Debriefing my First Rapid Response

[2020newgrad]

Hi all!

So I'm a new grad (just finished my first week off orientation) on a floor that's half medical patients and half post-op, but the cardiac unit downstairs went COVID around a month ago so we now get cardiac too. There are floated cardiac nurses on the floor to cover people on cardiac drips, etc, and it's definitely an interesting learning curve for all of us, especially for me as a newbie, to have NSTEMI and new onset CHF patients.

Well, I had a new CHFer recently who went into SVT on me. Tele called to say he was sustaining in the 130s, so I went in and got eyes on him, got vitals, called a rapid response and the covering provider from the room. His pressure was okay on paper in the 110-115/70 range, but his baseline was 150s/90s  so I was uneasy from a hemodynamic stability standpoint.

Then I stuck my head out of the room to alert the other nurses and get help, and saw no one.  Somehow I didn't think to hit the urgent call bell to get people to come running and instead ran out the 30 feet to the nurses' station to alert people, then turned around and went right back to my patient. The RRT got to the room just as I returned so it looked to them as though I had left my patient unattended.

I'd never even seen a rapid response before this and so I didn't really know what to expect. It was an odd and ultimately unsafe staffing situation that night - it turned out that between the 4 of us on the medicine side of the unit we had less than 4 years' experience, but I didn't realize until we were debriefing because I thought the two cardiac floaters had been there longer. Our resource nurse was also charge with a full assignment and was transferring a patient to the ICU at the time. When I notified my unit of the rapid response, just two nurses  showed up, neither with more than a year's experience. Which would have been fine, except that I felt in out of my depth and stopped thinking straight and didn't delegate. The RRT nurse had to call me out because I kept running errands for her. She stopped me and said, "Where's your team to help you? You should be staying with your patient." Of course I know that, but I felt useless and it didn't feel like the support was there. The experienced nurses from the surgical side of our unit had been occupied with other acute situations and showed up 10 minutes into the rapid response. I made a bit of a fool of myself - the team asked me what his baseline heart rate was and I froze up and second guessed myself even though on reflection I knew it. Ugh.

The patient's BP ended up coming back up to the 130s/80s and his sats were fine so it was a stable SVT; they tried metoprolol and diltiazem with little effect before a successful cardioversion to NSR with adenosine. It would have been really cool to watch if I hadn't been too busy feeling useless and incompetent (and feeling bad for my patient going through the misery of adenosine).

The nurse educators and leaders from the unit had a huddle the next morning and filed an incident report for the unsafe staffing situation. The universal response from my colleagues was to tell me I did fine for my first time and that they were sorry I didn't have the support I should have, though I know personally that there's a lot I wish I'd done differently. In the end, I'm grateful (and my unit) get to learn these hard lessons from a situation in which the patient ended up fine. As hard as it was to get the feedback I did from the RRT nurse, I pulled her aside once the patient was stable and let her know how much I appreciated it and got some good pointers for the future, so I'm really grateful for that also.

My questions for you all are:

1) How do you more-experienced folks mentally prepare for situations like this during each shift? Is there anything you emphasize in your start-of-shift review of the chart that a new nurse might not find intuitive? E.g., I recently was advised to pay closer attention to MEWS scores, which is something I'll be doing going forward.

2) Other than delegating and collaborating to make sure vitals, EKG, BG, etc. happen during a rapid response, what is your process before and after calling a rapid? Do you glance over crucial info (labs, baseline vitals, etc) before the team arrives or are you able to just hold it in your head from earlier in the day? I'm worried I might just have a crappy memory because I'm a nurse who needs things on paper, and so I fear I'll always be slow with that info when the team asks for it. I appreciate any and all tips.

3) How do you stay calm and grounded in these emergencies? What are your strategies for maintaining mental clarity and an atmosphere of calm? I really appreciated the resident who asked me to silence the Dinamap and the EKG machine because "none of us need cortisol spikes!"

Thanks in advance for any pearls of knowledge and experience.

 

[Davey Do]

I'm just a dumb old psych nurse who's been in a couple of Codes and RR over the years, but I wanted to support you in your endeavor to gain knowledge and learn how to do your job better, 2020newgrad.

I'm reasonably sure some competent seasoned medical nurses will come along and give you the advice that you request.

From my perspective, a lot of this ease at your job will come along with time. When I've been involved with Codes & RR, I've been relatively comfortable because I know my basics and I know my limitations. And it's relatively easy for me to separate my emotions in the situation.

I do want to comment on this portion of your post:

"Then I stuck my head out of the room to alert the other nurses and get help, and saw no one.  Somehow I didn't think to hit the urgent call bell to get people to come running and instead ran out the 30 feet to the nurses' station to alert people, then turned around and went right back to my patient."

In 1983, I was an LPN student doing clinicals on a medical floor. I walked into my patient's room and saw him with the HOB raised, giving the Q sign. I immediately checked for pulse and respirations while lowering the HOB. I dialed the operator to call a Code and had to go back in the hall to see what room I was in!

I just thought our situations were somewhat similar!

Good luck, 2020newgrad!