Did I do the right thing in this code situation?

[Nurse162]

Having some anxiety over how I handled a situation and would really appreciate some thoughtful feedback. Some background - I've been an RN for a little over 2 years, worked inpatient for 1.5 yrs & now work in a clinic. I have dealt competently and calmly w/ rapidly deteriorating post-surgical pt.'s on many different surgical lines (CT, vascular, ENT, etc.). Prior to being a nurse, I worked in a 4-bed stabilization room at a level 1 trauma center as an HCA, where I saw many traumatic resuscitations up close & did a variety of tasks during cases - EKGs, grabbed equipment, put syringes of blood into lab tubes, called stroke codes/trauma 1 or trauma 2/CT/house sup. about placement - but not giving meds or anything hands-on like the nurses & doctors. I've found that I am able to stay calm in stressful situations, however, I have not been the first one to enter a code situation nor have I actively participated in one. This entire situation lasted like 10 minutes but I've found myself stressing over it intensely since I left work. Any thoughts on the things I'm questioning/anxious about would be greatly appreciated. I'll take any advice for the future as well.

Today a pt.'s family member popped out of a room & yelled out for help. (The pt. hadn't been seen yet so no injection was given nor anything done that typically causes a few of our pt.'s to faint). I ran in the room, the pt. was upright in a wheelchair (not slumped over) staring blankly (my immediate thought was TIA/stroke/who knows). I quickly moved two fingers across his eyes while asking him if he could follow my fingers (nothing), then asked if he could grab my hands (nothing) - all was said & done quickly. A nurse said press the code blue button (I said it's a smart code right now, call a smart code). A moment later his head went back & he took a slow/gaspy kind of breath & then a bit of a pause and 1 more - during this I felt for his carotid & there was no palpable pulse. I pushed the code button, told the PA that had been standing there to help me lift him to the floor immediately, got him to the ground, told the PA to start compressions & the other person in the room to be prepared to switch with him. I ran out and said I need a crash cart now! (Clinic staff was aware and it was on the way already). It's hard to remember but at some point the provider stopped compressions and said that the pt. was making a (barely audible) sound when he did each compression (he was in no way resisting or moving). I said keep going. Only about 60 compressions were done in total because when the crash cart got there someone turned on the defibrillator & I put the pads on the pt., handed someone the ambu bag who had asked for it, the monitor showed an organized rhythm, he was breathing so we put a mask on him w/ O2. He had soiled himself. Quickly took vitals - BP 189/109, HR 60s-70s, O2 sat 91% on however many liters the person had turned it up to, got a FS of 129.

Things I'm feeling weird/just ruminating about:

- I didn't realize that, in the outpatient clinics, the code blue button calls out a smart code. We apparently get all the necessary team members, just less than when a code blue is called on an inpatient ward... I came from a post-surgical inpatient ward (same hospital), where we had rapid, our co-workers, & the pt.'s surgical & medical on-call providers to help w/ deteriorating patients, & then we just called a code blue for code blues... I guess I feel stupid for telling my co-worker to pick up the phone & call a smart code because 1) the button would have created the same result - not feeling super bad about that because I didn't know & didn't want to call a code blue on what I believed at the time may not have been but 2) it ended up being a code anyway, quickly after I said that.

- Me rapidly asking him to follow my fingers and squeeze my hand was sort of my way of seeing if he was at all responsive. He was holding his head upright but didn't move an inch. When I worked inpatient we did have some patients who basically went blank like that and didn't respond but also had a pulse... My mind was thinking stroke/TIA/something - not code blue. It wasn't until his head went back that I checked for a pulse and couldn't feel one.

- I can't confidently remember the sequence of events after the crash cart got there - dangit... Did I hand that person the ambu-bag before I grabbed the pads? Also, I now realize I don't think they weren't doing compressions when I was taking the stickers off the pads so why did they stop, did they feel a pulse or were they waiting for me to put pads on? My mind was just focused on what I was doing. Pads on - monitor showed organized rhythm - afterwards I realized the defibrillator was on monitor mode NOT AED mode... we would have figured it out if the rhythm was vfib/vtach or asystole or whatever but it appeared organized. I should have realized that it hadn't said "analyzing rhythm" though, but there was a lot going on.

- We used a hover-jack to get him on a stretcher and he was brought down. He wasn't speaking but did look at me at one point and looked a little scared, and I said everything was ok. Sounds like the he didn't say anything the whole way down but right when they got to the ED he then said something along the lines of... "I feel like ***." I looked him up later when I went in his chart to write my cardiac arrest note. Chief diagnosis at that point was syncopal episode. There is this thing in nursing where if you call a code blue and people feel that it "wasn't a real one" - you suck. No one acted that way at all, but it's like, his head went back and he took those weird breaths and I really couldn't feel a pulse. It's not like he woke up and rolled over or became alert at all when we brought him down to the floor either. I mean I did the right thing right? I was thinking, I should have tried to shake him a bit when he didn't move but then I thought... pretty sure if he didn't need CPR he would have reacted to being lifted out of his chair, brought to the floor, and given compressions... Looking at the chart - from the labs that were back, trop was negative, electrolytes normal, d-dimer 5000 (pretty sure imaging report was negative for PE). Idk.

- Everything happened so fast I now realize I hadn't really said out loud, with the code team there, that I saw his head go back and stuff. I feel so stupid for not saying that. In the rush of things I was just focused on helping. I know that other people were talking though and the PA was there the whole time so I hope he said something? From the notes the team wrote, it doesn't look like he did. But it does say the daughter was in there and yelled when the pt. stopped responding, etc. So it's not like he was found down and we didn't know for how long. And then when I charted I just said "Pt.'s daughter yelled for help. Writer ran to room. Pt. in wheelchair unresponsive w/ no pulse. Pt. brought to floor w/ assistance & compressions started - bla bla bla." Do I need to go back and create an addition to my note to change it? Or should I leave it because that will look weird/bad & I documented the point, which is that he went pulseless and we initiated CPR. Idk why I didn't write the first part. I was trying to be concise and feel dumb and anxious now but am not sure if my feelings are warranted.

- I think I also feel weird because it happened so fast and I'm going through my checklist like. Did I make sure compressions were good? Did we have anyone get epi. ready? But it was over as soon as it started. And I know I'm not a provider and that all of those things would have been done if the code continued because someone would have taken over and we would have been doing the appropriate tasks.

Thank you so much for reading that very long post & for giving feedback. Hopefully I am, for the most part, overthinking. I really do care about doing reflecting on first-time situations though and want to make sure I do the best I can.

[Nurse162]

Also, one of the ortho surgeons that was in clinic got really excited over it all for some reason & talked to the Chief of Ortho on his way out & apparently mentioned that myself & two providers really took control & responded right away & did a great job or something, & the chief put in for an award to be presented to us - basically cash & recognition. I think someone important actually comes to my clinic & makes a thing out of it & takes a picture. I don't even know if that provider was watching, he wasn't even there in the beginning so I don't know why he went & said that. He was telling old stories though & was very amped up so idk if it was just all the excitement or what. It makes me feel weird though, especially since I'm feeling insecure about the situation. I barely did anything, & I literally just did what anyone would have done, & 3 of my co-workers were also really helpful throughout.

[Nurse162]

Also, would CPR be considered a "recent trauma," causing the d-dimer to elevate that much?

[2Ask]

Sounds like you did what you were supposed to do and you need some debriefing with others who were there. Your patient coming out with a heartbeat, breathing, and talking is a GOOD OUTCOME. Don't beat yourself up!

I've only had a handful of my patients code in my 7 years of nursing so I don't have any comments about the technical aspects except to wonder about some type of seizure based on the patient's lack of response and soiling himself? We do tend to call RRT's early if a patient's condition is deteriorating- it gets the extra hands and expertise to the bedside quickly.

[2Ask]

PS If you have not gotten your ACLS certification, I recommend it. Going into depth studying and practicing the algorithms and doing a refresh of skills every two years will build your knowledge and confidence for the appropriate step by step approach to multiple scenarios

[Nunya, BSN]

You will always second guess yourself and wonder if you did everything PERFECTLY, unless you've done a million codes. Your patient is alive, you did good. Now keep these things in mind for the next one.

[HarleyvQuinn, MSN, RN, NP]

I second the debriefing. It's absolutely necessary and it gets completely disregarded in clinic settings. We had a code when I was the only RN in a Peds clinic and management disregarded my request for a debriefing session for all involved. They were then were mad when productivity was disrupted because people were "gossiping" and directed that the event couldn't be talked about. I know it caused more harm to me as I was still in the thought process of trying to comprehend the "how" and "why" of such a young loss. Even in a busy ER/Trauma unit we make time for debriefing.

[traumaRUs, MSN, APRN]

These situations are always difficult, especially if you don't do this daily or weekly. Debriefing is good idea.

[2BS Nurse, BSN]

I work in a clinic where codes are called. We have to remember... we have no real "rapid response team" with simulation practice as they do in the hospital setting. Very few of us are ACLS certified, most of our providers do not have ER training, and they are like deer in headlights when a code is called. All we can do is the best we can do. Although I am ACLS certified, I can only do on thing at a time and I have to prioritize. Most outpatient RNs aren't even comfortable inserting IVs because they are out of practice.

Consider yourselves lucky if a "debriefing" is called in a clinic setting. Sad, but true. We "ain't got time for that"

I agree 100% to HarleyvQuinn's comment above. Nobody gives a rat's &%$ about processing feelings, so gossip ensues.

[EllaBella1, BSN]

First of all, you did great. Second, I 10000000% believe that it's ALWAYS better to call a code when you're not sure. I know you said you felt bad that it "wasn't a real code".. wouldn't you feel worse if it was and you didn't call it?

A couple of things I would have done differently- I would have skipped the finger thing and gone right to a sternal rub. If he was kinda out of it, a little bit of painful stimuli might have snapped him back. I would have also insisted that someone write up a code sheet, not just notes. There should be code sheets on your code cart I'm assuming? You did CPR, even if it wasn't for long. It's important to document that the patient became unresponsive, CPR was initiated, and patient became responsive again. Assuming the patient wasn't on tele and didn't have any other monitoring at the time of the code- it's impossible to know what exactly was happening when it started. Also, did you check for a pulse after you saw the rhythm on the monitor? Remember, organized rhythm doesn't always mean pulse.

I agree with the others that a debriefing would have helped a lot, but don't beat yourself up. It sounds like you did the right thing.

[Workitinurfava, BSN, RN]

On 6/22/2019 at 1:13 AM, Nurse162 said:

Having some anxiety over how I handled a situation and would really appreciate some thoughtful feedback. Some background - I've been an RN for a little over 2 years, worked inpatient for 1.5 yrs & now work in a clinic. I have dealt competently and calmly w/ rapidly deteriorating post-surgical pt.'s on many different surgical lines (CT, vascular, ENT, etc.). Prior to being a nurse, I worked in a 4-bed stabilization room at a level 1 trauma center as an HCA, where I saw many traumatic resuscitations up close & did a variety of tasks during cases - EKGs, grabbed equipment, put syringes of blood into lab tubes, called stroke codes/trauma 1 or trauma 2/CT/house sup. about placement - but not giving meds or anything hands-on like the nurses & doctors. I've found that I am able to stay calm in stressful situations, however, I have not been the first one to enter a code situation nor have I actively participated in one. This entire situation lasted like 10 minutes but I've found myself stressing over it intensely since I left work. Any thoughts on the things I'm questioning/anxious about would be greatly appreciated. I'll take any advice for the future as well.

Today a pt.'s family member popped out of a room & yelled out for help. (The pt. hadn't been seen yet so no injection was given nor anything done that typically causes a few of our pt.'s to faint). I ran in the room, the pt. was upright in a wheelchair (not slumped over) staring blankly (my immediate thought was TIA/stroke/who knows). I quickly moved two fingers across his eyes while asking him if he could follow my fingers (nothing), then asked if he could grab my hands (nothing) - all was said & done quickly. A nurse said press the code blue button (I said it's a smart code right now, call a smart code). A moment later his head went back & he took a slow/gaspy kind of breath & then a bit of a pause and 1 more - during this I felt for his carotid & there was no palpable pulse. I pushed the code button, told the PA that had been standing there to help me lift him to the floor immediately, got him to the ground, told the PA to start compressions & the other person in the room to be prepared to switch with him. I ran out and said I need a crash cart now! (Clinic staff was aware and it was on the way already). It's hard to remember but at some point the provider stopped compressions and said that the pt. was making a (barely audible) sound when he did each compression (he was in no way resisting or moving). I said keep going. Only about 60 compressions were done in total because when the crash cart got there someone turned on the defibrillator & I put the pads on the pt., handed someone the ambu bag who had asked for it, the monitor showed an organized rhythm, he was breathing so we put a mask on him w/ O2. He had soiled himself. Quickly took vitals - BP 189/109, HR 60s-70s, O2 sat 91% on however many liters the person had turned it up to, got a FS of 129.

Things I'm feeling weird/just ruminating about:

- I didn't realize that, in the outpatient clinics, the code blue button calls out a smart code. We apparently get all the necessary team members, just less than when a code blue is called on an inpatient ward... I came from a post-surgical inpatient ward (same hospital), where we had rapid, our co-workers, & the pt.'s surgical & medical on-call providers to help w/ deteriorating patients, & then we just called a code blue for code blues... I guess I feel stupid for telling my co-worker to pick up the phone & call a smart code because 1) the button would have created the same result - not feeling super bad about that because I didn't know & didn't want to call a code blue on what I believed at the time may not have been but 2) it ended up being a code anyway, quickly after I said that.

- Me rapidly asking him to follow my fingers and squeeze my hand was sort of my way of seeing if he was at all responsive. He was holding his head upright but didn't move an inch. When I worked inpatient we did have some patients who basically went blank like that and didn't respond but also had a pulse... My mind was thinking stroke/TIA/something - not code blue. It wasn't until his head went back that I checked for a pulse and couldn't feel one.

- I can't confidently remember the sequence of events after the crash cart got there - dangit... Did I hand that person the ambu-bag before I grabbed the pads? Also, I now realize I don't think they weren't doing compressions when I was taking the stickers off the pads so why did they stop, did they feel a pulse or were they waiting for me to put pads on? My mind was just focused on what I was doing. Pads on - monitor showed organized rhythm - afterwards I realized the defibrillator was on monitor mode NOT AED mode... we would have figured it out if the rhythm was vfib/vtach or asystole or whatever but it appeared organized. I should have realized that it hadn't said "analyzing rhythm" though, but there was a lot going on.

- We used a hover-jack to get him on a stretcher and he was brought down. He wasn't speaking but did look at me at one point and looked a little scared, and I said everything was ok. Sounds like the he didn't say anything the whole way down but right when they got to the ED he then said something along the lines of... "I feel like ***." I looked him up later when I went in his chart to write my cardiac arrest note. Chief diagnosis at that point was syncopal episode. There is this thing in nursing where if you call a code blue and people feel that it "wasn't a real one" - you suck. No one acted that way at all, but it's like, his head went back and he took those weird breaths and I really couldn't feel a pulse. It's not like he woke up and rolled over or became alert at all when we brought him down to the floor either. I mean I did the right thing right? I was thinking, I should have tried to shake him a bit when he didn't move but then I thought... pretty sure if he didn't need CPR he would have reacted to being lifted out of his chair, brought to the floor, and given compressions... Looking at the chart - from the labs that were back, trop was negative, electrolytes normal, d-dimer 5000 (pretty sure imaging report was negative for PE). Idk.

- Everything happened so fast I now realize I hadn't really said out loud, with the code team there, that I saw his head go back and stuff. I feel so stupid for not saying that. In the rush of things I was just focused on helping. I know that other people were talking though and the PA was there the whole time so I hope he said something? From the notes the team wrote, it doesn't look like he did. But it does say the daughter was in there and yelled when the pt. stopped responding, etc. So it's not like he was found down and we didn't know for how long. And then when I charted I just said "Pt.'s daughter yelled for help. Writer ran to room. Pt. in wheelchair unresponsive w/ no pulse. Pt. brought to floor w/ assistance & compressions started - bla bla bla." Do I need to go back and create an addition to my note to change it? Or should I leave it because that will look weird/bad & I documented the point, which is that he went pulseless and we initiated CPR. Idk why I didn't write the first part. I was trying to be concise and feel dumb and anxious now but am not sure if my feelings are warranted.

- I think I also feel weird because it happened so fast and I'm going through my checklist like. Did I make sure compressions were good? Did we have anyone get epi. ready? But it was over as soon as it started. And I know I'm not a provider and that all of those things would have been done if the code continued because someone would have taken over and we would have been doing the appropriate tasks.

Thank you so much for reading that very long post & for giving feedback. Hopefully I am, for the most part, overthinking. I really do care about doing reflecting on first-time situations though and want to make sure I do the best I can.

How often have you practiced on the job for this? Unless you do it multiple times with different scenarious, how do you know how you will respond?, even then, you still may not respond how you think, I mean you know you will do your best but to do it to the T, I don't think that is possible without going through this type of thing mutiple times within a month. You did your best, so don't worry, plus the person is ok.

[Workitinurfava, BSN, RN]

Does the patient have a history of high blood pressure?