There are all kinds of codes in nursing. Code browns, code blues, code grays, no codes and codes din mah nose. The ICU/CCU nurse has a very definite image of what a code involves. A code is a patient situation in which the nurse needs to respond therapeutically, in a timely manner and may get only one chance to do it right.

Psych nursing has its own special kind of code. In Nursing of the Mind, "code" takes on a special meaning. Dealing with out-of-control patients is called many things, but the object is always the same. How do you get this crazy person under control without killing yourself and others?

For those of you who would aspire to nurse in psych codes but lack practical experience, here are some hints with practical illustrations.

Hint 1. The best way to avoid injury is to establish a plan. However, there are those who micro-manage code teams much like Patton ran his army. I can remember some codes that felt like being in a pre-battle briefing. Like the time when the code team was gathered in a conference room getting ready for the restraint, when in walked the self-appointed Code Commander-in-Chief to plan the attack.

"Tenhut!" someone screamed. We snapped to attention.

"At ease, troops. Smoke if you got 'em," snarled the commander.

"Ladies and gentleman, as you know the objective of this mission is to subdue and control patient Jones, Mike. This patient is particularly key in the establishment of a calm and quiet milieu. His defenses are heavy, his intellect keen. But with a good plan and teamwork we will be able to obtain the mission objectives."

She snapped her riding crop onto the table for emphasis.

"Now, observe carefully," and she pulled down a map of the ward with an attached anatomy chart.

"We will divide up into teams. Able company will approach the objective from the dining room and obtain control of the upper extremities. Baker company will go through the TV room and subdue the lower extremities. Charlie company will have the most difficult mission of all. You will subdue the command and control center on top of the spinal column.

"When the objective is surrounded and all extremities secure, we will escort the patient to Attitude Adjustment Room A102. When secured in five point movement control devices, Delta company will proceed with the Thorazine to the upper outer quadrant.

"Any questions? Good. Let's set our watches. On my mark it is 1902 and 30. Mark. We commence at 1904. Good luck. And I want you people to know, if some of you don't make it back, you're the best damn ward in the whole hospital."

This type of planning may work for Patton, but may not have total transferability to the medical world.

Hint 2. There is a popular notion that all you have to do for a code is to call security and get a large steroid-crazed maniac to stand behind you while threatening the patient into submission. In reality it doesn't work that way. The only steroid-crazed maniac who ever volunteered to help me was a COPD patient who wanted in on the fun. And most security guards, while extremely helpful, don't look threatening. A security guard once asked if he should take a nitro before a code, since he just returned to work after quintuple bypass surgery.

Still, you get by.

Hint 3. The way you carry out a code changes. I think the most unique innovation to code work came about when Universal Precautions regulations were developed. Initially, the regulations required all codes to be done in full body suits complete with face shields. The hospital where I worked was really hepped-up on these new regulations, and had people designated in each unit to ensure compliance.

One night, I was in a tense situation and felt the need to provide more external control to a particular patient. I summoned the team and formulated a plan. But before we could do the job, the compliance person made us suit up completely in surgical pants and smock, latex gloves, cap, shield and shoe covers. This particular brand of surgical suits had extra starch in the crotch, causing us to walk like the tin man in the Wizard of Oz.

While we were all getting suited up, the patient was completing a self-study course in interior decorating in the day room, by breaking and throwing the furniture around. While you may have disagreed with the patient's color scheme, Oprah really did look better with a potted plant hanging down in front of the TV screen.

When the five members of the code team walked into the room, we looked like the white coated scientists from ET, with the associated breathing sounds.

I pointed to the patient and said. "Come with us."

He put down the chair he was about to throw, looked right at us and said, "It's about time you got here. I've been sending signals for a week. How are things on Mars? Let's get going."

We did get going. Right into the old locked transporter pad.

Hint 4. There are many times when a code can be very frightening because you may be called into a situation you know nothing about. One day, while I was working on the open unit, the announcement, "Dr. Rush, Dr. Rush," from the overhead pager summoned help to the closed unit.

As I ran onto the unit I saw several people congregating outside the Quiet Room. Over their shoulders I could see a rather large psychotic gentleman who had detached a steam radiator from the bolts that held it to the wall. He was holding it over his head, offering it to a nurse to use as a bike helmet. I was told by the unit's charge nurse to "diffuse the situation."

At this point I had three choices:
A. Allow my internal waste disposal system to operate unchecked.
B. Look at my watch, say, "Oh, dinner time," and leave.
C. Foolishly think I could "diffuse the situation" and enter the quiet room armed, not with a whip and a chair, but with only the excellent psych skills I picked up in nursing school.

While A and B have their merits, at the time I was still a horrible co-dependent (my wife says it's okay for me to say I am not anymore), and so I chose C. Luckily this guy and I went way back and were able to calmly discuss the advantages of putting down the radiator, walking to another room, allowing himself to be put into five point restraints and having a shot. How much of this discussion was for his benefit, or mine, I don't know.

When I think about psych codes, I don't think of paddles and lidocaine or hitting on a chest and inserting a tube. I think of the smell of leather and the feel of an IM shot in a gluteus maximus, the clang of a door and the click of a lock. But I suppose, just once, it would be nice if a code meant therapeutically intervening with a patient who just laid there while you treated him.

And I don't think I would miss the spitting.

 

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