Ethical Dilemma and Worry

[32MedicRN]

I'm an ICU RN in a VERY small rural community hospital. We are a 15 bed ICU. We take everything but cardiac patients. Due to the rural location of our facility, we currently have an ICU full of brand new grads or nurses with less than a year of experience on night shift. (Day shift is by seniority). We have a charge nurse, but the charge is pretty much whomever is the most experienced that night between the ICU/PCU unit. (Regardless of actual ICU experience). This particular issue occured recently and I need some imput. The night in question, we were short staffed. We got two Rapid responses within an hour of our shift and were intubating. One had continuous BP issues (SPB in the 30's). It was just one of those nights....There were four nurses. Two are not ACLS certified and are brand new grads (Yeah, SHould NOT be working ICU if you aren't certified in my opinion). One was ACLS certified but had only been involved in a small handful of codes. I've only been an RN for a year, but I was a paramedic for several years before becoing an RN.

Our hospitlist accepted a new pt from an even smaller local hospital (think 2 bed ER). H&H was 4.4/12.2%. She had an unknown bleed and weighed about 226 KG so was unable to fly to a larger facility. The hospitalist felt we would at least be a step up so he accepted with the intention of transferring her out in the morning. SHe came to us on dopamine in a PIV. We got an emergent CVL placed (we dont' do PICCS). The doc did an IJ. She started acting a little odd and mumbling nonsense as he was inserting, and I looked at the monitor and saw multifocal PVC's. He finished up and walked out of the room. The RN who was taking the pt (Non ACLS cert/new grad), and I were cleaning up the mess. She went unresponsive, foamed at the mouth and pulseless. We called the code. The first code was a disaster due to lack of staff and only Two ACLS cert people involved. The doc was VERY unsure of himself and wouldn't run the code. I ended up documenting, running the monitor, doing meds, and coaxing the code along. *****. Somehow she managed to survive this and we got her back. Doc wrote for 4units of PRBC's, so I ran down to lab to grab them.

When I was downstairs, I hear the code being called again. By the time I got back upstairs, the ER doc and two RN's from ER had shown up and the code was over. THey had gotten her back again. She ended up coding a third time at shift change and we lost her. So, needless to say, the code sheets didn't get written up until about 0930. I sat with the new RN to try to help her fill hers out from the second code I wasn't there for. I found out NO ONE had documented. She had one napkin with Atropine and Epi written on it, and her monitor strip. *****!? FIrst off, why the HELL was atropine given? Secondly, as I look at the strip, I see VTACH. In a seven minute code, not ONE SINGLE SHOCK was delivered in VTACH. Pt received one dose of atropine and one dose of epi. Its a miracle that the pt ******* survived this. The new nurse documented everything on the code sheet but left out the atropine and wrote that shock was delivered. I asked her if it was? She said she couldn't remember.... I am seriously cocncerned for my license working at this facility with the severe lack of experience level. I'm also not even sure what to do about what I saw with the seond code sheet. I was not a witness to the events, only saw what was written.

The pt returned with a pulse, despite their incompetence. THere was a nursing supervisor, a doc, three nurses, in the room. NO ONE figured out the shock didn't get delivered? and Who the hell ordered the ATropine and actually administered it? I have no idea? Problem is, since I watched her fill the code sheet out and it already went into the chart, if I now say something after the fact will that implicate me legally? I really just wish I could unwind the whole scenario. I feel like not saying something will result in more of the same. Saying something may put me into jeapordy for not saying something earlier, plus she is bound to get fired.

[AJJKRN]

I think that you should do what is best for you and find a different place of work, if this is an option. I wouldn't open up a can of worms especially on the second code that you were not present for. I would find me a Level I trauma center/teaching hospital (the one I work at has its issues but its an awesome place to work regardless) and start to enjoy may career and specialty again!!! Good Luck...

[Guttercat, ASN, RN]

The scenario you described makes me wonder if that "IJ" really went in the "IJ."

Regardless, what a cluster. I'm sorry. That sounds like the night from heII for everyone involved, including the patient.

[dudette10, MSN, RN]

Here's the problem: You were not there for the second code! What could you possibly say? "I saw a napkin with the words atropine and epi on it that don't match what the code sheet says." Beyond that, you didn't witness anything.

What you can do, though, is talk to the unit manager about the way in which the first code was run, about the lack of experience on your shift, and about getting everyone ACLS certified so that codes will run much more smoothly in the future.

[Wile E Coyote, ASN, RN]

I say, bring your objective observations to leadership (with your own input on reasonable remediation, don't just gripe) and see where it goes from there. How that plays out would be most telling of your future at that facility, in my opinion.

[jadelpn, LPN, EMT-B]

The pp is correct, bring it to leadership. This type of situation is when the nursing administrator is called to the unit--the house supervisor, whomever is the supervisor of the house as opposed to the unit. I get that it was a whole bunch of things happening in a short amount of time.

Code teams are also a good thought. They could be multi unit. If someone doesn't have ACLS, then, they really have little clue. And someone needs to be the recorder. Always. No matter what else is happening.

If you are a multi-year paramedic with ACLS, then perhaps you need to lead the nursing team in a code. A new grad with no ACLS needs to only record. Not stop and do other things, strictly record. Stay far, far away from code #2. You were not present, therefore, that is your biggest risk should you record what you did not see. If you were charge that night, lesson learned and you do not leave an ustable floor when you are charge. Otherwise, you did what you could--and the person who needs to take the reins each shift and make appopriate assignment, know where the resources are and how to use them (ie: ER nurses? ACLS from another unit?) would be whomever is the charge nurse. Who ideally should have ACLS and some experience.

Great opportunity to get some education, certify who needs to be and do a bunch of mock codes--I question any faciilty that has an ICU with all new grads, little experience, and no supervisor available to come and help--all at the expense of patient care.

[xoemmylouox, ASN, RN]

Since you weren't there I don't know what you could report. Instead I would focus on talking to management about getting ALL of the nurses ACLS certified. Also run mock codes. I would also start looking for another job, but you being in a rural area may make this difficult.

[HouTx, BSN, MSN, EdD]

Totally agree with PPs - - - and a word of caution.

OP post has way too much, highly detailed information about a patient situation... if anyone is familiar with OP, the patient's ID could definitely be revealed. PLEASE summarize rather than including so much detail.

There is some very clear evidence emerging - patient safety is at risk if > 20% of the staff have

I want to go on record - "Rural" does not mean substandard. The issues in OPs post could have occurred in any setting.

[nurseprnRN, BSN, RN]

One other thing to think about-- if the people on duty that shift are so inexperienced, why are YOU going to the blood bank? If you don't have a unit clerk or aide to send (and yes, blood can be transported by anyone; in many places they put it in a tube system and nobody signs it out but the blood bank tech; the safety check is with two licensed personnel at the bedside) then send your least experienced staff, not your most experienced one.

Also you might want to ask for an appointment with the chief of the medical staff to discuss credentialing of the physicians who run codes.

[wanderlust99]

What a mess. I worry you've posted too much info that could identify you and implicate your coworkers and the physicians. Agree with not leaving the unit if you are charge. The whole story is puzzling as it's hard to imagine an ED doc, the house supervisor and the ED RNs wouldn't know what to do in a code. I can understand newer nurses not being comfortable. I would take a step back from blame and think about stepping up and providing leadership in this situation. What can you do to change this so it won't happen again. Were you in charge or was it someone else? The manager really needs to balance out the experience levels here and put some new grads on days if necessary and hire in an experienced RN to charge on nights.