ACLS algorithms - page 2

I am a new grad and landed my dream job in the SICU of a level 1 trauma hospital. It has been an incredible experience! However, I am freaked out. On Tuesday we will be running ACLS megacodes. Our... Read More

  1. by   yesdog
    IMHO your instructor is a bit of a bully and is being unrealistic and counterproductive

    HA!!!! You hit the nail right on the head! Luckily he is not my only instructor. He is extremely knowledgeable though, and I know that his intentions are honorable.

    I wasn't born yesterday This is my second career. So, I am really good at looking very calm and the other new grads look to me for support. I just want to perform well in front of my peers. I just took that pre-test and got a 90%, so I guess I'm ready. I will tell you all how it goes! Thank you all for your support!
  2. by   yesdog
    Hey all!!!!!! I ROCKED THE MEGA CODE!!! I volunteered to go first as team leader. I totally ran the V Fib code. Yeah! I also only missed 2 on the written test! WooHooo!!!!
    Thank you all for your words of encouragement!
  3. by   detroitdano
    See? I told you it would work out!

    Speaking of codes, I had a ridiculous one last night. Two hours of chest compressions, about 20 rounds of epi/atropine and extra epi for PEA(we emptied two crash carts and the Pyxis and had pharmacy tubing us extras), 5 or 6 rounds of shocking for V-Fib, multiple intubation attempts since she had a stent and horribly bloody airway. We have amps of Bicarb, Amiodarone, Levo, it was insane.

    Glad I studied up on my algorithms as I was the one telling people to back off so we could get some shocks in there.

    She lived thankfully, albeit with nasty pneumo's from the trauma of keeping her alive. Hope she makes it, she was fine a few hours prior.
  4. by   yesdog
    That's so great! So many times a code is such a feudal effort or it is performed on someone that should be allowed to die in the first place. I did my clinicals in the MICU and saw so many families thinking that we could make grandma all better if she was a full code. It was sad. My hope is to someday help with better education for families in order to understand end of life care.
  5. by   WindwardOahuRN
    Quote from yesdog
    Hey all!!!!!! I ROCKED THE MEGA CODE!!! I volunteered to go first as team leader. I totally ran the V Fib code. Yeah! I also only missed 2 on the written test! WooHooo!!!!
    Thank you all for your words of encouragement!

    There ya go! Congratulations---now just keep swimming!
  6. by   nurse_mo1986
    Quote from PDX_RN
    The current emphasis in ACLS instruction is to teach people to use their tools. At my hospital, we keep the alogorithm cards on the code cart. We are expected to refer to them in an actual code. Trying to rely solely on memory is a recipe for error. I doubt you will feel confident in taking on this battle, but I think that if your nurse educator is actually expecting you memorizing the algorithms and run codes without the benefit of memory aides such as the AHA cards she is behind the times.
    While I also think that the resources should be available in a code situation, I also think that yes, we should have the algorithms memorized completely. We see a lot of codes in my CCU, and I fully expect for myself and fellow staff members to be able run a code without having to stop and check a little booklet to "see if we're doing the right thing." You should know it inside and out before being expected to be an ACLS team leader.
  7. by   WindwardOahuRN
    Pardon me but there is no way in Hell that any self-respecting nurse who is a member of the Code Blue response team would depend on ACLS cards to get her/him through a code.
    There is also no way that you can function effectively in a code if you are still in the "oooh let me think oh I gotta look that up hold on a minute yeah I think I got it" phase.
    THINK, babies. People's LIVES depend on us. SECONDS count in a code. This is not a dress rehearsal or a mock scenario Mega-Code with a dummy who cannot die. You do not have the luxury of time, second guesses, ruminatiions.
    If it were your father/mother/spouse/child/loved one---how would you feel if you saw them crashing and burning and the people who were responsible for saving them were fumbling with cue cards while they were dying??
    An ACLS course certificate does not equal Code Nurse material.
    Laminated cue cards during a CODE??? Are you SERIOUS???? IMHO this is the height of idiocy and just so frightening. What's next, a copy of "CODES FOR DUMMIES" strapped to the code cart?
    To think that this anyone believes this is acceptable and even admirable is just plain scary.
  8. by   yesdog
    Are you my nurse educator? :hehe: I kid I kid!
    I think you are right. A member of the code team should know the algorithms inside out. The fear that the nurse educator put into me made me study the algorithms until I got into the "rhythm of the code". It was really hard work, but I am so glad I did it. Although I will not be running a code any time soon, I now understand the concept of the algorithms. With experience, I hope to someday be able to have the knowledge and ability to be an integral member of the code team. I sure wouldn't want anyone looking at a card in order to run a code on one of my patients...or worse....one of my family members.

    Thank you again for reminding me how important this issue is.
  9. by   WindwardOahuRN
    Quote from yesdog
    Are you my nurse educator? :hehe: I kid I kid!
    I think you are right. A member of the code team should know the algorithms inside out. The fear that the nurse educator put into me made me study the algorithms until I got into the "rhythm of the code". It was really hard work, but I am so glad I did it. Although I will not be running a code any time soon, I now understand the concept of the algorithms. With experience, I hope to someday be able to have the knowledge and ability to be an integral member of the code team. I sure wouldn't want anyone looking at a card in order to run a code on one of my patients...or worse....one of my family members.

    Thank you again for reminding me how important this issue is.
    The fact that you seem to grasp your limitations, as they are at this moment, is so refreshing. You're building a foundation here and I really think you get the concept.
    A little humility, a little sense of one's smallness in the huge venue of critical care is nice to see.
    I think if I see one more newbie declare that they are an "ICU NURSE---WOOOHOOO" after getting through orientation and preceptorship I will scream.
    No, dear...you're not an "ICU NURSE." You're a nurse who works in ICU.
    Big difference.
    It takes time and more than one baptism by fire to earn the title.
    Critical care is a very messy and often heartbreaking area of nursing. Requiring high-tech skills, quick reflexes (both mental and physical), and the ability to remember that, with all the high tech stuff, there is a real person in that bed. Juggling those high-tech tasks, high-risk meds, family needs, PIA docs, staff conflicts, no breaks,---it all adds up to such a very tough work environment.
    Good luck to you as you go on with your ICU career. Doubting yourself is not a problem, IMHO. It's the ones who are so damn cocksure of themselves (and there seem to be so many these days) that scare the crap out of me.
    And, BTW, I have been asked to be an educator more than once, LOL. I've politely declined, thank you. I'll gladly teach when the opportunities present themselves but frankly, I kinda like where I am right now and could live quite happily without the added aggravation.
    Last edit by WindwardOahuRN on Dec 8, '09
  10. by   yesdog
    Thank you again for your words of wisdom. In one week I will be on my own. As all of the great RNs that I work with tell me "on your own but never alone". I feel so fortunate to be in the place I am. Every day I learn so much. But also each day I am so humbled. There is so much to learn. Sometimes it is so overwhelming. What I fear the most are "the things I don't know I don't know". It is one thing to know that you need to ask someone, but what if there is something that I don't realize? I hope I can always look with a critical eye and know when I need help. As you said, I am not a critical care nurse yet. I am barely a nurse! I hope to grow and learn each day in order to someday be a critical care nurse. Thanks again!
  11. by   PDX_RN
    Quote from WindwardOahuRN
    Pardon me but there is no way in Hell that any self-respecting nurse who is a member of the Code Blue response team would depend on ACLS cards to get her/him through a code.
    There is also no way that you can function effectively in a code if you are still in the "oooh let me think oh I gotta look that up hold on a minute yeah I think I got it" phase.
    THINK, babies. People's LIVES depend on us. SECONDS count in a code. This is not a dress rehearsal or a mock scenario Mega-Code with a dummy who cannot die. You do not have the luxury of time, second guesses, ruminatiions.
    If it were your father/mother/spouse/child/loved one---how would you feel if you saw them crashing and burning and the people who were responsible for saving them were fumbling with cue cards while they were dying??
    An ACLS course certificate does not equal Code Nurse material.
    Laminated cue cards during a CODE??? Are you SERIOUS???? IMHO this is the height of idiocy and just so frightening. What's next, a copy of "CODES FOR DUMMIES" strapped to the code cart?
    To think that this anyone believes this is acceptable and even admirable is just plain scary.

    Ask yourself if you would be more frightened by having someone double check a drug dosage that they were not 150% sure of versus them relying solely on their memory in a stressful situation that for some of the readers of this forum is likely not an everyday, or even every month situation and likely giving your loved one the wrong medication? The fact is, people make mistakes in codes quite frequently. This is actually something that has been studied extensively and we know that patients get the wrong med, or the wrong dose, at the wrong time, around 10-30% of the time. Deviations from practice guidelines happen a lot. Many readers of this forum will read that and think they couldn't possibly be responsible for a med error, but it happens are patient outcomes not doubt suffer for it. I was not describing a situation where the code leader is clueless about what to do, and stares blindly at a algorithm, card like it was the first time they've seen one. But get serious, you got 2 minutes of compressions before the next action. Why not take a deep breath; look at your card; double check that dosage; make sure you aren't forgetting anything; ask your team members if they have any ideas? I don't think it adds anything to the discussion to scoff at someone who is humble enough to make use of an available tool, to ensure that they are adhering the best available scientific data as they attempt a resuscitation. Quick: what's the max dose of lidocaine you should give a 79 kg man in refractory v-fib? If you think you might have even a shadow of a doubt what the answer is in the heat of a code with the pressure cooker on high, why not make sure you know where your little flip book is? Because if you get it wrong, it will likely be by a factor of 10. That can't be good.
  12. by   WindwardOahuRN
    Quote from PDX_RN
    Ask yourself if you would be more frightened by having someone double check a drug dosage that they were not 150% sure of versus them relying solely on their memory in a stressful situation that for some of the readers of this forum is likely not an everyday, or even every month situation and likely giving your loved one the wrong medication? The fact is, people make mistakes in codes quite frequently. This is actually something that has been studied extensively and we know that patients get the wrong med, or the wrong dose, at the wrong time, around 10-30% of the time. Deviations from practice guidelines happen a lot. Many readers of this forum will read that and think they couldn't possibly be responsible for a med error, but it happens are patient outcomes not doubt suffer for it. I was not describing a situation where the code leader is clueless about what to do, and stares blindly at a algorithm, card like it was the first time they've seen one. But get serious, you got 2 minutes of compressions before the next action. Why not take a deep breath; look at your card; double check that dosage; make sure you aren't forgetting anything; ask your team members if they have any ideas? I don't think it adds anything to the discussion to scoff at someone who is humble enough to make use of an available tool, to ensure that they are adhering the best available scientific data as they attempt a resuscitation. Quick: what's the max dose of lidocaine you should give a 79 kg man in refractory v-fib? If you think you might have even a shadow of a doubt what the answer is in the heat of a code with the pressure cooker on high, why not make sure you know where your little flip book is? Because if you get it wrong, it will likely be by a factor of 10. That can't be good.
    Sorry, but if you are a member of the Code Blue Team you SHOULD know those things by heart. And if you do screw up the relatively simple stuff (like the max doses of code meds) you shouldn't be on that team.
    "Two minutes of compression before the next action"? Ah, what a luxury. Two minutes to browse through cards, maybe catch up on a little light reading, perhaps some meditation, a few stretching exercises. PDX, either you said this tongue-in-cheek or you haven't worked many codes. Those two minutes are often spent inserting lines, chest tubes, doing ABG's, grabbing labs, dealing with the concerns of the family members, making sure whoever is recording is recording correctly, preparing gtts.
    Tools are fine, tools are good. But, IMHO and IME, you simply cannot count on them as a resource during an active code.
    The standard meds for codes are rather easy to memorize. Dosages, max doses---not terribly difficult. Years ago we actually had more of a buffet of drugs that we used during codes, drugs that required escalating weight-based dosages (bretylium, for example) that we don't use anymore. Standard code drugs and their actions, doses, maxes---epi, atropine, amiodarone, vaso, etc---are relatively easy to park in your memory bank. The preparation of gtts should also be firmly planted in your brain too---for both peripheral and central administration.
    Yep, if my loved one was coding and the leader was thumbing through a stack of laminated cue cards as he or she worked the code I would be concerned.
    And BTW, it is standard practice to interact with your fellow team members and the floor nurses during a code. Standard practice for even a cardiologist to turn to us and ask if we have any suggestions, any ideas, or if we think we should continue with a code that appears futile. But no, we don't refer to cue cards before we answer.
    If a person is not comfortable working a code or feels that they're not ready to do so it is nothing to be ashamed of. In our ICU it used to be a requirement that the nurses working there would be expected to be part of the Code team eventually. When it became apparent that it was a terrifying experience for some and they couldn't function well during a code the requirement was dropped. Now only those who are comfortable AND function well are part of the team, which is as it should be IMHO.
    So just accept that you have to learn this stuff if you are going to step in and participate. That's just the way it is and the way it should be.
    And as far as "not doing these things every day" there should always be SOMEONE designated to respond to codes who DOES know what they are doing. AKA the "leader." There should never be a code where there is no one responding who is not very sure of ACLS protocols and algorithms.
    If a nurse who is ACLS trained and who is carrying that card cannot at least start the proceedings and keep things going until a leader arrives than they should hand back that card and take the course again. Think of the very first things you do as a first responder. Relatively easy, no? But you do have to do them quickly---seconds count. No time for card-checking....sorry.
    This is about lives, people, not protecting the egos of those who are not ready to participate in a code. Surely, with practice and study and guidance, you will be someday. It takes time, exposure, and the opportunity to merely observe and absorb before one can be expected to function in such a high-pressure situation. It's unrealistic and dangerous to expect otherwise.
  13. by   PDX_RN
    my point is actually really simple and can be summarized in three sentences. 1: deviations from standard clinical practice guidelines during in-hospital arrest are a very common occurrence - to simply say "not me"; "not my team"; "not my institution" is too live outside reality. 2: a major responsibility, perhaps the major, responsibility of the code leader is to make sure that the algorithms are being carried out correctly and optimally. 3: there are tools available, including the aha algorithm cards, which can be helpful to in some situations to assist the code leader in helping keep everything running smoothly.

    i think if anyone who has been to very many codes has seen some that frankly were not run well. the evidence demonstrates that happens way too often. and like 'em or not, when we deviate from the guidelines, we are not giving are patients the best chance for survival.






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