Environment of the room during a code

Blee O'Myacin, BSN, RN · Dec 15, 2007

First let me say, I am a labor and delivery nurse, so do not witness codes very often, in fact I've only been in on two - one in nursing school, and one in our ICU when we had enough RN's in our department for me to go and assist.
My question is - what is mood/environment like during codes that you've experienced? The two that I witnessed, it was strange to me - the nurses and medical personnel were just chit-chatting about their week, etc... while they did CPR - of course there were orders of meds being given and administered - with great care - but no one seemed sad, upset, serious, etc...... Now I must say - both of these were older people who had been sick - so maybe it's because of that - they no-one seemed to care? Maybe it's because I've not been around that end of it much, and death still seems so devastating to me. I could not help but stare at the person, and think that this is someones loved one - the most dear person in the world to someone - and their life is slipping away - someone's daddy, husband, brother, son. How would I feel if that was my loved one laying there, and yes - protocol and ACLS guidelines were followed, and everything possible was done, BUT - there was no evidence of concern in the people who worked on them - like it didn't really matter the outcome - it's just a procedure.
I just find this disturbing. I'm sure if was in ER, and someone came in and coded, there would be a sense of urgency and seriousness - I hope anyway. Maybe it's because the medical personnel knew these particular people were very ill, and it was better that they passed. I totally understand that. I guess I just can't understand how anything could seem funny or humerous, or trivial, when a life ends.
All I know is when we have a bad baby - one that requires complete resucitation, It is the most important thing in the world to me in that moment. Everyone ounce of me is seriously doing everything I can for my patient. Even in a situation where you almost KNOW the baby has really no chance, or will have severe brain damage. I believe it my job to try 100%, and out of respect for the family/patient, I could not imagine talking about what party I attended last weekend, while I was doing compressions!
Please, I am not trying to criticize anyone - I am just wanting to know how others feel about this, and what you have witnessed.
Also when I re-read this - I realized I sort of implied that the nurses in the code weren't trying 100% - that is totally not what I mean. Like I said - I believe good appropriate medical care was given, it was just the atmosphere/attitudes that I was wondering about. - Just to clarify.

I'm sure that must have been a surreal experience for you, but this is how people who code people often handle this. It's a job, first and foremost. If the people running the code have to talk about other stuff while still doing their jobs competently in order to get through having to code someone, then that's just how it has to get done. I've participated in enough to tell you that some are like that - we are pushing the meds, doing the compressions, keeping time, talking about other stuff that is going on while someone is going through the required two minutes of compressions between rhythm checks and possible defibs. I think its human nature to fill the silence. I don't think that anyone is "forgetting" that the person we are working on is, in fact, a person. Would you want the team coding your loved one sobbing uncontrollably while trying to find the right meds, charge the defibrillator, do compressions, bag or intubate, and keep time? I'd rather have the team that knows each other well enough to move like a well oiled machine - doing a "procedure" (your words).

Remember that TV is scripted and a code on L&D is not par for the course and the level of stress kicks up instantly when a mom goes into DIC or you have a crumping baby. An ER or a high acuity ICU may have 5 codes a week. It's part of the job. If I had to catch a baby in either of those specialty areas, I'd be freaked out for the rest of the day, at least!

Personally, if I put myself in the shoes of every family member of every person who I've ever had to code, there wouldn't be enough ativan in the world to get me through it. I do my best and maintain my professional distance. You say that the people there "didn't seem to care" about the outcome. Did you ask anyone afterwards? Were you there in the breakroom when the people running the code decompressed, talked about the things that went wrong, were done smoothly and how they felt when it was over? Or did you go back up to your unit thinking that the person was cast aside once they were done with the ACLS protocols? I look at it this way, if we do nothing the person stays dead. Maybe good CPR and the ACLS protocols will help prevent it - but not often. We just do our best.

I hope this helps give you some perspective.

Blee

ukstudent · Dec 15, 2007

It's not that they don't care. But you can't keep doing the job if you don't develop some mental boundaries. Most adult codes (cardiac), no matter how well done, do NOT survive. Talking about trivial matters sometimes allows them to give that 100% effort that you saw.

RN2Bn2006 · Dec 15, 2007

Well, no I certainly would not want the people running the code to be "sobbing" or acting hysterical, and it is comforting that they are able to do these codes as a second nature - because they are so experienced. I also totally understand the need to seperate yourself from the emotional aspect - not getting personal - lest you drive yourself insane.

While I was watching or helping as needed, I wasn't standing there getting upset, or crying or anything, I was just realizing that a life was passing. I guess those that deal with it on a daily/weekly basis are accustomed to it, and like you say must deal with it in their own way. Of course I had to go back to my department once it was called, and did not talk to the nurses afterwards, so have no idea how it truly affected them. I do know I have heard ER nurses discussing disturbing codes they have done on children before.

Anyway, thanks for your input. I guess I was looking at it wrong. I'm sure the nurses cared about their patient. Maybe that's why I gravitated toward OB - 99% of the time - our outcomes are good!

Altra, BSN, RN · Dec 15, 2007

The two that I witnessed, it was strange to me - the nurses and medical personnel were just chit-chatting about their week, etc... while they did CPR - of course there were orders of meds being given and administered - with great care - but no one seemed sad, upset, serious, etc......
I could not help but stare at the person, and think that this is someones loved one - the most dear person in the world to someone - and their life is slipping away ....
Also when I re-read this - I realized I sort of implied that the nurses in the code weren't trying 100% - that is totally not what I mean. Like I said - I believe good appropriate medical care was given, it was just the atmosphere/attitudes that I was wondering about. - Just to clarify

Blee O'Myacin posted a wonderful response. I don't have much more to add.

I can appreciate what you're saying. And peds codes / neonatal resuscitations are different. And I appreciate that you say you believe good care was given. But that "good care" and good use of ACLS protocols requires a certain level of detachment, not staring at that the patient and thinking that he/she is slipping away. That is an emotional luxury which has no place during the code.

I don't mean to minimize the emotional impact --just saying that it's for later.

I participate in an average of 2-3 codes per week. Anything that you do that often becomes familiar. Yes, I sometimes do chat with coworkers during a code.

RN2Bn2006 · Dec 15, 2007

It's not that they don't care. But you can't keep doing the job if you don't develop some mental boundaries. Most adult codes (cardiac), no matter how well done, do NOT survive. Talking about trivial matters sometimes allows them to give that 100% effort that you saw.

Thanks for your thoughts - I can see what you are saying. We've had two family friends die this week - cardiac related - unexpected, and I guess I have been thinking on these things. Nurses have to deal with so much sadness/grief - they would go crazy if they didn't find someway to deal with it. I know I feel drained emotionally when we have a devastating situation (which is unusual in my department), I can't imagine having to deal with such things everyday.

billythekid · Dec 15, 2007

I'm glad you added the last paragraph recognizing that the nurses were giving 100% even though the conversation in the room may have seemed elsewhere. Although I just finished up nursing school, I can tell you from my experience as a paramedic that your observations regarding the the atmosphere during codes is mostly accurate. It's not that the providers aren't doing their best, or that they don't care about the outcome of the situation, but IMO being somewhat casual and relaxed is a healthy coping mechanism for healthcare providers. On some days I had no codes to work up. On others, we'd do 3 or 4 arrests. As you mentioned, our patients are somebody's wife, husband, grandparent, etc, and their families are emotionally tied to the patient. But could you imagine as a healthcare provider that on certain days you allowed yourself to feel you had 'lost' 4 family members... all that negative emotion would cloud your judgment, and result in you spending a good portion of your offtime with a therapist.

I found your topic to be interesting because at one point in time, I always assumed that providers had the same opinion as me. During codes in the any setting, it is important to not only be running the code correctly, but to be aware of others (family members, other heathcare) perception of our efforts.

I can honestly say that after running 100s codes and knowing the ACLS algorithms that 'regular' conversation is a normal part of the atmosphere and in no way diminishes the efforts of the team or their desire for a successful outcome. In fact, when a patient actually responds positively to code interventions, you would very likely have noticed a 're-focus-ment' of the room as I have on many occasions, as the team pulls together to give a viable code every chance of pulling through. Once the code is no longer 'routine' and requires critical thinking and decision-making based on something other than asystole, generally you will notice the side conversations taper off and the mood becomes more 'medical' in nature.

Just my 2 cents :)

RN2Bn2006 · Dec 15, 2007

That is an emotional luxury which has no place during the code./quote]
I never looked at it that way. I agree.
Also I must say that my role in both of these codes were more of observing - the first in nursing school - of course - I was just watching to see what happened in a code. The second one - I was the one charting.
I actually feel better after all the responses, and I understand that this is a normal coping mechanism. I am just inexperienced in the area, and didn't know quite what to make of it.
Thanks to everyone for your insight!

Medic/Nurse, BSN, RN · Dec 15, 2007

It can be a bit disconcerting to those that are not used to this practice reality in the acute care settings (heck, in any setting!).

I know it may have appeared that those caring for these patients were not fully present in the moment - and I do not ever try to explain the actions of others. Appearances can be deceiving - or not. I can be fully present without being emotional - in fact, my job often demands just that. I find that when I do become emotional, it effects my clinical performance in a bad way. However, to others that may view my actions it could appear that I may not "care" because of my lack of emotional behavior.

I have to be able to "run" the code or the rescue. I have to be full on and bringing 100% to it. My teams demand the same. Our patients are entitled to the best we have to offer - emotional decision making is not in anyones best interest. It is never easy.

A "code" or any emergency situation is not the time/place for the tears or a discussion of the life and family of the person we are coding/rescuing. I agree with Blee, there is not enough Ativan in the world to allow me to be that involved. I (and most of my team - anywhere) would just come undone if we allowed the intimate details of our patient into these situations. I care. I have great empathy for the patients/families and their situation - but at that moment my job is simple. Do whatever is necessary to SAVE this LIFE. We are very often unsuccessful.

I know there is a move to allow families at the bedside during codes. I have had a few and generally the staff expects it, a support staff person is "assigned to the family" and overall the "environment" is more subdued. I personally think it is heartbreaking for the staff to witness the "goodbyes" that the families say to the "patient" that we are coding. But, we are here for the patient and family - and just because it may be more difficult for me, I'd never refuse a family request (unless they disrupted the care or we could not provide dedicated support to them during the resuscitation efforts).

Practice SAFE!

nurz2be · Dec 15, 2007

I am a student and have witnessed 2 codes as a student. One was on a respiratory floor with an elderly lady, around 75-80, who had long term emphysema and 14 other problems. The room was much like you discussed in your post. The staff were 100% doing all they could but the mood in the room was "calm" for a situation that I would have up to that point assumed would be like they show on TV. Not the case. The elderly women did not make it and the staff called TOD, contacted the family, cleaned her room and her person, and a nurse was waiting with the Chaplin for the family. VERY professional.

Now, second one was all together different. This was a 12 year old boy who came into the ER after collapsing on a football field. TOTALLY different atmosphere. Not to say that the elderly lady didn't get the care she should because she did. But the air was different with this young boy. The doc snipped orders, told people to shut up if they weren't him, not rude just controlling a highly volatile situation. In comes mom and dad in hysterics, rightfully so. Nurses remove mom and dad and staff continue working with the boy. He did not make it either but the air was urgent with this code. Maybe it was due to his age, maybe it was due to the doc running the code, I am not sure. What I am sure of is that in BOTH cases the chatties with the elderly women and the stiffness in the young man, those patients could NOT have had better teams working on them. I can completely understand having to "remove" yourself or you could EASILY get caught up in the death and lose sight of what you are doing or trying to do.

I think each team is trained and acts/reacts the best way they can to handle the patient with the best of care but also to care for themselves and their sanity.

RN2Bn2006 · Dec 15, 2007

I'm glad you added the last paragraph recognizing that the nurses were giving 100% even though the conversation in the room may have seemed elsewhere. Although I just finished up nursing school, I can tell you from my experience as a paramedic that your observations regarding the the atmosphere during codes is mostly accurate. It's not that the providers aren't doing their best, or that they don't care about the outcome of the situation, but IMO being somewhat casual and relaxed is a healthy coping mechanism for healthcare providers. On some days I had no codes to work up. On others, we'd do 3 or 4 arrests. As you mentioned, our patients are somebody's wife, husband, grandparent, etc, and their families are emotionally tied to the patient. But could you imagine as a healthcare provider that on certain days you allowed yourself to feel you had 'lost' 4 family members... all that negative emotion would cloud your judgment, and result in you spending a good portion of your offtime with a therapist.
I found your topic to be interesting because at one point in time, I always assumed that providers had the same opinion as me. During codes in the any setting, it is important to not only be running the code correctly, but to be aware of others (family members, other heathcare) perception of our efforts.
I can honestly say that after running 100s codes and knowing the ACLS algorithms that 'regular' conversation is a normal part of the atmosphere and in no way diminishes the efforts of the team or their desire for a successful outcome. In fact, when a patient actually responds positively to code interventions, you would very likely have noticed a 're-focus-ment' of the room as I have on many occasions, as the team pulls together to give a viable code every chance of pulling through. Once the code is no longer 'routine' and requires critical thinking and decision-making based on something other than asystole, generally you will notice the side conversations taper off and the mood becomes more 'medical' in nature.
Just my 2 cents :)

Well, I appreciate your explanation. I totally understand what you are saying. I guess if the code team is able to "converse" then that is actually a good sign - they obviously know their stuff - if they can do it like some one said earlier "a well oiled machine".

I'm just glad to know that just because they are chit-chatting - doesn't mean they don't care- I should have known better - but it just seemed odd to me. Also, because at this point in my career, I couldn't imagine being able to do anything but concentrate 100% on what I was doing in a code - because of my lack of experience - that is was hard for me to grasp.

Thanks for your reply. It helped alot.

RN2Bn2006 · Dec 15, 2007

I know there is a move to allow families at the bedside during codes. I have had a few and generally the staff expects it, a support staff person is "assigned to the family" and overall the "environment" is more subdued. I personally think it is heartbreaking for the staff to witness the "goodbyes" that the families say to the "patient" that we are coding. But, we are here for the patient and family - and just because it may be more difficult for me, I'd never refuse a family request (unless they disrupted the care or we could not provide dedicated support to them during the resuscitation efforts).
Practice SAFE!

Thanks for your response - it explained things very well, and I can totally understand "WHY" now.

Your last part about families being present - I can see a positive and negative to this. Positive being - the family can actually SEE that everything was done for their loved one, and in the ill/elderly can see how traumatic chest compressions can be, and actually influence the family in letting the patient go in peace. But on the negative side - I can now see why emotions should not be involved in a code situation - and if a weeping family member were present - it might make it hard to stay focused, and might cause you to become emotionally involved - despite the need to stay detached!