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.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
Kudos for saving the patient! There was a positive outcome. All is well.
Your mind is processing the event now. Debriefing with the people who were there is so helpful. If your hospital doesn't facilitate that, get together on your own with at least one other person and talk it out. You just need the perspective and support.
If you find yourself spinning wheels in your head for more than 2 weeks, see employee assistance or a private therapist. We nurses experience psychological trauma at work.
I agree a debriefing is necessary. I think you did a find job too. Just remember the basics of BLS, you don't do sternal rubs, check pupils, or other such stuff. You check for responsiveness, get help as soon as you determine that they are not responsive. Simple.
You can do a unofficial debriefing, why don't you go out with your coworkers after work to dinner in a private setting and discuss the events, Just remember to follow HIPAA.
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.
It was wrong of your bosses to not allow opportunity for all involved to discuss the matter, especially since the patient apparently died.
Thank you for doing your very best and here's a hug and pat on the back. I hope you are OK. God bless.
If something like that happens again, do an informal one. Everyone will be thinking about it and talking about it anyway.
It was wrong of your bosses to not allow opportunity for all involved to discuss the matter, especially since the patient apparently died.
Thank you for doing your very best and here's a hug and pat on the back. I hope you are OK. God bless.
If something like that happens again, do an informal one. Everyone will be thinking about it and talking about it anyway.
Not my first loss, as I'd worked ER/Trauma and Military prior. Just my first loss that young (<1 mo). I did speak to the NP and a couple others involved and provided updates about the outcome as we heard to try and do an informal bit of debriefing/information sharing. That's what was classified as "gossip" and we were accused of creating a liability problem and being disruptive. I was working out my two-week notice at the time. When we were interviewed by the Quality department, I mentioned the lack of debriefing and how important it is for staff involved in these situations. I'm not sure if they changed their practices. In psych, debriefing is an important part of the process after any hands-on intervention with patients.
To the OP, I hope you're doing well. I've found journaling helpful in sorting out my thoughts so that I can organize them, reflect on the situation, and find closure. The first code situation is always hectic and scary, but as you build training and experience both yourself and as a team, it becomes a much more fluid and smooth experience. Nothing is ever exactly the same, but the preparation pays off. Find the time to care for yourself. Stop and acknowledge what you're feeling, know that it's valid, and build healthy strategies to cope. For example, since starting school for my MSN I needed a hobby that takes little time to enjoy, so I started trying to keep a Venus fly trap alive. Not an easy task! Doing well so far, though. So, little joys. Little triumphs. Find yours. ?
I work in a clinic and any major medical emergency is a code blue. Most of the staff aren’t knowledgeable enough to differentiate between what code to call and it would waste team. If someone scares the team enough to call a code its a code blue and we come with all we got. Better safe than sorry. I have no idea what a smart code is even though ive been in a hospital for 3 yrs prior to clinic. The first time a new nurse heard us call cold blue he had out cardiac meds defib cables and all in our treatment room. We usually just grab our bags and boxes of supplies and the aed lol. So far no actual cardiac codes in my 2 yrs but we’ve had respiratory distress and diabetics go unconscious
Agreed with others that there should be a debriefing. We do this at both places Ive worked. It helps make things go smoother the next time and gets things off your chest. Also agreed that only those who do this regularly, execute things in perfect ACLS mode.
I have had 2 experiences where I have come across people who needed CPR. I still second guess my every move and choice. 1 person lived the other died. The one who died had a bike accident, he was face down gasping. I had 3 people help me turn log rd him over to make sure his clothes weren't restricting his breathing. He then stopped breathing and I couldn't find a pulse so started CPR. This was out in nowhere so help took forever. In the end someone got a defibrillator and he had no rhythm, nothing to shock. The 3 doctors who showed on the scene said stop CPR. I did not want to give up on the young man but at that point I think it had been an hour. I said to one of the docs did I do the right thing turning him over, what if he had a broken neck? The doctor said "God was here before you were". And agonal breathing is not breathing. In the end I have to accept the fact that I did everything I could to save him, but it wasn't to be. Sad....
"God was here before you were." Paraphrased, but pretty much the best tidbit of wisdom I received in ACLS training. We can do our best, but ultimately we are not in control of the outcome. I tell myself this after every code.
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FolksBtrippin, BSN, RN
2,324 Posts
Kudos for saving the patient! There was a positive outcome. All is well.
Your mind is processing the event now. Debriefing with the people who were there is so helpful. If your hospital doesn't facilitate that, get together on your own with at least one other person and talk it out. You just need the perspective and support.
If you find yourself spinning wheels in your head for more than 2 weeks, see employee assistance or a private therapist. We nurses experience psychological trauma at work.