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Reflections after my first code

Mar 17, 201610 yr

Patient was scheduled for an elective, outpatient surgery. Woke up early to shower, and fell to the ground, breathless and weak. Wife called 911. Pt coded in ambulance. Coded again in ED. A third time in CT. Found a massive PE. tPA was given and pt was sent to ICU.

When I assumed care, pt was on Levo, heparin, bicarbonate, MIVF. No UOP despite being 8L positive. Poor neuro exam. Became more hypotensive with stable H/H, and dobutamine was started. Then he became bradycardic and lost his pulse. I was the first on his chest. His ribs were already broken. 2 rounds of CPR, and some epi, and he went into VT. 1 shock brought a rhythm back. Started epi drip. Had to add vaso, as I couldn't keep his pressure up with everything else maxed.

It looked like he was gonna code again, but I was able to speak to the family first and tell them that it wasn't a matter of if he would code again, but when. I told them that we would respect their wishes, but that we were doing our best to keep him alive and his heart couldn't take much more. And that even if we got him back he would never be the same. They decided against more CPR/shocks and elected to let him go as peacefully as possible (still intubated, sedated, and maxed on 4 pressors). He died shortly thereafter, his family surrounding him and holding his hands, instead of having his chest pounded on and electrical currents rip through his body.

I'm 5 months in as an ICU nurse, and this was by far the most unstable patient I have cared for. While it is very sad that his life ended in such a tragic and unexpected way, I am glad that I was able to help this family accept their loved one's death and allow him to slip away with some semblance of dignity and comfort.

I am not a a cryer, and maintain a healthy disconnect from my job, but as I held the wife of this man, I wept with her. As I watched his brothers say goodbye, I remember having to say goodbye to my husbands brother, who was taken from us all too quickly as well, and the tears came. I was in no way emotionally connected to this family, and my tears were not for me. I have now become a major player in the absolute worst day of their lives. They will remember my face, my words, my actions. My tears were for them. They will remember a nurse who was willing to grieve with them and recognize that my average day at work was the most horrific day they have ever experienced.

I came home that night, took a bath, drank some wine, and went to bed. I will return to work, return to another sick person, and life will go on.

They will return to an empty chair at the table, a vacant side of the bed, family photos where one is missing.

This job is sacred. We are walking the line between life and death, between hope and hopelessness, between "do everything" and "let him go".

I am proud to be an ICU nurse.

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Mar 17, 201610 yr

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Mar 18, 201610 yr

Thank you for telling them what they needed to know so they could make good decisions.

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Mar 19, 201610 yr

If he was 8L positive, perhaps his heart was overloaded and a combination of CHF and MI's took him out. Obviously it all started before you ever saw him.

The family may look back at you as a comforting presence in a world of pain. That's a great thing.

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Mar 19, 201610 yr

Sounds like you did an amazing job from every aspect. It's weird waking up the next day and getting on with your own life after events like that. I can never decide if I want it to stop feeling that way or not.

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Mar 19, 201610 yr

Author

If he was 8L positive, perhaps his heart was overloaded and a combination of CHF and MI's took him out. Obviously it all started before you ever saw him.
The family may look back at you as a comforting presence in a world of pain. That's a great thing.

I'm sure his death was very multifactorial. He had no CHF hx, and the echo tech was on their way when he coded, so the echo wasn't ever done to confirm that his heart was damaged. The rapid bedside echo in the ED was read as normal, but he had coded 2-3x since then, so I'm sure he had some wall motion abnormalities and the extra fluid probably didn't help but he wasn't sustaining a blood pressure and had no urine output with 4 pressors on board, so what else was to be done? I usually am under the impression that diuretics are held when someone is so drastically hypotensive, but if he had maxed out on starlings curve perhaps it would have helped. I'm not sure...

At that point however, I was concerned that the neurological damage he had sustained would make his future very bleak, even if his heart somehow could have recovered. With 4 rounds of CPR, his brain perfusion couldn't have been all that great, even with the best compressions!

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Mar 21, 201610 yr

Wow all this going on. I wonder if the activase had any part of his demise with those broken ribs and all the CPR. Good story with an unfortunate outcome.

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Mar 21, 201610 yr

I have a similar story but mine involved an older lady who had a massive PE. Coded in CT room and coded again in ED. Got a total of 100 mg tPA and they initiated her on hypothermia. When I came on shift, she was really unstable, vented, and had MULTIPLE drips running all at the same time: heparin/fentanyl/Ca/K+/Mg/IVF/propofol/insulin/levo/vasopressin/dopamine. I broke a sweat caring for this lady the entire night. No one thought she was gonna make it. But needless to say, she started following commands upon sedation vacation, got extubated and continuing to do well.

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Mar 22, 201610 yr

Author

I have a similar story but mine involved an older lady who had a massive PE. Coded in CT room and coded again in ED. Got a total of 100 mg tPA and they initiated her on hypothermia. When I came on shift, she was really unstable, vented, and had MULTIPLE drips running all at the same time: heparin/fentanyl/Ca/K+/Mg/IVF/propofol/insulin/levo/vasopressin/dopamine. I broke a sweat caring for this lady the entire night. No one thought she was gonna make it. But needless to say, she started following commands upon sedation vacation, got extubated and continuing to do well.

For some reason this person wasn't cooled per the therapeutic hypothermia protocol - as I understand it is was because he was a PEA arrest and very hemodynamically unstable - but I don't know for sure. I wonder if his outcome would have been different.

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Mar 25, 201610 yr

One thing I have to add- obviously I was not there so I don't know what was happening- but i am reluctant to pull the plug on people who are fully functional prior to admission. Sounds like your patient was super sick. Sometimes people pull through even when the odds are stacked against them. Depends on a lot of factors/ age, comorbidities, etc.

you can be surprised how people turn around occasionally.

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Mar 26, 201610 yr

This reminds me of the ICU nurses that took care of my grandmother when she was ill. It's exactly as you said, you remember their every action, every word and facial expression. The fact that not only the nurse there, but the entire team, did the best they could, really made the grieving process much easier. My grandmother is part of the reason I decided to pursue nursing and posts like these make me more and more confident ICU may be the field for me, so thanks for sharing.

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Mar 28, 201610 yr

I am proud to have you as a colleague in arms in this small but very important world of Critical Care Nursing

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Reflections after my first code

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