First code blue, hard not to blame myself.

[1793stopper]

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.

[amzyRN]

It's weird the CT wasn't done initially especially with a high d dimer. That's unusual actually. Unless her Hgb is like 4 or 5, the CT angio should have been done as soon as the d dimer was found to be high. Unless the patients bleeding out, I don't get why the CT was delayed. A hgb of 7 isn't critical and might not even need a unit infused in the ED.

[CCU BSN RN]

This sounds entirely like an ED nurse didn't want to place a second IV to give CT Contrast Dye while blood was infusing, so they elected to send the patient to the floor without the CT being done. I'd ask your manager if there's an actual policy that they can't get a CT while blood is infusing, just so you'll know if you ever come across a similar situation in the future.

Honestly getting a CT 30 minutes earlier...it likely wouldn't even have been read before she coded anyway, let alone notifying the MD, ordering the heparin, starting it, reaching therapeutic blood concentrations...you still weren't going to be able to fix it before she died. All critical care patients have elevated D Dimers. It's such a useless lab.

Patients die. A lot. It's usually not your fault, and in this case it's definitely not your fault. Find someone to talk to about these types of cases, and learn to deal with it now. You're likely to have a lot of patients die in critical care, so you need to find a way to cope with it now before it happens again.

[CampyCamp, RN]

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.

Then, NO, you should not consider leaving the unit. Not as long as you're detail oriented and asking why about everything. That's critical care nurse stuff.

[eCCU]

No you shouldn’t quit. You have now learned something about massive PE. It sounds like the ER dropped the ball on that one and should definitely review this case for future improvement. On an experienced standpoint, anytime you feel that care has been delayed significantly in this case CT scan in a patient with high risk PE. I would advise to escalate it before they decide to wheel the patient in ICU. Call your pulmonary doc or cardiologist consulted to follow the patient and notify them your concerns. The reason why I say this is because they can ask the ED doc to do a quick FAST exam to determine the RV stress in PE which would determine a need for STAT systemic TPA or EKOS.

This is a case you can use to drive change in your hospital to improve care. My ED any imaging ordered especially CT is usually completed prior to transferring patient in ICU. Do not quit☺️

[murseman24, MSN, CRNA]

On 12/3/2018 at 7:43 AM, Eze4life325 said:

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.

Why do you keep harping about the wheelchair? The D-dimer was elevated b/c she had an embolic event. This patient needed the CT-scan in the ED STAT. The blood was not a priority, but none of this was your fault. If anything it was poor prioritization on the ED. You called Rapid, you noticed the lab, you called for the scan. Unfortunately this pt was on their last leg and you were just the one to be there when she crashed. The w/c didn't kill her. It may have caused the pt to exert themselves and cause some sort of ischemic/hypoxic event, but it was b/c she had a PE. tpa could have saved her but that would be a pretty bold call with the bleeding and without a scan. Possibly during the code that could have been an option b/c what do you have to lose at that point? You did ALL the right things. You are a great nurse for sure

[Rosie_one]

Don't blame yourself. Good to look back on performance and spot whay could have been improved on, but you have to remember they were sick and despite medical/nursing care people still die. I had a very traumatic death my first year out and a nursesaid to me one, "some people are going to die, but you give them a chance at living".

Patient should have been treated with suspected PEs anyway till more stable to transport. Unsure about why this patient wasn't taken on a bed as risk of deterioration was on the cards.