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Discussion

Code Blue: Where Do I Stand?

  • Experts

A bed alarm went off. A chair alarm next. Silence. Then the code blue alarm. I didn't make the connection until I arrived in the room. It was the patient I had seen only mere hours earlier, a close friend really, and they weren't moving. They were laid flat, unresponsive and gasping with their eyes wide open. I shuddered, thinking about those piercing eyes, engaging me on multiple occasions over the last two years in many a room on my home unit. I hated that I was here in this moment, tearing the Ambu-bag from its plastic encasement to place forcefully, flush to that sweet face.

The room was chaotic. Every second, every movement, every choice was personal at this point. I could feel that our brains were simultaneously clouded and afraid. We were upset and unaware of the turmoil that was billowing from our joined essence. The room was powerful enough to explode in that moment. All forms of controlled demeanor and professional cordiality were out of the window in a screaming frenzy. Chaos. Utter chaos.

I couldn't think until we had our dear friend and patient on their ventilator in the ICU, echoes of their family wailing outside in a holding area for the unit. It was one thing after another.

I stayed behind with my charge nurse and one other nurse who had been caring for this angel all day until now. We waited, assisting in setting up equipment and placing a familiar frail form in the safest, most comfortable position we could muster. The oncoming ICU nurse was caught in another room, so we waited, watching heart rhythms dance across the monitor screen. I checked a pulse after what felt like every 30 seconds because I knew what was coming. I could feel it. I could sense it. And I hated it entirely. I knew it wasn't my call, but still I fumed in total selfishness knowing that this was a battle this tired body was going to lose. In the end, it was triumphant. This wonderful being was released from an exhausted, strained fleshy envelope. But still it stung. And it stung deeply.

As soon as everything ended, everything was over, immediately my mind was turning over each second, examining it with undeniable scrutiny. If it wasn't for the debrief that occurred shortly after, looking back at those high strung moments would entail an entirely different emotion in the pit of my stomach.

I write this to you not only to educate but to also heed a warning, or a thought perhaps. This code was unorganized. We were so stunned at the situation, so blown by our emotion when it happened. Amazingly, they lived. For a little while at least. In reflection, we did not assign roles, our voices raised and at one point, some egos came out to suggest outcomes and action beyond our control.

Yes, my friends, the ACLS video is possibly one of the most mind-numbing repetitive videos for education out there. But I have to tell you, it does this so that you remember your role. So that you remember what has to be done. It is performed in order that you see how well a code can be performed if you just take a breath and allow the situation to unfold. For this, I love that video, the education, the step-by-step guidance.

Just a few weeks ago I participated in another code that happened two days after I had recertified with my ACLS. The situation was extremely drastic and the patient's history was cumbersome. Two nurses had beat my arrival to the room and they were already bagging the patient and compressing the chest as the alarm sounded above. I arrived with the code cart and cracked that piece of metal with an odd calmness that had my mind humming with clarity. The patient's chest was covered by two alternating nurses, there was a nurse Ambu-bagging, one nurse recording, the nurse who cared for the patient was reporting as I was manning the cart and meds. We cared for that patient through three rounds of CPR and the first dose of epinephrine before a physician arrived. The second round of epinephrine clutched in my hand as I saw the white coat in the corner of my eye. When clutter attempted to ransack our flow I yelled and told those who did not belong to remain at the door until necessary. They all listened.

With fluidity, we near emptied the code cart from its entirety of medications. This patient had lost a pulse, respiratory effort, had seized on and off and had used up two Ambu-bags due to severe bloody regurgitation blocking the airway. Blood squirted to the high heavens as the warning rang out in the air through the calm voice of a very controlled respiratory therapist. EKG was able to come in, IV therapy and lab, all the while others remained at the door waiting their turn. Just like the story before this, the patient was able to return to spontaneous circulation and we hustled down the hall to the ICU for an open ventilator awaiting a great and terrible need.

Yes. The code concerning our friend could have gone more smoothly. We all knew what could have been better. But as we debriefed, when we wrote down what went well, someone powerfully and plainly noted, "they lived". As our rapid response nurse, and close friend, read this Earth-shattering, yet simple information, everyone exhaled and bit their lips. It was true.

Beyond it being personal, beyond our hang-ups, the patient lived. We all fell into silence as our friend continued her debrief, "just because you felt a way about a certain situation doesn't mean that was how you performed." The light went on. We knew the code stung, and that it was going to sting. We knew this patient. We loved this patient. We called this amazing person a friend. Yet everything we heard, despite our better efforts and every hang-up, were all true. They lived.

None of this, my friends, is being told to you and written in vain. Immediately after this code, I emailed my boss, our patient care supervisor, and our shared governance president, specifically asking a call of action on this front. We needed this situation to happen to know that even though we have the power to change the circumstances of a person's life, ultimately, it's not our call. On an emotional front and skills front, our lives had been shaken. Our resolve had been tested.

We have the power to make ourselves as ready as possible so that when the tide comes we refuse to sink and be overtaken, but rather swim and fiercely so.

It is our duty and our honor to be everything for those who wish to have every precaution taken every stone unturned.

This duty is furthermore calling us to be as educated, dedicated and as willing as our faith and abilities allow us.

Keep fighting the good fight.

    • Featured Replies

    As difficult as it may be in this kind of situation, with emotions running high and when every second matters, staying calm and in control is vital. The last thing a critically ill or dying patient needs is a room full of healthcare providers who are so frantic and distraught that they can't think or act logically. Usually, just one person who takes charge and directs the flow of everyone's coordinated actions helps to create a calmer atmosphere. That's why in BLS/ACLS training, knowing your role and using concise communication with the team is taught.

    I try to use every code or other emergent situation I am involved in to build on what I could improve on. Staying calm is a skill, and it takes time, experience and evaluation of previous situations to develop.

    As an upcoming nurse I thoroughly appreciate you writing this. It is realistic and informative. Thank you

    [COLOR=#000000]I have seen the madness that can occur in codes all too often. For some the ego of one provider conflicts with the ego of the others, sometimes you only have under-educated staff to assist, and other times despite everyone's best efforts and a "flawless code", the patient still dies. I am glad to hear you are taking this on as an improvement initiative at your employer. Others would just say "this is how it is". We should never stop trying to improve ourselves and the outcomes for our patients. [/COLOR]

    I really enjoyed this article and the perspective of a young, "up and coming" nurse. The compassion present in the narrative seems genuine (Nursing must be your calling, LOL) and the quest for improvement is loud and clear, as well as heartfelt. I applaud these qualities in you!

    From a somewhat, "crusty" CCRN, Flight Nurse and 20+ years as an instructor in BLS, ACLS, PALS and NRP (formerly NALS) perspective let me offer these few guidelines:

    1) Training should be taken seriously at all times, especially when training

    is taking place.

    2) Repetitive simulation is effective for serious training to succeed.

    3) When the "real thing" happens you will only be as good as your training

    and experience permit.

    4) Never "blow off" hands-on skills thinking that you already know them!

    5) Teach and encourage your colleagues!

    6) Apply diligence to being prepared through training (what if scenarios)

    7) If IT IS your day to go, you cannot stay; if it is NOT your day, you must go.

    Check out the poem by Rudyard Kipling: "IF" (don't be offended by the last line, He's talking to his son).

    If you can keep your head when all about you

    Are losing theirs and blaming it on you;

    If you can trust yourself when all men doubt you,

    But make allowance for their doubting too; .....

    Thanks for sharing! Much more could be said. NURSE ON!

    Great article. I haven't participated in many codes, and I will tell you they terrify me. But it is more the fear of the unknown. We have several mock codes each year and my hospital does offer code blue classes run by the ICU nurses that really break it down - they get you hands on with some of the medications and the procedures, and it helps immensely. Every time I take it I leave feeling "refreshed" and confident that I could react accordingly in a code situation. :)

    This year I will have been a nurse for 27 years. I have worked in many environments. I have learned a lot of complex information, fancy drugs, procedures, pathophysiologies, but I have found that often what brings success with patient's outcomes are the basics. ABC-airway, breathing circulation. when you are faced with a situation if you take a deep breath and rely on training and repetition and I would say, if you don't have the luxury of a simulation lab, close your eyes and picture the situation and yourself walking through it adn do it over and over until you are comfortable. When you encounter a code, which is often the most terrifying thought a nurse faces daily. You can face it calmly and with the assurance that you have the tools to do the best you can, ABC. When you look back to decide if you did all you can in a bad outcome, the answer is, if you covered the ABC's, you more than likely did. We never have full control over a person's destiny.

    Nice writing on a difficult, frustrating situation. Sorry about your friend.

    Some loses are harder than others, and I know that coding your friends and loved-ones ranks among the "toughest stuff" in nursing. Also, add situations where you may care for and even ultimately have to "code" co-workers in certain nursing jobs and it brings a new meaning to the phrase "rough day at work".

    Recognizing that the situation was so uncomfortable that it spurned you to want to make changes is a good thing. It may not feel that way, but a situation that strongly impacts you can serve to bring a very positive change.

    Although you have only been a nurse for a few years, if you are fortunate you will continue to have situations that challenge you to want to make changes your entire career. I do hope that you have less heartache, but even the experience and the most awesome ACLS skills will not protect you from that, I'm afraid.

    That "discomfort" has happened to me several times through the years and I always called them "shaping incidents". These are the events in clinical practice that serve to drive me to a place of growth. And from this place I made strides as a clinician and sometimes personally.

    Most of my "shaping incidents" had a few commonalities. Generally, they were "high stakes" situations—either for the patient or me or both. Often, these were "spinning" situations —lots of people involved and lots of moving parts. Although not all of the "shaping incidents" involved a bad outcome, many were less than textbook ideal.

    The real gift of these experiences started after they were over and when I started looking back to go forward.

    Could this have been handled differently?

    What could I/we have done different? What went right? Wrong?

    Who/what worked best? Who/what didn't work out so well?

    As difficult and frustrating as it may be, that's the way growth occurs.

    I always tell tell folks to make their clinical practice "comfort circle" as tight and as absolutely solid as possible.

    Know your stuff cold. Up, down, right, left. In the rain, on a plane, on a train, through the grain, and the insane.

    (My apologies to Dr. Seuss). But the fact is, when you are stressed, you come back to your "comfort circle".

    You always come back to what you know and know cold. So, what do you want in there?

    When you start out your circle is small. You may only know where to stand and not get in the way. But, that needs to change and change fast. You determine your "comfort circle"!

    Be brave. Take the classes. Be the "go to". Step up. Stay current.

    Your "comfort circle" will depend on constant review and renewal. Keep learning, stay fresh.

    Be the best you can be!

    Practice safe!

    Thank you for this article. I could envision myself participating in the code with you.

    Having worked in the Emergency Room and ICU, I participated in many CPR cases. I'm afraid

    only a very few were successful.

    Prior to transferring to the Emergency Room I was a Charge Nurse on the Renal Floor. I had a patient

    go into V-tach and another RN and an LPN were with me in the room when the code was called

    out over the intercom. The House Supervisor cracked the door open, saw the three of us and said,

    "well, I see you all have this in hand...I'm going to lunch." We were working as hard as we could, to

    no avail. The physician had not arrived as of yet. Respiratory Therapy finally arrived and took over the

    bagging duties. The House Supervisor was reprimanded for her actions and was no longer in that role.

    Know your stuff cold. Up, down, right, left. In the rain, on a plane, on a train, through the grain, and the insane.

    This is awesome advice. I have participated in many codes as I work on an extremely high acuity unit, and we have a lot of codes and deaths. I still look over my ACLS book from time to time just to make sure I've got it.

    I highly encourage anyone who is ACLS certified to buy the book, not just borrow it from your unit, and reference it often. At least once every couple of months, skim through it again. We forget things we don't do on a daily basis, period. Reviewing that material over and over again is boring, sure, but it's necessary.

    On the flip side, it is definitely possible to be too comfortable during a code. It happens pretty frequently on my unit that there are people cracking jokes and laughing during the codes. Codes are a social occasion sometimes as people working on different parts of the unit might not have had the chance to talk to each other all night, but now they're in the same room for the code, so there's often a lot of "Hi! Haven't seen you in a while! How was your weekend?" going on. I find that inappropriate. Find your buddy after the code to catch up - don't use a code as a gossip session.

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