My first... Code.

  1. Where do I even begin? As a new nurse... this is probably the worst thing that could happen. I've had families be extremely rude as well as MD's... but I don't think anything prepared me for my first code.

    .. The pt has a pretty extensive hx. Bundle branch block, inferior/superior infacts, Ejection fraction of 35%.. came in for a radical subtotal gastrectomy, wedge biopsy of the liver and j-tube placement.

    I had had the pt for the past two nights and thought that they were looking much better last night when I came on. They were sitting up, talking to me.. and asking for a few things..
    ..They were getting tube feeds from 7p-7a only.. and around midnight they started to get a little nauseated and started to vomit VERY little. I turned off the tube feeds.. checked residual (20cc) .. I flushed a little and then clamped the jtube. Told the CA to set them up a little bit further. I was going to help the CA give the pt a bath.. but they called another CA in to help. So I went to get insulin to cover fingersticks (including this pts.) ..and get stuff to draw AM labs. They got them bathed.. and in the time that it took to draw up insulin.. They called me to get in the room asap. I ran in there.. the pt was grey and o2 sats were 40%. Thankfully, the CA was thinking quick enough to grab the pulse ox... so I knew what it was when I got in there.. I told the ca to turn up the 02 and went to get the charge nurse.
    ..She went in the room and someone along the way told me to get the crash cart. I got back in the room.. setting up the cart and they were calling the code.
    Of course now everyone is rushing in the room..and everyone knew they're role. I wanted to CRAWL under the table when the Dr asked who the pts nurse was. And I explained everything that led up to this moment. And he tried to make a complete ass out of me infront of everyone.. asking me why I didn't call if the pt was nauseated. If I called the dr everytime the pt was nauseated? .. and what IF i did call.. and he ordered phen. ...then everything they were doing would have been ten times harder.
    So the pt ended up going into asystole. CPR started.. They got a pulse back.. intubated (and got 200cc of dark dark liquid) and then got ready to transfer them down to the icu. I was told to go report off to the icu nurse.. and in that time the pt started to brady down to the 20's and they ended up pushing atropine.
    They sent them down and the pt ended up flat lining 4 more times for them.. And the aide that took the pts belongings down said that the pts stomach had gotten huge.

    ..perforated bowel? or bleed?

    This night was extremely overwhelming.. and all I can say is thank god I"m not back tonight. I'm surprised I didn't throw up or freak out during the whole thing. I had no idea what to do.. and the only productive thing I did was get a manual BP when the dr asked.

    The Dr came up later that morning and wanted to know everything that happened. I explained it all again.. and he was asking me over and over again like he was looking for something that I did wrong. And then looking at me for a long time like I was lying about something.

    I know working in a hospital there's going to be codes. But I'd never seen a code let alone been a part of one. The sad thing is .. the pt was telling me just minutes before all this that if they would have known that they'd be this sick and not feel good they would have never had the surgery. =(


    ..thanks for listening.


    ..and ps. I've only been off orientation for a month..or a little over.
    Last edit by ashley_michelle on Dec 1, '06
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  2. 12 Comments

  3. by   P_RN
    That sounds terrible for you. I might guess at what happened, but until the doctors find out that's all it would be is a guess. Your patient was extremely ill already. They don't do wedge bx and subtotal gastrec. on people who are healthy. He had cardiac hx. Don't beat yourself up.

    A code is a scarey thing for a new nurse, and for us old nurses too. (When you said crawl on the floor, I have actually done that during a code because of all the people who crowd into the room. )

    When things return to "normal" ask your clinical specialist or charge nurse or whoever is your mentor to review with you the code cart...ours was respiratory on the right and iv stuff on the left. Go over the drug box. Review where the leads go for the monitor (though you patient probably was being monitored?)

    Ask to be allowed to watch any code that happens. Get a mock code scenario and go over it. Codes are for sick people, nurses care for sick people, but we can only do the best we are able.
  4. by   ashley_michelle
    My guess is that the pt aspirated. But they weren't pulling out tube feed... so I'm guessing.. that the tube feed made her nauseated.. which caused her to vomit (whether she had somethin goin on. ie. bleed, etc) and she was aspirating the emesis. ..but that's just my guess.
  5. by   youngatheart
    ashley michelle,

    So sorry to read about a code, I dread every night that one will happen to me. We do have a rapid response team member that floats around and we can call if anything looks suspicious. I work on a med surg tele floor and most of these people come from nursing homes. I have had 2 deaths since being off orientation (off since september) They both were just put on hospice at the time so it wasn't that extreme, but I know I will feel just like you. Sorry that it happened, It sounds like the doctors were covering their own butt, which you can't blame them with all the law suits today. At least you have been through one, I am waiting for my turn. Its hard sometimes I only know a few things about the patient when i take over for my shift, at least at night I can read up about them.
  6. by   muffie
    he sounds like not a good surgical candidate to begin with
    how old was he ?
    was he in icu for a few days post-op ?
    and that was big enough surgery
    he probably had more heart trouble
    learn from each situation what you can
    codes are never comfortable situations but we try to help the patient the best we can
  7. by   augigi
    Sounds like you did fine for your first code! It can often be helpful when you're learning to have a debriefing session with the staff involved afterwards, where you can all discuss who did what, and how to improve next time. I know my hospital did this while we were new in ICU.

    Please don't take this as critical, as it is not intended that way, but to give you a couple of ideas for next time which helped me

    - Our units required someone to check the crash cart every day and sign it off as stocked. Can you see if you can do this, or even informally as suggested above. Going through every single thing in the cart and checking it off gives you a good understanding of how the equipment is laid out and can make it that little bit easier next time.

    - If I encountered the situation above, I may have stayed with the patient while the CNA went to get the nursing manager (if you don't have a code alarm at the bedside like we do). It's so understandable and natural to freak out and forget everything, but as the first nurse on the scene, you can get a lot done before the code team arrives; assess level of consciousness, check airway, apply high flow oxygen, get vitals and attach a monitor if they don't have one, get the patient positioned right in case they need CPR, move stuff from around the bedside and start writing down the time of events (you'll definitely forget later!).

    I don't know your doc, but they feel just as bad as we do when a patient codes, so he may have just been trying to identify any signs he missed which could have prevented the code. Try not to take it too personally - the medical profession has a culture of examining treatment events and critiquing their role, so they can improve next time (morbidity and mortality meetings etc). I'm sure this guy needed to answer to his boss as to why he didn't see this coming, and was trying to gather information.

    It's awful, but at least it's over! Well done, and keep your chin up
  8. by   ashley_michelle
    Thank you for all the replies and tips for next time. And I think that I will take a good look at the crash cart..study it and have a general idea of where everything is located.

    ... and you are right. I should have been the one to stay with the patient. Thankfully, the nurse was sitting in stepdown.. which was just a room away from where she needed to be. Also, the STAT nurse was making his rounds and was on the floor asking us if we needed anything. So I wasn't gone for anymore than a few seconds.. just to pop my head out the door to tell her to please get in there. But, I should've stayed.

    as ignorant as this sounds, I had no idea that someone was supposed to be recording. We've never walked through a code before... and obviously I'd never been in one.. But someone along the way decided to start writing stuff down.

    Everyone knew their 'role' in the code and it came together well. People stepped in where they were needed and it was a calm situation. Everything was already set up (thank god)... Suction, o2, etc. The pt was on tele.. but they never called me to tell me that she was off... or um.. went asystole. But they ended up taking those leads off and putting different ones on for another monitor.

    I had actually just set up suction the day before.. it's so weird how things work out.

    But anyways, she was 76. I agree that healthy people don't just code.. there was something else going on.. It's just hard not to beat yourself up and go over everything that you could've done differently.. and if you would.. would she have coded.

    I did have a 'debreifing' .. I had gone into a back hallway to get away after everything was over.. collect myself.. and chart everything that had happened so I could get the charts down to icu. Of course once I got by myself I cried. but I gathered myself and started to chart..
    Two of the nurses that were in the code came to talk to me. They were wonderful. We went over everything that led up to that point (mostly for my reassurance) and we talked for a bit and then they shared their first codes. It's amazing how everyone pulls together to work as a team and everything runs smoothly.

    So anyways, Thanks for the tips and replies. I'm definitely glad that my first is over and maybe I can not be like a deer in headlights next time.. and actually be of some help..or have a clue what to do.
  9. by   RNSacht
    I recently had a very similiar experience.... only my patients code lasted 45 minutes with the doctor calling all sorts of questions., The code was finally called after 45 minutes and the patient did not make it. I had to call the famly and I was there when the doctor told the family.... a horrible experience for any nurse let alone a new grad nurse I cried all the way home..... :icon_sad:
    To make matters worse... She was sinus rhythm on the monitor, she had PEA pulsless electrical activity.... I cant say how horrible this night was for me...
  10. by   Indy
    The brown liquid, and that much of it, coming out of the patient's lungs can't have been good; who knows what that was... ick.

    Know that you answered as well as you could; you're not psychic, and you certainly sit up a patient, turn off their tube feed, etc. and see if you have PRN's ordered prior to even considering calling a doc about a nauseated patient.

    The other poster said it, but I'll reiterate it. The doc was going over the case because he's going to have to explain it. The surgeon's going to have to explain something to someone, as well, possibly anesthesia, etc. There are people involved who may look intimidating to you, but they've got really large malpractice premiums and they're trying to make sure they didn't miss something. Hence the question about why you didn't call.

    Sometimes, the answer to that is, that you didn't have time! Or, you gave the PRN's and hadn't had a chance to see them work yet... or that the patient got relief so no, you didn't call. In the end, no one is psychic. In the future you may be a little more watchful (or paranoid) of your post-ops, but hey, you gotta relax sometime. We had a little fella one night who had, I swear, no normal labs. I was looking at his labs on computer and it astounded me. 6-8 pulmonary emboli on CT scan. Numerous DVT's on venous scan. ABG's were so screwed up I could not even begin to interpret them. I had assigned him to a nurse with 20 years of experience on me, so I was relieved a bit while looking at this stuff... while thinking, what the heck is he not doing in ICU?? I looked at the patient, took him to the bedside commode once, etc. He was completely asymptomatic. He got phenergan IV in the morning for a bit of nausea, which turned out to be his only symptom prior to coding. It was a long code, and he died. That was a case of half and half: halfway shoulda seen it coming, d/t yucky labs and generally awful condition, and halfway who'd have known, he was mostly asymptomatic. In his case the nurse did call to get him some phenergan as there wasn't any ordered.

    Don't beat yourself up too much, really. And try not to read into what people are thinking, like saying the doc was looking at you like he thinks you're lying. He could be thinking lots of other stuff. Just because you're intimidated or nervous, or freaked out, doesn't mean he's thinking ill of you; he may be thinking other stuff altogether. He's probably lacking some people skills, as in, no "good job" or whatnot. Many people lack people skills in stressful situations so I wouldn't judge him on that one situation. He may be like that all the time, or he may not. You'll find your strength and be able to talk to the docs at some point, without feeling like you're two inches tall. I promise! It just takes time.
  11. by   ashley_michelle
    Again, thanks for all the replies. I did find out today that she passed away mid morning Friday. =( I figured she wouldn't make it... But I guess I still held out a little hope.


    How do some of you leave work at work?
  12. by   GracieLVN
    ashley michelle.. i can't imagine what you must have been through.. I have never seen a code or experienced one for myself either. i'm not yet a nurse.. just took my nclex about 2 weeks ago (still anxiously waiting for results). As i'm waiting.. i have nightmares about codes and being a horrible nurse.. just kinda scared but excited that if i do pass my NCLEX i step into the real world of nursing. I don't have enough credibility to say much, but i think you handled it well. On a bad day (clinicals.. nclex studies etc...) I come home to my dogs (2 huskies.. 2 pugs) they usually cheer me up enough otherwise i pop in Lakehouse and drool over Keanu Reeves.
  13. by   GrnHonu99
    You did everything right! Im a new grad too and Im telling you I think we allll feel that way! My preceptors have given me some good advice....as a new grad in any area you are not expected to know everything, that takes time and you will never know everything, the most important thing is to recognize a change in your pt., and you did that! You did the right thing and you couldnt have prevented this. I had a pt. go bad on me the other night...it was sooo scary, I was practically useless, I just stood there while my co workers did everything....Turned out she was ok and we didnt have to code her but I was convinced for the rest of the night that I had caused her to almost code. I titrated one of her drips and I thought geez maybe it was that that threw her into rapid A-fib. My precpetor assured me it was coincidence and later I found out she had a history of A fib. However, I know just how you felt. Another tid bit my preceptors have shared with me is that....not every pt reads the text book, they dont all respond how they are 'supposed' too....you just cant ever predict what is going to happen. Dont worry you did a good job. Oh and when you figure out how to leave work at work, let me know!
  14. by   NYpedRN
    Hey, I just read your topic. How horrible. I am working in a peds-transplant, and med-surg(heavy) unit and I was told that my kids were "general med-surg" kids. WELL, all my kids are heavy. Everyone has TPN, everyone has CL's, some are being transfused, some are on cpap, some are from the onc unit that love our nurses so come to our unit. So here I am thinking I"m going to a unit that is general, and I'm not. so I have my first code, while I'm still orienting! It's not my pt but it was a full code. In my hospital, all the charge nurses on every unit have code pagers as well as the peds ER chief and the Picu cheif. The room was flooded with medical personnel. I couldn't even do anything. One nurse recorded, one drew up meds, one passed supplies, one ran for supplies....all in all I just stood and watched in fear that we would lose the pt. The pt transferred to PICU, was intubated, and expired a week or 2 later. I felt so bad, but hoped I would never have another code. a month later an "almost" code, but pt transferred to PICU in time! I must say codes are horrible and its hard to leave work at work. I still think of the day with my first code. it's like your first time losing your virginity, you never forget your first! lol.....
    anyway, that DR did have to question you but not in an intimidating way, and you did everything right. how were you supposed to know, I would not have called everytime my pt was c/o n/v. good luck in the future....

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