An 80-year-old man with a history of coronary artery disease, hypertension and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxiety. On hospital day 2, he had sudden onset of confusion, bradycardia and hypotension. He lost consciousness and a code blue was called. The inpatient psychiatry facility is adjacent to a major academic medical center. Thus, the code team, comprised of a senior medical resident, medical intern, anesthesia resident, anesthesia attending and critical care nurse, within the main hospital was activated. The message blared through the overhead speaker system, code blue, fourth floor psychiatry, code blue, fourth floor psychiatry. The senior resident and intern had never been to the psychiatry facility. How do we get to psych, the senior resident asked a few other residents in a panic. So the senior resident and intern ran down numerous flights of stairs outside the front of the hospital, down the block, into the psychiatry facility and up four flights of stairs. The two buildings are actually connected on the fourth floor. Upon arrival, minutes later, they found the patient apneic and pulseless. The nurses on the inpatient psychiatry ward had placed an oxygen mask on the patient, but the patient was not receiving ventilatory support or chest compressions. The resident and intern began basic life support, CPR with chest compressions, with the bag valve mask. When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient up to their portable monitor. Unfortunately, the leads on the monitor were incompatible with the stickers on the patient, which were from the psychiatry floor. The stickers were more than 10 years old. The team did not have appropriate leads to connect the monitor and sent a nurse back to the main hospital to obtain compatible stickers. In the meantime, the patient remained pulseless with an uncertain rhythm. Moreover, despite ventilation with a bag valve mask, the patient's saturations remained less than 80%. After minutes of trying to determine the cause, it was discovered that the mask had been attached to the oxygen nozzle on the wall, but the oxygen had not initially been turned on by the nursing staff. The oxygen was turned on, the patient's saturation started to rise, and the anesthesiologist prepared to intubate the patient. Chest compressions continued. At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and shouted, Stop! Stop! He's a no-code! Confusion ensued. Some team members stopped while others continued the resuscitation. Although a review of the chart showed no documentation of a do-not-resuscitate order, the resuscitation continued. The intern on the team called the patient's son, who confirmed the patient's desire to not be resuscitated. The efforts were stopped, and the patient died moments later. Take-Home Points A rapid and robust response requires prior planning, training, and equipping of all hospital areas. CPR training should be performed on a regular basis, even for these low-risk areas. The same procedures need to be reliably done. Standardize equipment throughout the hospital to prevent ergonomic issues as seen in this case. Systems need effective processes to ensure communications are shared by all.

80-year-old man

multiple health issues

psychiatry facility

code blue

resuscitation efforts