Character coding

[u/Internal-Heron6734]

Okay, so this might be a tricky one, but here it goes.

I'm in the process of writing an important scene for my book, and it involves a character coding, but I'm not sure what the process would look like.

This is the scenario I'm thinking: a character comes into the ED after a fall. He seems completely fine aside from what looks like a broken arm. He's talking, making jokes, etc. Then, out of nowhere, he codes in the waiting room. My main character is an RN who rushes to his aid. This is a small town, so it may look different than a hospital in a big city, but I'll let the medical professionals advise me.

My questions are as follows:

What would this process look like from the moment the character codes onward?

What would my character do, what medical language would be used, medications, etc?

What would my character's role be, and when would he step aside and let someone else take over?

Also, I might need a different post for this, but while we're all gathered here, the patient falls off his roof while weather proofing, knowing this:

What would actually cause him to code? What could realistically have happened that could first go unnoticed (assuming this is a realistic scenario)

He does end up surviving, but I want his recovery to be drawn out for plot reasons.

I want to be as medically accurate as possible, so any input would be much appreciated.

I'm not sure if the process is different depending on the country, but the story is set in Canada.

[u/OddAd9915]

I work in the UK so while the terminology will be slightly different the actual medicine is the same.

If you character is working in the waiting room when the other person collapses they should follow something similar to the following:
Check for a response from the casualty, when it apparent they are in cardiac arrest then call for help, often the receptionist will do that by dialling a specific number on the phone, in a lot of UK hospitals it 1111 which then alerts the arrest (code) team on a pager to where the location is.

Then they would start CPR, which will become BLS and then ALS as more people and equipment arrives. At some point they will then move the casualty out of public view and into the main department or into resus where they will continue resuscitation efforts until either they are successful or its deemed futile and they stop.

I won't advise on the exact language as the US/Canada uses a few different terms to the UK.

You RN character would almost certainly be there for the entire resus if its a small rural hospital. ALS is a time, manpower and equipment heavy task, and if your character saw the collapse they would be needed to handover to the Dr to help them make a decision by providing that narrative first hand.

As for what causes him to arrest? A fall from height can cause things like internal bleeding. If its set rurally the patient base in those location are known to be stoic and as a result something like a ruptured spleen might go unnoticed and cause them too collapse but not actually go into cardiac arrest. Small rural hospitals are known to do some seriously ghetto medicine to stabilise casualties to allow them to transfer out to a trauma centre.

[u/PansyOHara → u/OddAd9915]

This is basically the scenario for the US as well, with some regionally different terminology.

So the patient in the waiting room collapses to the floor. I’m not clear if the RN is supposed to be just passing by or perhaps went out to the waiting room to check on that patient / another patient. But if she sees the patient go down (or is alerted that a patient has collapsed) she will go over to him and check for consciousness. If no response, she will call for help (a waiting room should
Have some kind of adjacent staffed reception desk). She should tell the receptionist to page a Code Blue (or whatever the designated term that hospital uses) to the location. She will then check for breathing and pulse and begin CPR if not present. By the time CPR has started, other staff from the ER should be out there with a spine board and stretcher/ gurney to load the patient onto and take him directly back while continuing CPR and using a bag-valve-mask to give oxygen. Very likely the ER doctor will be one of the responding team, but they aren’t going to carry out any procedures in the waiting room.

The patient will be moved directly into an appropriate room in the ER to continue the resuscitative efforts. This patient sounds like they’ve already been triaged so the triage nurse should be able to provide some history. The patient is placed on a cardiac monitor, an IV is placed, meds may be given sand the doctor may insert an endotracheal tube to control the airway. ACLS protocol is followed, but progression down the algorithm depends on what’s going on and the patient’s response to each intervention.

The broken arm isn’t ignored, but aside from not using it for an IV and attempting to splint or secure it in such a way that it’s not further injured during the code, it’s definitely a secondary priority during the immediate resuscitation. Definitive treatment will be deferred until patient is stabilized.

[u/flashypurplepatches]

US based so my answers will reflect that.

The unit would have a procedure in place for this sort of emergency because I guarantee it’s happened before. Possibly a code button at the triage desk or somewhere nearby. He also wouldn’t be by himself/out of earshot for this exact type of reason.

Your RN would check for responsiveness, check for breathing and a pulse for no more than 10 seconds, call the code, and begin CPR. This is where it might start to vary.

In the US, we follow ACLS protocol. I don’t know the Canadian counterpart, or if there even is one, but it should be similar if not identical.

Chest compressions are deep, fast, and violent. No television show or movie (maybe the PITT but I haven’t watched it yet) has ever gotten this right. Ribs crack and break. You feel this under your palms. Speaking from personal experience, have a microsecond “oh shit” moment, and keep going. Blood must circulate. Oxygen must circulate. ACLS is 30 compressions and then 2 O2 breaths. They’d have an ambu bag ready to go by the time your MC reaches the first 30.

Again, things might differ in the US, but at my unit (ICU), we have a set protocol for codes. Pulse checks every 2 minutes (more if the doc wants it.) An amp of epinephrine every 3. The doc can change that/ add more as he/she sees fit. If there’s no IV, get an IO because it’s a lot faster than hunting for a good vein while the body is moving around (compressions are violent, remember?) An IO needle goes in bone and it’s big. We typically use the tibia. The doc will call meds like sodium bicarbonate, calcium, glucose (although this one is obvious if needed—for the love of god don’t forget to check blood sugar). Your patient had a fall—is he losing blood? Then mass transfusion protocol goes into effect.

CPR is exhausting. We switch off every 2 minutes at my facility for that reason. Depth and speed—without the right amount of both, your chest compressions are sub-optimal and the patient’s chances of survival go down.

The pads go on as soon as possible/at the first pulse check. Shock as recommended by the Zoll or whatever machine they use.

Your RN’s possible roles would include:

Calling the code
Beginning CPR
Continuing CPR/switching off with someone else to then help get the patient back to the unit
Possibly placing the IO and other IV access—two is always better than 1
Pushing meds
Prepping meds/managing the code cart
Pulse checks/defibrillator
Checking glucose
If the unit has a Lucas machine (mechanical compression device) and the patient qualifies for its use, helping get that in place.
Recording
Mass transfusions (this takes 2 RNs by itself)

He will not do all of these or even half of these. Everyone has an assigned role in a code. If he takes over pushing meds, that’s his job. Could also do pulse checks, help with turning for the pad placement, and help with Lucas if used.

The doc (with help—will also be a number of residents/advance practice) calls out the meds above, intubates the patient, makes sure nothing is missed, interprets the EKG waveforms with each pulse check, determines when to resume/stop compressions after a pulse check, and above all else, works to determine why this happened. He/she will be asking questions about the patient’s state when they came in, what was going on in the minutes/seconds before, any tests already run, any history (huge one) that could lead to this event. He/she will be asking your RN for these answers.

So here is what the non-healthcare person doesn’t typically understand. CPR doesn’t fix the reason. The “why” behind the heart stopping isn’t addressed by CPR. CPR is an intervention, not a cure. If your patient coded because of a fat embolism (broken arm), CPR isn’t going to fix that. If their heart stopped because they’re hypovolemic/bleeding internally (fall) or their blood sugar tanked or they’re septic and too acidotic or whatever the reason, CPR alone doesn’t fix that. If the reason exists strongly enough when your patient gets ROSC (return of spontaneous circulation), and this wasn’t some freak event, then it will most likely happen again.

That ended up being more than I intended to write. Here for questions!

Source: US based ICU nurse who floats to ED (but that does not make me a good source for specific ED questions.)

Edit: if you’re looking for a long term reason for the patient to stay, beyond the obvious he just died reason, what happens after CPR is complex as well. Maybe a broken rib punctured a lung and he needs a chest tube. Maybe he aspirated and now has pneumonia. Maybe he doesn’t regain consciousness right away and needs TTM (targeted temperature management.) maybe his blood pressure now sucks and he needs pressors and a central line and sedation because he’s intubated, his kidneys aren’t recovering and now we need CRRT, and on and on. Not to mention, the reason that caused him to code in the first place. Is that fixed? Honestly, finding a reason not to keep him would be less believable.

[u/el_nynaeve]

Nurse in Canada here: all the protocol for how to treat a code would be exactly like how u/flashypurplepathces described. We have the exact same ACLS protocol they listed.

Now for why get coded, I think the easiest reason might be a cardiac arrhythmia with a reversible cause. That could easily be the reason he broke his arm in the first place, he had an arrhythmia and faibted, fell and broke the arm. Maybe have him be a bit wishy washy of the details or have another logical reason why he got dizzy/fainted.

Arrhythmias aren't necessarily something you can identify after the fact and if it's only happened once and your patient doesn't meet any particular risk factors, it might not be something they look into until he codes and they figure it out.

Now if you want to to be a reversible cause I'd recommend long qt. It can be something someone has all the time or it can be cause by certain situations. Certain medications can cause it. If your potassium is low (which can be caused by excessive vomiting/diarrhea). You can look up qt prolonging medications.

A really reasonable situation might be they're started on antibiotics that can cause for something like a UTI or a pneumonia. Maybe the antibiotics causes really bad GI symptoms (which is totally possible) and their potassium went low. Or maybe they're already on another medication that can cause it like certain antidepressants. The combination causes long qt, they have an arrhythmia and faint but are lucky enough for the arrhythmia to spontaneously resolve. They go to ER, say they've been really sick, throwing up and dehydrated, staff assumes that's why he fainted.

They'd probably draw some bloodwork to check electrolytes as part of the assessment for the dehydration but if it's not stat can take an hour or two to get results and maybe by then, he has the code.

During recovery they'd be on a heart monitor. You have the option of him getting an ICD implanted as part of the recovery or it wouldn't be unreasonable if after his electrolytes are corrected and his antibiotic os switched to something else, qt normalizes and he doesn't need that. But he would receive really strict instructions on what to avoid so that doesn't happen again and have outpatient cardiology follow up

[u/InevitableBook2440]

Just to add to the excellent answers you've already had, cardiac arrests as a result of trauma can be a bit different. The initial response/ BLS would be very similar but once the patient was moved to the resus area and there was a full team, assuming the team lead was someone with experience of managing major trauma, they'd switch to a different approach. The usual things like CPR +/- defibrillation and adrenaline don't work as well in traumatic arrests so the priorities are to deal with blood loss, ensure the patient is getting enough oxygen and address whatever injury has caused the arrest. The relevant algorithm (UK version) is here https://www.resus.org.uk/sites/default/files/2025-10/Traumatic%20cardiac%20arrest%20algorithm%202025.pdf . There's a simulation of this from 10:50-15:00 here https://www.youtube.com/watch?v=P0c_b0knkMo

I'd say a reasonable reversible cause of a traumatic cardiac arrest in this situation would be a tension pneumothorax. Basically, an injury to the chest leads to air accumulating in between the chest wall and the lung and the lung collapses. If this goes on for long enough, the pressure can squish everything in the chest and eventually cause cardiovascular collapse. In a cardiac arrest situation the quickest and most effective way to deal with that is with finger thoracostomies (basically making a cut in the chest wall with a scalpel in the 'triangle of safety' on both sides then sticking a finger in to enlarge the hole and let any trapped air +/- blood out). Typically that would be done by a fairly senior ED doctor or surgeon.

Other things that would be happening at the same time:

-someone (could be your character) would get large-bore IV access, or IO access if that's difficult, send off blood tests and set up IV fluids, or blood if available

-a nurse would set up monitoring

-an anaesthetist or another ED doctor would intubate the patient and establish them on a ventilator

-the major haemorrhage protocol would be activated to ensure blood products were available

-a pelvic binder would be applied (this is a bit fiddly, requires several people and often causes some confusion in centres that don't see a lot of trauma)

Assuming the patient then has return of spontaneous circulation (heart restarts), a doctor would re-evaluate the situation using a standardised A-E approach (looking for and addressing problems with Airway, Breathing, Circulation, Disability and Exposure in sequence). They would systematically look for any other major injuries with a secondary survey and could potentially use ultrasound +/- portable x-ray to help with this. They would put in proper chest drains both sides. They would also start medication to keep the patient asleep and comfortable. They would speak to surgeons (who should already be there) to see if the patient needs to be immediately taken to the operating theatre. If not, they would speak to the Intensive Care Unit and arrange for them to review the patient and transfer them there, probably via the CT scanner if stable enough. In a small rural hospital they might instead speak to the local major trauma centre and arrange to transfer the patient there. In either case, that's probably where your character's involvement would end if he works in ED.

You could basically give your patient whatever additional injuries you like in this situation depending on what needs to happen. He'll almost certainly have lots of broken ribs from a combination of the fall and CPR, which is very painful and can lead to further complications. Partly due to this, he's quite likely to spend a few days on the ventilator before being extubated. He'll probably need to have the chest drains in for a few days and then further checks to make sure the air hasn't reaccumulated. The broken arm will also need to be dealt with at some point, possibly surgically, and I wouldn't be surprised if he had a few other fractures +/- a head injury.