Calling them like you see them: Codes

[MarisL]

You know how once you have been nursing a very long time, you often know early on when a patient is going critically bad? Some of the clues you can articulate, others are harder to put into words.

I was wondering if anyone else has ever had an occasion where they KNEW their patient needed to go to the ICU, so they called for a rapid response (or the local equivalent)... only to find their another nurse actively inserting herself into the team's assessment to guide them away from viewing the patient as critical (why is a different topic).

The patient was tripodding, elderly, stridorous respiratory rate closer to 50 than 30, AMS, pallor, accessory muscle breathing, and had developed severe tachycardia from misfocused interventions. ICU had beds, but the team choose to leave him where he was: as one of my 8 patients.

I'd appreciate advice on staying clinically cool when you aren't being heard and you know your patient's life depends on it.

[MarisL]

OK. Slip-sliding to more useful question, then: Disregarding the specific circumstances of the prior post, how about a broader question: Have you ever had difficulty calling a code, OR more broadly, getting your patient what they need, because of your unit's culture? If so, how did you overcome it? If not, what do you attribute your success to?

[missmollie, ADN, BSN, RN]

I get the feeling that you're new to nursing, and I think we all feel this way in the beginning.

I felt like that in my first year of nursing because I was unsure of myself, and I had not witnessed enough to make the correct judgement calls. Now I gather all the information I need before I call a doctor, and generally when I call I'm ready for any question that could be thrown at me. The doctors/surgeons also trust me a little more as I've grown as a nurse, and that does help. I have had one incident where I had to directly confront the doctors on their decision, and my unit manager backed me. We pushed the bed out of the room while the medical team stood there, and that patient was in surgery thirty minutes later.

Sometimes it's about understanding what you do and don't know, and recognizing that maybe the situation was (or wasn't) as dire as you thought. Think through it, write it down, and put it in a drawer. Come back to it in a few months. Your view may change on what you did, but it's good to know why you felt that way. As you continue to experience more in nursing, judgement calls and advocating for your patient will be easier.

Hope that helps!

[MarisL]

Thank you for the useful feedback. I've seen things change a lot over the many years I have been in nursing, and you are spot-on that an organized, articulate presentation can open closed ears. Any other specifics jump out at anyone (regarding what it takes to overcome a unit culture that dissuades calling codes etc.)? In the specific event that led to this post, it was fortunate that after some push back, I was able to make myself heard, or the patient would have expired that night, within the hour. No question. I'm working on sussing out specific things in presentation that can lead to getting some one a needed intervention faster. As you have noted, with experience we come to know things instinctively. What I'm looking for is moving that instinctive knowledge into specific suggestions. Organization, articulateness, knowing the background answers that you'll need - these are all exactly the kind of specifics I'm looking to have contributed here. Thanks. Any others come to mind?

[P B and J]

I actually called a code before the pt coded...

I was talking with a pt and they seemed to suddenly act strange, my charge nurse happened to be walking by in the hall, and I asked her to call an RRT for me (rapid response team), (I didn't know what was going on but I knew it was bad!). I turned to the pt and said "nevermind... I think he's gonna code!" and pushed the code button. The code team arrived and the pt was still sitting on the side of the bed, (with me standing by wide-eyed!) the first couple to arrive asked why I called a code blue, and within a second the pt turned grey and fell backwards in bed!

Long story short, it was a real code, I have no idea how I knew (I was still pretty new), and he didn't make it. We called his mother to come in and she didn't seem shocked at all. Very calm and matter of fact. I asked her if she was really OK and she said "I knew it was coming, he called me tonight and told me 'bye' and that he loved me very much, but that he knew he was going to die tonight"!!

:wideyed: Anyway, trust your gut. If you know something is wrong but you don't know what, ask for help! Our hospital has a rapid response team, who we can call for help, another set of eyes, and just when you know something is wrong but can't put a finger on it!!