patient is in acute distress or if they have already lost their pulse,” said Dr. Ana Negron, JAHVH Medical Intensive Care Unit director.  “But outside the hospital, in the outpatient areas, they’re going to call Code Blues in any kind of emergency.”

She gave the example of a Veteran showing up at valet parking feeling too weak or lightheaded to make it from the vehicle to the hospital without assistance.

““Even though he’s not a patient down, they’re going to call a Code Blue in the outpatient setting for any emergency whatsoever to bring highly skilled nurses and a physician to that patient for disposition,” Negron explained.

Whenever a Code Blue call goes out, a large rapid response team assembles to examine and, if necessary, treat the patient.  The team includes at least three different physicians, critical care nurses (who respond with a crash cart including a defibrillator), respiratory therapists, pharmacists, VA police officers and VA chaplains.

“Those patients are very sick so you can have 10, 12 people looking toward the patient trying to rescue them.  The police are going to keep everyone safe,” Negron said.  “They’re the ones looking outside to make sure everything goes smoothly and that there are no problems.  The chaplain is very important as well because we don’t recover all of these patients and the chaplain’s responsibility, together with the medical team, is to be get hold of the family, to wait for them and comfort them.”

For a Code Blue in the hospital’s outpatient areas, the team responds to determine what the situation is.  From there they can begin treatment, transport the patient to the Emergency Department or, in some cases where the patient refuses assistance, do nothing and return to their individual work areas.

For Code Blues called in the outlying areas of the hospital campus, such as in the parking garage, Lucy gets the call to action.  Lucy is a modified electric cart similar to the courtesy shuttle carts visitors use to ride from the garage to other areas of the hospital campus, but with a stretcher and rescue equipment instead of multiple rows of seats.

Code MRT’s are different in that they are used to hopefully prevent a patient’s condition from developing into a Code Blue.  They’re only used for inpatients and Community Living Center residents, but they can be called by anybody – doctors, nurses, family members or the even the patient – who sees a change in the patient’s status such as difficulty breathing or decreased alertness.  The idea is to provide treatment early before the situation develops into a Code Blue, Negron explained, with a critical care nurse and respiratory therapist responding to the patient.

A Code STEMI is called when clinicians are concerned that the patient is having an active heart attack.  An interventional cardiologist responds with the team to determine if the patient needs to be rushed to the cardiac catheterization lab right away.

For Code Stroke, the MICU and neurology teams respond to evaluate the patient right away.

“In the radiology department they’re going to keep a CT (Computerized Tomography) scanner open to bring the patient, get a head CT and see if the patient is a candidate for tPA,” Negron said.  Tissue plasminogen activator is a drug treatment that can, if given quickly enough, dissolve the blood clot in the brain that is causing the stroke.  According to the American Stroke Association, the treatment can not only save the patient but can also reduce the long-term effects from the stroke.

While different codes are called for different medical situations, they do have several things in common, the most important of which is the teamwork that takes place to treat the patient.

“The nice thing about the VA is that everybody who comes into the code knows basically what their role is,” said Dr. Nikesh Kapadia, JAHVH chief internal medicine resident, after a recent Code Blue simulation training session.  Kapadia said he has worked somewhere between 50 and 100 code calls.  “You really want all those people there because the code requires so many different team members.  If one or two are missing, that’s the worst thing that could happen.  You’d rather have too may than too few.”

Kapadia said he was nervous during his first few code calls, but now he looks at them objectively.

“You think about it in an organized and systematic way,” he said.  “But you just realize that there’s a human being on the other end and on the other side of the door is the human being’s family and friends.”