It can happen to anyone, anytime

DeLana_RN, BSN, RN · Aug 23, 2009

You're so right, the patients who die (not just codes) are often those you don't expect to - "relatively healthy" and/or young. It sounds like the code didn't faze you at all - which is great in a setting where they rarely occur - and you handled it beautifully; and of course, the outcome is wonderful.

In the 5 1/2 years I worked full-time in a dialysis clinic we had only one code while I worked; it was an 82-year-old who also seemed to be in good shape, had walked in, no c/o. Fortunately, we some very experienced staff working that day and the code went well. Better yet, the pt fully recoved and lived for another 6 months! All of this is a miracle because we often had inexperienced staff working and the facility never did mock codes (it should be required in an outpt setting); other than the annual BLS/inservice, there was nothing (and ACLS was strongly discouraged!). Many times we were very, very lucky that nothing happened.

Congrats on a job well done! Glad to hear the pt is doing well.

DeLana

Trauma Columnist · Aug 24, 2009

I must preface this with the fact that my nursing background is level one trauma center. I came to HD as a mid-level provider doing rounds for the neph practice. I go to two HDUs and I think it is infinitely harder to code someone you "know" versus a total stranger.

I'm so sorry for you!

workingmomRN · Aug 26, 2009

I've worked in HD for 10 years & have seen a few codes. It seems like it is always the one you least expect. When you have a relationship with the patient, it is certainly an emotional experience. You also don't really have time to grieve when they don't make it because you still have a other patients that need you as well.

Chisca, RN · Aug 27, 2009

I can't remember where I read it but there are more codes on Monday than any other day in dialysis. The added stress of going two days without dialysis being the contributor along with more patients in the MWF rotation.

GeauxNursing · Aug 29, 2009

Now I don't want to sound stupid, but how did it come to be noticed that he had arrested? I look at every single pt as I'm walking by, whenever I'm doing anything. What if they just look normal? Like they're sleeping? And our BPs only take q 15mins. Often they can go "out", right in front of me, before their BP would even indicate something.

I just want to be more diligent about assuring safety I guess, so can you just tell me how you recognize an arrest? Thanks all!

workingmomRN · Aug 30, 2009

Some of the patients will have c/o CP,SOB, not feeling right, anxiety, etc prior to arresting. Some will not have any symptoms at all. You have to be diligent when they go to sleep because they may not have any obvious symptoms. I always look for the chest rise & fall to make sure they are breathing. Another thing that some pct's & nurses both fall into is not actually looking at the patient when doing the vital checks, just the machine. The bp should be taken at the time of the vital check, not 10 or 15 minutes prior.

HDNurse · Sep 14, 2009

This particular patient was found clutching his chest and trembling. When the tech was not able to get him to answer her she called me. Within seconds, I had ascertained that he was not breathing and there was no pulse. You are right that they could look like they are sleeping and be in more trouble than is apparent. I am much more aware of their breathing patterns now.

On a good note... This patient is now alive and "well" and back at his regular treatment time at our clinic. He returned to the clinic two days before his 79th birthday. He got a pacemaker and his BP is so much better now than it was prior to his arrest. He usually had a BP with a systolic in the 90's. Now he runs in the 120's. He is still having a lot of pain in his chest wall due to the separation of cartilage during the CPR-sure wish there was a way to avoid that, but the alternative isn't acceptable is it? He doesn't remember any of it and asks me repeatedly about details of that day.

anurseadvocate · Sep 14, 2009

HD Nurse: Congrats on being well-prepared and for being so compassionate with your patients. We all are aware that not everyone working in dialysis shares that which you have expressed... Your story touched my heart and I can imagine how you were feeling. Your concern to go to the hospital shows true compassion and how much you care about your patients. THANK YOU.................anurseadvocate

He is 78 years old and one of my favorite patients. A very sweet, gentle and pleasant man. He is never any problem to care for. He is totally compliant with his diet and fluid restrictions. We never have to take more than 2 kg off of him at a time. He is the perfect patient. He has never given me any indication of being acutely ill. His history shows having a CABG in 1987 and no problems since then.
Monday, he drove himself to treatment, walked into the clinic by himself, had no complaints of feeling ill. His heart and lungs sounded great. 57 minutes into his treatment and after removing only 0.8 kg, he arrested. Just like that. One minute he is fine, the next minute he is technically dead.
We started CPR and put on the AED until the paramedics arrived (10 minutes later!). The AED said no shockable rhythm, continue CPR. For 10 minutes I did compressions on that man. The paramedics arrive and someone says, "Lori, Mr. so-and-so is here and needs to be put on." So I'm right back into the dialysis "dance" for the rest of the day. We had no idea if he made it or not.
I stopped by the hospital after my shift to see if he had made it. He did make it, and more importantly, he is alert, following directions and recognizes me. He is neurologically intact! He is expected to make a full recovery.
I once was a firefighter/EMT and I've performed CPR before. Usually on people who have been down who knows how long. They never made it. They were strangers to me. This man: I have a relationship with. This was different. I have been a nurse for almost 19 years and I have never had a patient code right in front of me. I've taken CPR classes year after year to make sure I was prepared, and to be honest, the last few times I didn't take them too seriously 'cuz "I've been there, done that." Those "mock codes", that I once thought of as rediculously a waste of time are no longer going to be looked on with disdain. Today I'm glad I was prepared. I saved a man's life. God, it feels great to be a nurse! I've made a differnce.
Of all my dialysis patients, this man was not the one I expected to code. He was "stable". It can happen to anyone, at anytime. It pays to be prepared.

Lacie, BSN, RN · Sep 14, 2009

I had to recent instances prior to leaving my last clinic of which I was the DON. Both these instances had a great deal with my decision to leave. Both patients were those who we would have never expected to code. I was off both these days but it sure did enlighten me as to how "UNPREPARED" my staff truly was. The first was a 44 y/o male new to dialysis and been treating for approximately 1 month. Very compliant, loosing weight and kept great lab values. Couldnt have asked for better and he was intent on getting that new kidney doing everything he could to get it right. He presented for tx stating he didnt feel too well, the chg nurse initiated treatment. He later spiked a temp so MD notified and Vanco was ordered. Note she had taken him off the machine. She then restarted treatment in order to give him the Vanco (CVC) and soon as she started it he went out!! Unfortunately he passed. When I returned to the clinic and reviewing the code sheets found NO ONE ventilated this man during the code! They put an o2 cannula on him and that was it. Considering he had no spontaneous respirations. Then instead of pushing saline in the nurse continued to pressure push the bag containing the Vanco in!!!! I was astounded as I had believed I had good staff that could handle this situation.

The second one was a 56y/o man came in on his non treatment day, shirtless, shoeless and appeared confused. The staff told him he had the wrong day and since he was too weak to walk to his car they wheeled him out in a wheelchiar then allowed him to drive home!!! I came in to work the next day and was informed of this and also he had not yet showed for his regular time which he never misses. I ended up calling the police to check his home and sure enough he was found nonresponsive and in bad shape. He past 3 days later from a massive CVA and Sepsis. Killed me as there was no doubt in my mind we could of head this off if we insisted he be evaluated the day he came in the clinic confused. I was also upset over the potential danger my staff put the pt and the public in allowing him to operate a vehicle of which he also backed into our wall! We have to be alert and learn to know our patients well enough to pick up on suttle signs. Sometimes those suttle signs may save there lives. Get this my administrator didnt see this a neglectful actions!!!!!!!! No doubt in my mind they were.

romansten9 · Oct 1, 2009

Great Job, you were prepared. I'm a Paramedic with 20 years experience. (more codes than I can remember) I also have a new job as a dialysis RN in a large hospital. We also take care of inpatients that need dialysis, some brought to us very sick, and some we treat in the ICU. I think I'm the only dialysis nurse with ACLS. They rely a lot on the ER and ICU to come help with codes, but they want me to run them through some "mock codes" soon. I hope several of them will take ACLS. The dialysis unit is considered a "critical care" area in this hospital, so there should be nurses with ACLS. (they have a crash cart of their own, so why don't they have ACLS???)

TraceyLPN · Nov 12, 2009

I have had that happen to me where they look "fine" when in reality they are not. Now I do not want to offend anyone reading this story, however; if you've been in dialysis long enough you will totally understand. We are fortunate enough to have just one "problem" patient in our clinic...you know the kind, misses frequently, whines, nothing is her fault, cusses, etc. One day she comes in, gets on, and is hollering and crying "JESUS OH JESUS JESUS!!!" over, and over, and over....until my fellow nurse mumbles "I wish Jesus would come on and take her!" Eventually, she goes to sleep. Her bp's show fine, she is breathing, because I'm checking that when I walk by to make sure, because I'm sure not going to wake her up, right? Then her dr. comes in to see her, calls her name....no response...we readjust her bp cuff, and it shows a significant drop, below 100 systolically. We lay her back, give her saline, all the things you do...call her name, her eyes are rolling back in her head, we call 911. She never stopped breathing, was just unresponsive. By the time the ambulance got there we had her stabilized and responding. The nurse I mentioned early said when it was all over with, "I said I wanted Jesus to come take her but I didn't really mean it!!!" Thank goodness she was ok, but the moral of my story is, sometimes you just can't tell unless you DO wake them up. She was breathing fine, bp showed fine, I think maybe she had her arm bent or in an awkward position and possibly it just wasn't registering correctly. But how often do we wake a patient up just to ask, "are you ok?"