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Futile ressusitation

Emergency   (7,535 Views 32 Comments)
by amzyRN amzyRN (Member) Member Nurse

amzyRN specializes in ED, Cardiac-step down, tele, med surg.

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Nurse_ has 7 years experience and specializes in Trauma | Surgical ICU.

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Working in trauma/surgical ICU, I've seen people recover. Just the past weekend, the patient came in with a stab wound to the neck that severed the carotid artery. The doctors told the family not to expect him to survive and that they should say their goodbyes. Twelve hours past, then 24-hours, then he was started in CRRT...

Now, he is extubated and talking to family.

He is one of many that I've seen survive.

We lose many battles. But we fight it anyway. Because there are people who wants to fight back, who has that determination to live if we only give them a helping hand.

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calivianya is a BSN, RN and specializes in ICU.

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Most CPR is futile. I'd say 90%, at least, of people that get their pulses back either code again within a couple of days and we can't get them back, get withdrawn on and die, or spend the rest of their lives in a LTACH.

But.

We had someone recently who was in her 30s and went into a lethal arrhythmia at home. Unresponsive when she first got a pulse back, posturing and seizing within a day of arriving up on the unit with us. She arrested something like five more times, all v-fib. We did the hypothermia protocol, put her on a boat load of seizure medications, etc. Most of us thought it was a wasted effort.

She bought herself a defibrillator for her tendency to go into v-fib, but was otherwise perfectly fine. Woke up and started following commands, and was extubated within a week. I mean ZERO deficits of any kind - not even slow speech. She talked as fast as I do and that's pretty dang fast, moved all extremities, was walking to go to the bathroom, etc. She told me before she left that she was going to "quit her f'ing job because her boss was a f'ing a-hole that was trying to kill her" and that she was going to pursue art instead, which she'd always wanted to do but had been worried about making ends meet. She decided since she'd already died once that life was way too short to be in a high powered job that she hated. Several weeks later she came back and took pictures with us and brought us food, and showed us pictures of her paintings, which were actually very good.

You really never know.

The thing about working in the ED is you don't get to see any of the long term outcomes, so I imagine it's especially disappointing for you guys. ICU staff at least get to see the patients wake up, if they're going to.

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11 Followers; 3,662 Posts; 27,102 Profile Views

8 whole units! my god it must have been awful for you. We gave 60 to a criminal who slit his throat and wrist after barricading himself in his house after he just murdered his wife and child.

It's unfortunate to see this kind of sarcasm and belittling tone here. We are having a discussion - - and the topic at hand is one that many, many of our nursing colleagues wonder about at some point in their careers. I think it is an intelligent question that can bring up various ethical issues that are interesting to discuss, and that each of us must come to terms with in our own way.

Quite frankly not everything we do in these situations is good. This is a legitimate topic of concern.

I'm sure you did good work on the case you mention - your abilities and genuinely good works of service to others should afford you the stature (professionally, ethically) to be gracious with your colleagues when an opportunity arises.

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kbrn2002 has 25 years experience as a ADN, RN and specializes in Geriatrics.

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I work in a SNF and a few residents that are full code really shouldn't be. People at the end stage of completely debilitating always fatal disease, post devastating CVA with no chance of meaningful recovery and for whatever reason family members that insist that absolutely everything possible be done. When the time comes for these residents I don't expect that any kind of life saving measures will be at all effective, but try we must. While I sincerely hope that doesn't happen on my shift, try I will. I may not agree with the families decision but I have to respect it.

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54 Posts; 1,561 Profile Views

After having been through this situation on a personal level I can say that I would hope that you would try to change your attitude just a bit.

A month ago my husband walked into an ER with chest pain and lost pulse as he got up on the table. They did CPR for almost an hour and I still didn't get there in time.

I will be forever grateful to the ER staff who worked so hard to try to save him. After hearing the MD and nursing staff give me a recap of their efforts I can know for sure they did everything they could.

I am a nurse and have been on the other side many times, but when it is your loved one, your rock, your everything, it is so overwhelming to go through a death, but every minute that staff attempted to bring him back means the world to me.

Thanks to all of the awesome ER staff who do this every day!

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bgxyrnf has 10 years experience as a MSN, RN and specializes in Med-Tele; ED; ICU.

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I just feel disheartened sometimes that despite our best efforts, the patient dies or won't recover to a meaningful extent. I will always continue to do my best, it still bugs me sometimes when efforts fail.
The rate of intact survival from cardiac arrest is very low; the more fragile the patient and the more comorbidities, the lower the rate.

Traumatic arrests are nearly always futile. Generally, if a trauma patient arrives in cardiac arrest, our docs will do a quick bedside ultrasound examination of the heart and call it immediately if there's no heart wall motion.

We did have a GSW who was talking to the medics and then lost pulses shortly before they rolled in. We pushed the blood and did CPR. The trauma attending never showed up. The trauma chief made the call to take him to the OR, while we were doing compressions. A quick pulse check after he was moved to the OR table found him with pulses again. Taking a patient to the OR with compressions in progress is a no-no but the chief didn't get in trouble because the guy lived. Probably he hadn't actually arrested but just had such feeble pulses that we couldn't feel them in the 10-sec window before you start CPR. In this case, they hadn't done the bedside US to ascertain heart wall motion.

In his case, the pt was fortunate because the internal bleed was a venous bleed rather than arterial.

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18 Posts; 751 Profile Views

Hi amzyRN - I think this is an excellent discussion topic and one that we all seem to go through all-too-often. I just finished my perioperative nursing residency and spend 3-4 weeks at an L1 trauma center, where we, as O.R. nurse were often called down to the trauma bay or more often, the SICU (both peds and adults) for bedside surgeries.

I absolutely hated the trauma cases where I was literally on top of the patient pounding on his / her chest with no chance at ROSC, but they had brought the family in (another controversial topic). I don't know how to say how I felt other than...I hated them watching me. That was heartbreaking to me.

I experienced my fair share of bedside ex-laps on children and those were the absolute worst. Our rooms had scrub sinks outside so the parents would be watching us wheel in all of this intimidating equipment and then see us 'gear up' before going in. The parents were often asked to go to the lobby, but on rare occasions they were able to stay outside the room...even though they couldn't see what was going on. A couple times, we had opened the bellies of children with aggressive abdominal cancers and when they went into PEA, the attending wanted the team to proceed with a thoracotomy - i still cry thinking of those cases watching someone just massage and massage and massage with no change on the monitor...

I know the surgeons like to say, "We did everything we could", but I often wonder if they should slightly rephrase it to..."We did everything we SHOULD."

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AnnieOaklyRN is a BSN, RN, EMT-P and specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

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In my state as a medic I can work the patient at home for 20 minutes and call it, thus not wasting precious resources and causing the family thousands of dollars in bills to accomplish nothing. We do what the ER will do, just in their house. I always talk to the family first before doing it, if they don't agree with it then we transport. I also give them the option of coming to see the patient while we are still working on them so they can see that we are doing everything and they can talk to them before we stop. I can honestly say 100 percent of the families I have asked have chosen to stop efforts at the house and no-transport.

i would imagine this will eventually be the standard for almost all EMS systems, but it will take time to catch on and for people to get comfortable with the idea.

Traumatic arrests don't even get worked if it's blunt force, or they have injuries that are obviously incompatible with life. Penetrating trauma to the chest will get worked (if they don't have signs of a prolonged death and/or their blood volume isn't sitting on the floor next to them).

Annie

Edited by AnnieOaklyRN

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AnnieOaklyRN is a BSN, RN, EMT-P and specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

1 Follower; 2,577 Posts; 34,418 Profile Views

I aslo wanted to add that I don't get why families watching codes is controversial? They have been watching EMS providers working their family members for decades with no controversy involved. The ER/ICU or whatever is no different!

The care of your family member shouldn't be a mystery no matter what they are in for, including cardiac arrest.

Annie

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1 Follower; 1,319 Posts; 12,294 Profile Views

Hundreds of codes in the 20 years I have been in EMS or nursing, know of 2 that have walked out.

Was it a waste for those 2?

Odds are, more walked out of the hospital than you are aware of.

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Kuriin has 2 years experience as a BSN, RN and specializes in Emergency.

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You guys are saying these are futile resuscitative attempts. To your eyes, yes, they are. To the families watching that every possible thing is being done for their loved one IS NOT FUTILE.

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CampyCamp has 18 years experience as a RN.

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Are you using hypothermia s/p ROSC? As a CCU/ICU nurse, that seemed to be a turning point in how many were walking out instead of becoming vent dependent with other anoxic brain injury insults. I used to do private duty for a disabled teen who survived two codes due to LQTS. I wish hypothermia had been available for him.

I know ER has many codes, long and short that never make it to the units. But of the ones who did, I saw quite a few walk out. Especially the cooled ones (and some of that might simply be that be meeting the criteria to to be cooled in the first place indicated a greater chance.

One of the most memorable walk outs was actually a man who lived down the street from me. He was lucky enough to collapse in front of a co-worker who had just taken a CPR recert. He was lucky enough to work 3 blocks from EMS, who were in station and 1/2 mile from our hospital. After ROSC, he went to the lab, had occlusions opened, IABP started and sent up with swann showing poor to fair numbers. Cooling went by schedule though and he was waking meaningfully after rewarming. Kept sedated for vent and balloon until weaned. Step down and ambulating one week post-code. Tragically, he collapsed again at home 12 months later and didn't make it. But those 12 months? He saw his daughter get engaged, his son and their car race another season, his foster son start picking colleges and play another season of football, he made cookies with his children and their partners, his foster kids, and my daughter, he worked, and he cuddled his dogs.

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