Code blue

[rehric00]

Picture this: young-ish chronic trach/vent patient. You know him well. Hes been on your unit for months waiting for placement. You know him, he knows you. he has family, they don't come to see him much- they are broke and cannot afford to come see him- so you ARE his family.

The day starts out fine. Nothing out of the ordinary. Lunch time passes, you step off the unit to transfer another person out- come back to find that Mr Man is not doing so hot. You and RT work to get his sats up but not much is helping. Doc orders a CXR via phone- but that's it. Results are phoned to him- at this point sats are 91% so hes pleased.

20 minutes later, you walk in- notice a HR of 28 on the monitor in the room... "Hey, Sir, Are you with me? Sir" shaking him feverishly. No response.

"I NEED SOME HELP IN HERE!!!" you shout to your buddy nurse. She enters, you've already begun compressions, she hits the code blue button and yells for more help. Its a Saturday, so you do not get the usual influx of people.

The patient looks at you. He is awake. "You with me?" he shakes his head yes. "You're scaring us man..." He is a trach so RT is bagging him.

His heart rate begins to drop again, his eyes roll to the back of his head. Dr orders some epi. His rate is back up to 50's. Atropine is given. nothing really happens. Epi wears off- hes bradying down again. More epi. More atropine.

His wife is called, but does not understand the urgency and couldn't get to the hospital even if she wanted to.

Dopamine drip is started, lines are put in. Meanwhile- he is blue. Mottled. Cold. Mostly unresponsive. Seizing.

Code continues. You are hoping that this main can just be left alone and out of his misery that he has been in for months, years now. But- we have a duty.

Code continues. Labs are drawn, severe metabolic disturbances. More meds. More fluids. Nothing. 2 hours later, doc calls the code. You tell him you are hear with him, he is not alone. It is OK to "go". That he is not alone. His agonal rhythm eventually stops.

You have to tell his wife he was died. He is dead. She is not understanding this information well. Now, once he is dead- an wave of family swarms in. "why couldn't they be here when he was alone??" you ask yourself.

You know he is in a better place, but you still feel off. Sad. But, Mr Man looks more peaceful, laying there without his vent, IV, tele leads... More so than you have ever seen him.

You carry on with your work and make sure everyone else is OK. Incoming shift is shocked to hear the news, you finish your mounds of paperwork, go home, and think long and hard about the events that unfolded during your shift.

[tokmom, BSN, RN]

(((hugs))) it's a very helpless feeling to lose someone suddenly. I still replay a recent death of one of my patients who suddenly passed due to a PE. I think we as nurses wonder if we could have done something different, something sooner....

[rehric00]

I agree, this was the best thing for him. He was sick for a very long time. He would go through "panic" spells, get himself worked up, get SOB, low O2 sats, but always recovered after some morphine and a few hours... This time was different. But he was sick. Heart disease, lung disease, kidney disease, etc. I just feel sad his family could not visit. All he wanted was to go home, although that was not a possibility for several reasons.

[rehric00]

Did a doctor have a discussion with him about code status? You use the phrase "out of his misery." Did he want to go? I hope someone talked to him about his wishes….as a nurse we may need to facilitate that discussion between the pt. and the doctor.

Either way, talk to someone about about. It should get better with time.

They had in the past. I believe at one point (on a prior admission) he was a DNR. But this time, he did want to live. He was a Full Code and he knew what it all entailed. He had coded a few other times during this current admission even, always came back and always decided (with full mental status) to remain a full code. However, as all of you know, we can only do so much in our measly "human power". I think this was in God's hands.

[rehric00]

That man's death sounds like the best outcome for him considering what all was going on. And who the heck codes a patient in that condition for 2 hours?

I was asking myself the same question. I suppose because he would gain his HR back but as soon as the meds wore off, it would brady down and we'd start compressions again. I started asking myself "why can't we just let him be" after the first 30 min. He was lifeless. Bad color. Bad everything. I think this might be part of the reason I feel so off about it. The doc even said things like "well at least if it gets brought up in court we can show that we put forth the appropriate effort". I am OK with death- have dealt with it a lot. I do not even cry when patients die.. but I guess I feel like sometimes we try too hard instead of letting people go peacefully.

[firstinfamily, RN]

There have been articles about nurses experiencing PTSD usually with multiple exposures to trauma, emergency nurses seem to have this more than other nurses but I think we all are susceptible. I encourage you to seek out someone to discuss the code with and perhaps there is a nurse liason who would be helpful. If your medical insurance is through your employer they should offer a counseling session to their employees free of charge. This is a limited benefit but one you should take advantage of.

[DaniV.]

I am still haunted by my first code. The patient had been a young guy, in his mid-40s. He had been a paraplegic who had started on the unit with vent, trach, urostomy, iliostomy, and wound vac. He had been one of my patients for months, and during his stay, his wound healed, he was weaned off the vent, decannulated, and scheduled for discharge in 3 days.

He had always been very motivated to go home, so right after he was decannulated, he had asked for his PRO breathing tx every 6 hours ATC until we got him to understand that they were for when he had difficulty breathing and not just because the clock told him he could have one. He also got to know the pattern of people's walk to the point that he could call out your name while facing the window. But he was not on heparin, lovenox, aspirin, or coumadin....

On his last day, he was a pain. He was anxious, up all night, and despite knowing he has to wait at least 5 hours between breathing tx, he was asking for one almost as soon as you took the mask off. Finally, at 6am, he asked for another Xanax to help him sleep.

At 7am report, I was whispering to the oncoming nurse what he was like all night, and she peeked into his room and saw he was Grey and not breathing. Being a nursing home, we didn't have a code team and it was up to us to call 911, do compressions, with the RT to bag him. No emergency meds available for us to use...

He died in the hospital after throwing several more PEs, and it still haunts me that I didn't catch that he was bed bound and not on blood thinners or the s/sx of him throwing a PE. I had only been a nurse for 5 months...

[Txldy]

First, we work overly hard to say things like "he is a trach." It certainly dehumanizing him, doesn't it?. Maybe THAT'S what feels...off. I was reminded regularly, when I worked in several unit situations, to get my paperwork in order and carry a copy of my simple living will with me everywhere. I don't want to be a "chronic vent" or trach or tube feed or drip. I want to remain human. I suggest that all nurses do the same. When I had my mitral valve replaced quite a few years ago, I had ONE nurse who spoke to me like I was human, even though I had extended time on a ventilator. ONE.

[CathySweeney]

First {{{{HUGS}}}} You may now feel that you are coping well with this but do not be surprised if it comes back at some time in the future. The next code, a young patient, someone in a similar position can set it off. It is okay to feel this way and their may be others on the unit that feel the same way. Maybe you could have a unit memorial service for all the patients from the last quarter so that everyone who may need to express themselves can. Is there a pastoral care person on the unit or a social worker who could lead it. Being a hospice nurse I have had my share of attachments and need for memorial services. If you cannot have a memorial service find your own why to let him go, release a balloon. place a rock. send a paper boat on it's way. Anything that will help you works.

We are human and will get attached , what we need to do is learn how to handle it. I know I certainly had my problems by was lucky enough to work with people who would help me by reminding me if they notice you doing so, helped me many times. I could see me getting attached to this patient.

[DanaLonsinger]

And then you cry.....