First Code Blue

SwansonRN · Oct 21, 2012

My first code blue died as well I didn't find him unresponsive, but I did watch as he flipped his axis from a normal sinus rhythm to ventricular bigeminy. I was actually explaining to the family what the different numbers on his bedside monitor meant because they had asked when it happened. Before I knew it he was in pulseless v-tach...then asystole. I took turns with a few others giving chest compressions for about 45 minutes. That was my role in the code. I was exhausted. When they called it, my eyes welled up. I was still on orientation so after everything I went up to my preceptor and said, "Please tell me that wasn't my fault." I felt very guilty. Thing was, he was very very sick with no quality of life, pouring out blood, no mental status before the code, but still. It wasn't easy.

Help is important, it sounds like you did a fine job!

Davey Do · Oct 21, 2012

1. How do you handle situations where you find a pt unresponsive?
2. How did you feel after the fact?

I've only come upon about a half dozen Patients/People who had Permanently Ceased Spontaneous Respirations, but I've always gotten A Feeling at the time.

I handled my First Code Blue much in the same way you did, liveyourlife- I acted. I was an LPN Student, found my Patient with a Q-Sign, felt for a carotid pulse as I lowered the head of the bed, telephoned a Code Blue, got the foot board off of the bed as a Respiratory Therapist ran into the room. We lifted the Patient up, set the footboard under him, and I initiated compressions as the RT bagged him. Within seconds there was a Crash Cart, Nurses, and a Doctor in the room. It was great!

We brought the Patient back for a while but he ended up succumbing anyway.

I have always felt like I did what I could, and that, in and of itself, has given me some Peace. I have empathy for the Patient and the Family, but that's about where it ends. There's no use expending Unnecessary Energy on something we can do nothing about.

Oh- and as far as standing around feeling like you're doing nothing: You're there and that's what matters. Unless you work in ER or Some Place that regularly has Code Blues, all you really can do is initiate the Code, start Basic Life Support measures, and then just be there.

Good move in asking your Superiors for Advice and Critique. Your Action proves you want to be Assessed and Learn more.

The Best to you, liveyourlife.

Dave

Do-over, ASN, RN · Oct 21, 2012

Patient unresponsive? Check for a pulse and yell for help. Proceed accordingly.

I think self-reflection is helpful and necessary in any situation like this. But, don't let it go on too long - we can only do the best we can and learn from our experiences. Felt like a ding-dong the first time I was involved, felt much more competant in subsequent ones.

As far as standing around... If it was your first code - I doubt anyone expected you to know much. Watch and learn. Do what you can do (compressions, prep supplies). If you are the primary nurse be prepared to answer questions of the code team.

Esme12, ASN, BSN, RN · Oct 21, 2012

You did good.....:hug:. You did everything by the book.....once the code team arrives there is nothing else to do but provide information and be a go-fer, call the MD/family. It is difficult not to personalize situations when they are close to home. I think it makes you a better/empathetic nurse.

How do I feel? It depends on the code. I always feel sad and say a prayer (that's my thing) and there are times I will cry. Then you move on to the next. I'll go home and hug my kids/hubby and when I was single I'd hug my dog.

Good Job!

echoRNC711, BSN · Oct 21, 2012

First off,you did beautifully. This is a good time for you to review BLS and ACLS protocol.

Most important thing is call the code and begin CPR. Direct someone to ambu. (try to remember bed board/CPR mode of bed )

(at this point everyone arrives )

If you have a code team they will pretty much handle it from there. Your role as a new nurse is to observe and learn. Codes can feel chaotic but there is an order. See if you can see it.

1 Dr. and 1 nurse should be the "charge " people.

After you reach a point of understanding a code one of the best ways to learn is to be the one who documents.

Alternatively if you are not too freaked out ambu pt.It gives you a birds eye view of whats going on.

What is helpful to the code team is

1. prime an IV line. Caution you are going to be bolusing. Remove any IV that has KCL in it already running and attach new tubing.

2 get ice for ABG, bring back CS box with you to check sugar.

3 ONLY if you feel proficient get bristo jets you will likely need ready like EPI. (only do this if you don't have code team ) Address the charge people only. LOUD voice '1 EPI right? 'or #2/ # 3 people get a little squirt happy so make sure charge person knows the # being given.

Begin to see the minimum standard equipment, Intubation -yankeur,suction,ET (often 7.5 /8)inner guide ,syringe to inflate, ABG kit, central line kit.

CLEAR the room! More people equals chaos.Do not feel awkward in saying 'ok anyone who is not giving direct care now OUT!

It is helpful to review yourself afterwards.See what you did right.Look up what you didn't know/understand.

As regards emotions,it varies markedly in how well you knew them ,prognosis,age(child ),unexpected. There is no "right" response.Lastly remaining calm is the single greatest gift you can give your pt. If you have to in the code,close your eyes give yourself a 10sec cool down, exhale . This wil help you think clearly again. It's a team,it's not all on you.

You did great!!

Sugarcoma, RN · Oct 21, 2012

“What I didn't like was that I felt like all I did was stand around. I wasn't sure of my position, and didn't know who to ask so I could know what my role was.”

This is normal. I always felt like this when I worked on the floor! You do not have the training necessary to care for critical and crashing patients, (not to mention the ratio or resources!) if you did you would be in the ICU, ER, or on the code team yourself! Members of the code team have defined roles and the training and experience to deal with emergencies.

You did much more than stand around! You: recognized your patient in an emergent situation, knew they were in an inappropriate position for CPR (whether consciously or not), got help immediately to move them, and got the code team there ASAP. Effective CPR and ACLS drugs were the only shot your patient had of living and a very slim shot at that. You got them there for your patient! I am most impressed with the fact that you stayed in the room and helped anyway you could. You would not believe how many nurses run out of the room to hide and chart, leaving us with no one who is familiar with the patient’s history, what meds they have taken recently and other information that may help us treat their patient. You did a wonderful job!

If I could write a policy for the role of the primary RN for a patient in distress or coding it would be this: Call for help, do not leave your patient, delegate to coworkers to help you until the team arrives (they can assist with interventions such as CPR, bagging, getting the patient hooked up to the crash cart and a dynamap etc.) stay in the room during the code to answer questions and help as needed!

As for your questions:

1). Follow your BLS protocol when you find an unresponsive patient. Can your rouse them? Are they breathing? Do they have a pulse? Call for help and then follow the interventions that are appropriate depending on what your assessments reveal.

2). It is absolutely normal to question your actions and to reflect upon the experience. There really is no right way to respond or feel. I have felt numb at times, sad at times, and relief at times when patients code and do not make it. It will take time to process the experience. I like the fact that you were able to speak about this experience with your coworkers and they offered you support. Sounds like you have a pretty decent team of people where you work.

liveyourlife747 · Oct 21, 2012

Wow! Thank you all for your wonderful responses. I was back at work today and was able to discuss the situation with those who were interested (those involved in care at least, HIPPA maintained!) The one thing I didn't do that I wish I would have was check for a pulse first thing (whoops), but it was obvious he wasn't breathing and was unresponsive. In seconds the code team was there and asked for a pulse, started the difib etc.

Im glad to know that I wasn't just "standing" around. Makes me feel a little better about the situation. I feel at peace with his death, but it seems other people on my unit aren't exactly coping with it well. I kept hearing today "I saw that mans face all night." Of course I did too, but I tried not to dwell on it. I had that gut feeling that something was going to happen and knew if the pt continued to refuse care he would become deathly ill from what he was in for and either pass in pain or go through tremendous loops to get well again.

I am very very happy for the responses! It really made me feel better about the situation. I am so glad for AN and for my nursing team at work. They are amazing! Thanks guys/gals!

Sadala, ADN, RN · Oct 21, 2012

People react emotionally to emergencies in different ways. The ability to be detached emotionally during an emergency is not a bad thing. The fact that you question the detachment and the way you handled yourself (which sounds fine to me, btw, from my limited knowledge) makes me think that you aren't as "not worked up about it" as you think (or feel).

Sometimes, people who are detached think well in emergencies and the emotional part hits later. Sometimes, much later. I think you care about the care that you give. That's an important thing.

**NickiLaughs, ADN, BSN, RN** · Oct 22, 2012

First codes are always hard. If you manage to remember to call for help in a timely manner that's pretty good. I've seen a lot of codes but I went over 2 1/2 years in ICU before my own patient coded. You are kinda in shock and get kinda fuzzy. That's the nice thing about a team. I ended up doing compressions and they pulled me out of the room to focus on documentation while everyone else handled the code. It was probably the best thing for me. What's sad is I had told the charge nurse at the beginning of the night "I think she's gonna code, just have a feeling." And she did.

You run through your head multiple times if there was something you missed. But the reality is that patients are in the hospital because they're sick. And some are not going to make it out. It will get easier as time goes by!

BostonTerrierLover, BSN, RN · Oct 22, 2012

Every patient that coded in my first year of nursing had received Digoxin IV the prior shift, so I spent months being paranoid of Dig, and watching them like hawks!!! Best of luck in your career!

root.user · Oct 22, 2012

1. How do you handle situations where you find a pt unresponsive?
2. How did you feel after the fact?

While my perspective is a little dated (I haven't worked clinical/direct care in a number of years) here is my 2 cents. Background: I used to be a certified EMT-P that work as a tech in the ER, volunteered for a local VFD, and routinely pulled shifts on the ER crash team. Unresponsive/unknown down calls, and CPR in progress calls were not uncommon.

To answer your questions:

(1) I used to teach American Heart CPR, and it is just drill for me now. Shake/Shout, call for help, start ABCs (airwary, breathing, circulation). [i don't understand why they moved away from this.] It works with a full crash cart in the hospital, on the street with full ambulance, or on the day off being a good citizen. Follow your BLS procedures and you can't go wrong. Not sure? Over-react and get some help anyway. Take the jokes as what they are, and know your patient is still alive and learn from the situation.

(2) I have had every reaction in the book to crashes. My first, was when I was a student and I was in shock the whole time. The family was there when Dad passed out in the grocery store. All I could was hold things, reach for things, and stay out of the way. I have thrown up from the nerves and stress, I have cried with the family that came in and was visiting when the patient turned. There is no "right" reaction, we handle every crash individually (just like every living patient). As someone that has worked many many crashes, I always needed a few minutes after the fact, regardless of the outcome. The stress is overwhelming and can seriously stir up any number of emotions.

My thoughts on your situation is you absolutely did the right thing. As it has been mentioned before, having some background on the patient is ALWAYS more helpful than not. If the patient is yours, you may know if they have been recently administered narcotics, has a cardiac history, their rx'd meds, or any other number of facts that may help the doc may a better call.

Also the best place to be in these situations is outside a 2 foot perimeter of the entire team (think surgical room). Sometimes we move without looking behind us, we reach where something should be or just don't want someone know working on the patient in our space. Step back, man the drug cart (only if you are familiar with it), be ready to swap out with compressions/ambu but most of all LISTEN to the team and the calls they are making. You will learn things in time, and while no crash is "routine" they do have a flow and procedure.

The last piece of advice I can give - ask questions and try to learn as much as you can. If you don't get an answer from your charge, ask another senior rn. If you have questions about procedure, review your ACLS & PALS. Remember they aren't written in stone, so where you see deviations - [politely] ask why. Shows you care and want to be more involved, which is always a good thing.