My patient coded, and it's giving me nightmares!

[NickiLaughs, ADN, BSN, RN]

I work in Critical Care and I've had lots of patients die, they were all either on comfort care or switched to hospice. Two nights ago was the first time my patient officially coded.

All she had had was a nose bleed that worried me and I kept calling the doctor. I just had a feeling all night she was going to go down hill. All her objective clinical signs (ABG's, vital signs, etc) were doing ok so I didn't have anything to back me up even though I asked a couple times if we could intubate her, she just seemed like she was working hard, RR was 40s-50s. But because her ABG was better, the doc just wanted to watch her.

3 hours later she's pretty much hemorrhaging from her mouth and looks like she can barely breathe. I was harassing the pharmacy for some Vit K they were taking forever to deliver and then I was going to call the doctor back, and she coded on me.

It was just one of my bloodiest situations thus far, and I can't stop feeling like I failed her. Anyway, I've been having nightmares of constantly coding patients since and just generally super violent deaths. I've never had a problem with deaths before, but maybe it's a good thing I'm leaving my job for a case management gig. I feel like I have PTSD all of a sudden from critical care. My families, patients and coworkers have always said I do good, and that I am a good nurse. I don't know what caused the sudden change, anyone else ever have this happen?

[NurseLoveJoy88, ASN, RN]

I had it happen to me once when I was a student. The patient was a walkie talkie then all of a sudden he codes and frothy blood spewed from his mouth. Blood was everywhere! Another student broke down crying, I held it together there but could not stop thinking about.

It will get better with time, its hard to deal with... I know.

[Sun0408, ASN, RN]

What was her admitting dx.. Why was she in the ICU, that may be the first clue to why she coded.. Nose bleed shouldn't be that serious but her increased resp rate and work of breathing is a major concern and red flag. So she went from bleeding from the nose to the mouth, did she have a history of varices or cirrhosis?

Yes, I have had it happen, codes are pretty common in my ICU only because it is the trauma unit. We have had a few that were normal surgical pts that should have been fine but never left the unit alive. It is hard when it is someone you didn't expect. Sometimes we do everything right but the outcome is still bad..

[tokmom, BSN, RN]

Not icu, but got tired of sick pt's that were young and dying from cancer. It took a toll on me to the point I was having anxiety attacks as I drove in the parking lot. I left for a few years and eventually was able to come back.

Curious on why the MD didn't want to intubate? How long did he think the pt could keep up that RR without becoming fatigued?

[AnonRNC]

It's normal to be disturbed by a particularly bloody code. Codes are vastly different than an expected (and "permitted") death. It's only been a couple of days; I think you are quite normal to still be uncomfortable. If you're still having problems in a week or two, then I would suggest seeking help from your primary care provider.

You sound like a good nurse: you recognized "something wrong" when the objective signs were still okay. Your patient's physician should have listened to your intuition.

[Nascar nurse, ASN, RN]

Had this happen once in LTC. 90 year old walkie talkie. Started as a slight nosebleed - within minutes heavy nose bleed - within minutes full hemorrhage from nose and mouth. I swear clots the size of golf balls were suddenly spewing out. I was a 20 year old newer LPN. Still to this day (I'm almost 45 now) it is the absolute worst death I have ever witnessed. I was just sick over it all. I was so worried that I let her die. Luckily a much more seasoned nurse arrived on the scene and told me after it was done that there was nothing any of us could have ever done to fix that. Since then I have watched MANY people die - this is the one that still haunts me and I hope to never see it again.

[NickiLaughs, ADN, BSN, RN]

She was in for CHF exacerbation, went bad on the floor and CO2 over 100. When I got repeat ABGs she was back down to 30-ish. He didn't want to intubate despite the respiratory rate because her ABG had so much improvement. It looked like after we finally did that she had aspirated a blood clot. Bad heart history but nothing else significant. I honestly came in for my shift and looked at her before I got report and just "felt" she was on her way to heaven.

[rn/writer, RN]

See if your employer has and EAP (employee assistance program). If so, you should be able to get a number of short-term counseling sessions at no charge and get a referral if more are needed. These folks are well-versed in PTSD, sleep disturbances, feelings of anxiety r/t your job, etc. Sometimes it helps just to talk with someone who understands the situation and the stressors you face(d). I highly recommend this option.

Hope you're feeling better soon.

[Corey Narry, MSN, RN, NP]

Either what rn/writer said or try to see if speaking to your hospital chaplain is an option. Where I work, a chaplain responds to codes and will take down names of all staff present during the code. We then get an email from the on-call chaplain offering debriefing services should we need them.

I think you did everything right by being concerned from the get go. Nosebleeds are never always benign because of the risk of airway compromise as you saw. It's easy to beat ourselves with thoughts of what could have been done. In hindsight, a scope by ENT could have identified something that could go wrong or a pre-emptive intubation could have changed her hospital course.

[caroRN]

I'm in my first year as a surgical floor RN. My first code was pretty traumatic for me too and there wasn't even blood or the other concerns involved like yours. You sound like you were very on top of your patient's condition and you asked for appropriate interventions. You did all you could do.

I was very disturbed with my code for some time. My patient coded on the floor, was brought back enough to be transferred to ICU where they then passed. There was nothing I could have done to prevent the code or the change in the patient's condition but it still bothered me. I actually went to see a therapist for a while because it was very disturbing for me. I'm doing much better now but it still bothers me a little when I think of it. I think firsts are probably always a little harder...

[Been there,done that, ASN, RN]

If the respiratory rate is 40 -50, I don't care WHAT your ABG's look like ... you bought yourself a tube!

Look at what you have learned from this and move on. Counseling is an excellent idea.

You will never let pharmacy drag their heels on a stat med again .. will you?

And.. most important of all.. sometimes it is just their time to leave us , despite our puny efforts.

[NurseCard, ADN]

I had a similar thing happen to me. My lady was actually on the regular floor, but was going downhill. Her main complaint was abdominal pain that the doctor could not seem to find a reason for, and was intractable. She ended up coding; she apparently had something about to rupture somewhere in her abdomen, that finally did. I was still on orientation as a new RN. It's the worst code that I've ever experienced, to this day. I still get chills.