Really Bad Code...

[al7139, ASN, RN]

Hi,

I need to share this, in hopes that another nurse has experienced this.

I work on a Tele unit where the patients are mostly stable with MI, CHF, post STEMI, etc. We do not generally have codes on our unit...we usually can tell if a patient need to be transferred to a higher acuity unit before that.

Three days ago, I was working and a code was called on a patient.The patient had had open heart CABG about 2 weeks prior and was in our hospital being treated for Heparin Induced Thrombocytopenia. I ran to help, and relieved the person doing chest compressions when I got there. When I started doing compressions, her incision site came open, which really freaked me out, but the MD running the code told me to keep going. I also felt her sternum give out while I was doing CPR. I was worried that I might hurt more than help , but we did get a heart rate back after CPR, defib, and drugs. Unfortunately, she died the next day.

I guess I was just really traumatized by the experience...I have participated in several codes, but none as traumatic to the patient as this.

I was wondering if this is typical if you have to code a patient after open heart surgery that their incisions can open, and if there is a better way to do compressions on a post surgical patient with a fresh incision?

Amy

[ghillbert, MSN, NP]

Unfortunately, it can happen that the skin incision opens. It's better than being dead, so you have to just cope with it.

Sounds like you did a good job to get a HR back - it's just unpleasant to have a messy, bloody code. Make sure you talk about it with your coworkers or unit educator etc.

[mama_d, BSN, RN]

"I was worried that I might hurt more than help..."

As a much more experienced nurse pointed out to me when I was new to tele...Honey, they were dead already, how could you have hurt them more? I know that sounds kind of callous, but the worst thing that could have happened is that they would have stayed that way. Although, on second thought, we've coded quite a few that I personally felt would have been better off staying dead due to the hypoxic damage they incurred while down.

I remember the first time I did compressions on anyone, it was a frail old man who was skin and bones. I swear I broke every single one of that man's ribs; someone else had to take over b/c feeling them crunch was keeping me from doing adequate compressions. The doc pointed out to me afterwards that at least that meant that I had had enough pressure initially to be pumping his heart for him, which is the goal, of course. Still gave me the heebie-jeebies, though.

[pricklypear]

Nope, there really isn't any to avoid that happening on a recent post-op. That's just the way it goes. I think it's perfectly normal to feel traumatized after a code like that. I'm sure it will happen again, and it really always feels bad/weird when you feel bones breaking under your hands.

Hang in there!!

[al7139, ASN, RN]

HI,

Thanks for your replies. It makes me feel better to hear you all saying that it happens like that sometimes. I had participated in other codes, and have broken ribs, but never have I seen/felt anything like this since we do not generally have recent open heart patients. I have talked about it with my coworkers who were there and with my unit mgr who is very supportive of us, and they agree we did everything right, it's just plain unnerving to have that happen, especially since we are a small hospital and we don't do major heart surgeries. They go to our sister hospital for that, and we rarely see them back fresh off the table. I feel better for that, but I confess I am irritated with the staff that wasn't there because they seem to want me to relive the gory details not to help me but for the "Ick factor." I just tell them I don't want to talk about it. I too felt like this was an effort in futility since we did not know how long she had been asystole prior to the code (I found out later that the MD had D/C'd the tele the day before, so it's not like they had immediate warning like we do if the patient is being monitored). She was a full code so we had to do what we could, but I think her brain had been too severely damaged by anoxia even before we started (the MD running the code agreed).

This may sound callous, but I am really glad this was not my patient, because there is some question as to when the last time this patient was checked on, and IMHO, the tele should NEVER have been D/C'd on a fresh CABG with HIT, until the second before discharge! You can bet that if I had been assigned to this patient I would have been questioning that order, and taken it to whoever I needed to to get the tele order reinstated. Seems to me like a lawsuit waiting to happen, and I feel for the RN assigned to her that shift, and the MD who D/C'd the tele.

Thanks again for being able to relate to me, and help me to see what we DID do for her instead of the horrible trauma we caused. Even though she passed the next day, I think sometimes that God brings back people temprarily so that the family can have a chance to say goodbye, and accept that their loved ones time has come. I can't say that the outcome would have been different if we had known right away the patient was in trouble, but at least we tried, and I guess that's all anyone can ask for.

Thanks,

Amy

[elthia]

The sternum should be wired together, so just compress away. The skin incision will open, and sometimes I've heard of the doctor's opening the sternum to do cardiac massage on the fresher open hearts (I've never seen it on a CABG, but I saw it once on a thoracotomy code).

When I renewed my ACLS, I was told that effective compressions should show up as a rhythm or line of pvc's on the monitor.

I truly believe that after every code the nurses involved need a chance to decompress. Not a fault finding session, but most floor nurses are so rarely involved in a code, and if it's a long drawn out code, or a traumatic code, we need the chance to review it. It not only helps with our practice, it helps prevent stress and burnout.

[Spatialized]

"I was worried that I might hurt more than help..."

As a much more experienced nurse pointed out to me when I was new to tele...Honey, they were dead already, how could you have hurt them more? I know that sounds kind of callous, but the worst thing that could have happened is that they would have stayed that way.

Yep, push away, you're really only going to help. I responded to a code on a post-op day 4 CABG and ended up doing compressions. They went to the Unit and came back. I was helping a nurse with their bath and he said, "Be careful around here -pointing to his chest- it still hurts." But he was alive and later went home. The moral: just do the compressions.

As for decompressing post-code, we all need it. It doesn't happen all that much, many times we just run back to whatever was interrupted for the code and carry on.

Best of luck,

Tom

[al7139, ASN, RN]

Thanks again all of you who replied. I feel much better knowing it has happened that way for others. It was horrible and sad. I have not heard anything else about the lack of telemetry, etc., but all of us who were involved did get a chance to discuss it with our clinII and decompress. I still think about it, but I look at it as a learning experience and know that we did everything we could for her.

Amy

[rjm09]

I work on a CV post surgical unit and as a new nurse, I wanted to know if it was appropriate to do compressions on a post-op CABG as well. One of the older nurses who worked on the unit at the time also told me that if we were doing CPR, the patient was dead, so compress away! I have also heard that if you place a phone book (or something of the like) over the chest, it causes less damage. Not sure how it would effect the quality of compressions though...

[cardiacmadeline, RN]

I was once told if doing compressions on a post CABG to place a bedpan over the sternum, place your hands in the bedpan and do compressions that way. Fortunately, I have never had to do it.

[criticalHP, MSN, RN]

The sternum should be wired together, so just compress away. The skin incision will open, and sometimes I've heard of the doctor's opening the sternum to do cardiac massage on the fresher open hearts (I've never seen it on a CABG, but I saw it once on a thoracotomy code).

When I renewed my ACLS, I was told that effective compressions should show up as a rhythm or line of pvc's on the monitor.

I truly believe that after every code the nurses involved need a chance to decompress. Not a fault finding session, but most floor nurses are so rarely involved in a code, and if it's a long drawn out code, or a traumatic code, we need the chance to review it. It not only helps with our practice, it helps prevent stress and burnout.

I assisted in coding a pt of mine-post CABG POD1. We opened the chest in the room, surgeon did open cardiac massage. pt lived and was discharged to rehab a long time later (I think at least a month) Pt went through Hell first though-neuro, renals too a hit but eventually recovered (except neuro).

[Suninmyheart]

Last week we had a code where the patient collapsed while transferring to the bedside commode. He was on the floor all tangled up in his legs with massive amounts of poop and pee all around him. I immediately ran around the room grabbing blankets and anything I could fine and throwing them on the floor next to him so nurses wouldn't slip and slide all over while trying to compress and bag. What a mess! He didn't make it.