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1793stopper 1793stopper (New Member) New Member

First code blue, hard not to blame myself.

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Hi everyone, I am a nurse with one year of experience

About a month ago I had my first code blue. Its really hard not to blame myself. Heres a short version of what happened.

50 y.o with hx of chronic bleeding and anemia. Was admitted to the ED for c/p, sob,n/v. BP 110s. D-Dimer was done at 1400 results were >10K. No additional test were ordered after that. Finally at 1830 ER calls me for report to transfer the pt to my floor. I skimmed the chart, saw that she had blood infusing and that an ASAP chest CT with contrast was ordered at 1830. I question them why dont you take her to CT first then bring her to me. ER nurse tells me its contraindicated bc of the blood infusing. another thing i asked if there are any pertinent lab results i should be aware of, she says no. she didn't tell me of the d-dimer! I say ok, bring the pt up. Pt comes stable. Blood finished infusing, then i saw her d-dimer so i tell the charge we need to take her to CT. She helps me move her to wheelchair. pt becomes symptomatic. I call a rapid response. Her BP tanked, started her on pressors, still its not helping. The Dr during rapid makes the call to take her to CT. After CT was finished she crashes on the table and dies.

After this I was traumatized and in depression. Now I feel so incompetent as if I failed as a nurse.

I would just want a fresh perspective from someone whose not working with me. Should i quit that unit? because at this point I dont know how I feel.

Thank you so much for reading all this.

Edited by traumaRUs

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So very sorry for this. First codes are difficult. Please talk this thru with a supportive co-worker. Ruminating on this is counter-productive. There is nothing you could have done to prevent a PE. Whether the high D-dimer and CT being done sooner would have made a difference, maybe, maybe not.

Please take care of yourself.

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No you should not quit the unit! That would be akin to driving a thumbtack in with a sledge hammer! You didn't cause the PE. You didn't have anything to do with the events that occurred prior to her admission to the floor. The D-Dimer should have been reported to you and the CT-PE should have been a priority, probably over the blood in a patient with chronic anemia but I wasn't there. The only thing I would have done differently is I would have never moved the patient to a wheelchair for transport to radiology. Bed or cart would have been my choice. Don't get me wrong, I am in NO way saying that caused the subsequent cascade of events. Causation and Correlation are two entirely different things. You need to debrief with someone.

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No, you should not quit this unit. Don't let this unfortunate situation define or break you. I can tell that you are thoughtful and have strong critical thinking skills because according to what you wrote, your actions are appropriate.

First, the patient arrived to you stable. When you saw the critical lab result, you responded efficiently. You called a rapid response quickly. You did absolutely everything you could for this patient.

From a larger perspective, there are always things that could have been done to change the end result. But don't doubt your skills. You had the correct train of thought from the beginning by asking the ED nurse about pertinent lab values and questioning the timing of CT.

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Need more info. She was getting blood for a reason. What was her PTT/INR? Was she on any anticoagulation? Elevated D-Dimer tells me nothing. I hate that lab. What was her physical assessment? Did she look pale? Was she requiring more oxygen? Also, if she is coming to the ICU, and she is an ICU patient. She should go anywhere in a bed. Not a wheelchair.

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Her initial diagnosis was Anemia because her h/h was 7/21. She was diagnosed with bilateral massive PE after CT was done. Thats another reason we attempted to transport her in a wheelchair because she was not diagnosed with PE.

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Thank you for such kind words, truly helped. My problem is that I care about every detail when it comes to my pts therefore I ask a lot of questions and I can see how others get annoyed of that. But that doesn't get to me.

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CT read massive bilateral PE. prior to the scan she was diagnosed with anemia and chronic blood loss. Therefore I didn't think about not moving to wheelchair.

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Sounds like a lot of things went wrong with her care, and you just happened to be the last person taking care of her. ED doc and nurse dropped the ball, and Im sure you didn't put her in the wheel chair yourself. Someone helped and others watched you do it.

Lessons learned, never move an unstable patient to a wheelchair. How was she being monitored in a wheel chair? Nursing is about asking the right questions. What is causing her anemia? What is causing her elevated D-Dimer? Is stable enough for imaging? Imaging doesn't do any good if the person dies trying to get it. You're a new nurse, you did the best you could. your resources failed you.

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So, why wasn't she taken to CT with blood infusing? We have patients go for imaging all the time with blood infusing? Honestly, when she started decompensating, and if there were no contraindications, she should have been given systemic tpa if clinical suspicion was high. I certainly don't think you were at fault with the information as you've provided it, but delays in care can be costly.

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