Trauma Queen » How does it taste?.
Dude’s on a mountain bike responding to EMS calls. How cool is that? Oh yeah, also has great teamwork and gets a guy back too.
Seriously, go check it out!
Drowned Boy’s Family Upset With Officer’s Response – KWCH – Kansas News and Weather -.
Sad, sad sad…
That’s why every police/fire/parks & rec/ranger/scout leader should be trained in basic CPR. I’m not saying much more as it is too hard to say what truly happened, but that it sounds like this may have been averted.
We had a code the other night. It was by far the “best” code I’ve ever been privy to. No yelling orders, no standing around waiting, no egos, just a concerted effort to save a dying (well, dead) patient. The resident running the code was calm, cool and collected. As we did our interventions he worked through the H’s & T’s trying to figure out if we could fix anything. Outside of my ACLS megacode, I’ve never seen that. But moreso, he asked the staff if there was anything that we thought he had missed. And before he called it, he aksed if anyone else had any objections. Truly it was a team effort.
But for some reason I can’t seem to shake it off. I had no real connection to the patient, other than being the charge nurse. They weren’t one of our frequent flyers. But something reached ahold of me and won’t seem to let go.
Maybe it was the fact we found her already down in her room. Or the fact I felt the ribs snap under my palms. Or it was that we did CPR on her for 30 minutes, rotating between 2, then three of us. Or that we threw everything in the code cart at her, and some things that weren’t, but nothing seemed to help. Our CPR was some of the best I’ve ever seen/felt. We shocked her a total of 9 times. She got tubed incredibly quick. But it didn’t seem to matter.
For the last couple of nights, I’ve laid awake and thought about it. Re-running it over in my head, which then sparks memories of other codes and then to the memory of running in to see them performing CPR on my little girl. For some reason, this one cracked my shell. Like the title says, I can’t put words to the feeling.
Maybe though, it re-affirms that I am human and that I do care, something that I’ve been feeling a great distance from. Maybe I’ve grown cold over it all- something my wife mentioned in passing not too long ago. Maybe this nagging sense of malaise over this event is me re-examining myself over this coldness and cynicism and the realization that I’ve moved that direction has left me a little out of sorts. More than anything though, it serves as a reality check, a visceral reminder of what we do as nurses when things do go south.
I know with time this angst and malaise over it will fade. I’ll make peace with the way I feel about it, but like all the others, I’ll never forget.
According to CMS, we experienced a “Never Event” last month. But the even itself illustrates in my mind the flaws inherent in the whole concept of a “Never Event”. Theoretically, the idea is agood thing. There should be events that could occur while a patient is admitted to a hospital. Some things should never happen: like wrong blood, surgery on the wrong part of a patient or abduction of a patient of any age. Some stretch the bounds of rational thought though. The one that comes to mind is patient falls.
In the hive mind of CMS, patients should never fall. Once again, theoretically, not to mention from a public relations standpoint, the argument is sound. What they and the public tend to forget, that unlesss someone it at the bedside 24-7, falls will occur. You can follow every published guideline out there. Scheduled toileting, hourly rounds, bed alarms, reduction of the use of medications that can cause or enhance delirium are all really great ideas and have been proven to reduce falls. But the bottom line is that when our elders, especially those that may have dementia tned to fall. Add illness, strange environment, odd noises, unnatural schedules and new medications and you cook up a recipe that could conceivably lead to a fall, in spite of any and all safety measures we as caregivers may take.
But people fall. Sometimes people fall and there is nothing we can do about it.
Exhibit A:
click for larger size
Anyone who knows EKG tracings can immediately grasp the bad things going on here. But for those who may be a bit rusty, let me break it down for you. The patient is rolling along in normal sinus rhythm until they get hit with a R-on-T PVC (a premature ventricular beat the falls when the myocardium is not yet fully repolarized, see below) initiating a run of Torsades de Pointes. Torsades, meaning “twisting of the points” is a life-threatening ventricular arrhythmia that can rapidly devolve into ventricular fibrillation and death. It is a form of ventricular tachycardia (VT, V-Tach) characterized by the rotation of the complexes around the isoelectric line illustrated by the increasing/decreasing amplitude of the waves in a near sine-wave pattern. Treatment in an emergent situation is the following of the V-Tach leg of the ACLS algorithms, although usually a bolus of magnesium sulfate can terminate this as well. Usually though, when we see this though, the proverbial shit has hit the fan.
In this particular case the patient had been ambulating in the hallway and flipped into Torsades. The red mark is about where we figure when he hit the floor. Not for sure, but the timing seems about right. Now what would CMS say about this? The patient was awake, alert and oriented x 3, ambulating under his own power when he fell. So it is still a “never event”. And this is why a one-size fits all labeling makes no sense.
First, does this mean we shouldn’t let patients ambulate? They might fall. Second, should we not give medicatons that may cause arrhythmias like this (more below…)? They might fall. Third, should we not anti-coagulate patients who are under treament for atrial fibrillation and thus increase their risk of bleeding with a fall? Painting in broad strokes doesn’t always work.
Unfortunately, the patient had previously been in atrial fibrillation and been anti-coagulated with warfarin for an INR of 3.2. He had been cardioverted out of a-fib into sinus earlier in the day and was intiating Tikosyn therapy. The truly unfortunate part is that when he went down, it was like a tree falling in the forest: straight back off his heels with his head striking the floor. CT showed a massive cerebral bleed as a result and family chose to withdraw support allowing him to pass. So this is a huge “never event”, as per CMS, “Patient death associated with a fall while being cared for in a healthcare facility.” If he had not been ambulating, odds are pretty good that he would have made it out of the code, as there was a spontaneous return to sinus rhythm right after the scanned strip ends, with spontaneous return of circulation as well. But since he fell in the hallway and hit his head, the deck was stacked.
As for the medication, Tikosyn (dofetilide) is a Class III antiarrhythmic medication that works by prolonging the cardiac action potential duration. One major hallmark is that it subsequently prolongs the QT segment. A prolonged QT interval increases the risk of ventriclar arrhythmias as the repolarization of the myocardium happens at different rates allowing myocytes that have already passed their absolute refractory period to depolarize early and possibly causing a re-entrant phenomenon, kind of like a viscious circle. The FDA actually mandates that anyone being started on Tikosyn gets themsselves a 3 day vacation on a telemetry floor for this very reason. Usually we monitor the QT/QTc closely in these patients, obtaining a baseline, then 12-lead EKGs 2 hours post-dose to ensure that the QT/QTc is still within limits.
So was this a “never event”? Probably. Could it have been prevented? Probably not. There were too many variables in play to do so. Sometimes shit just happens, no matter what we do.
While I may be superstitious, my rational side is usually able to concoct an explanation for circumstances of what may seem to be divine intervention, or lack thereof. But I can’t on this one. The only plausible explanation, the only one that makes even a shred of sense is the totally irrational one. How else could you explain 6 codes in 1 night?
Yes, we have sick people, sicker than normal in house right now. But 6 codes? That’s more than a typical week, even more than a typical month. So yes, 6 codes, 4 in the Unit, one upstairs and one on my floor. The code team was looking ragged, the doc looked like she was one of the walking dead herself after being abused all night long. I think our Materials people were going to throw a fit if they had to throw together another fresh code cart. It was one of those nights.
But the explanation you ask? Friday the 13th. It’s the only one that makes any sense at all. Even though it was only the 13th for half of last night, it’s insidious reach kept things interesting. The worst part of it all though is that now, tonight, Mr. Blackcloud (me…) is in charge. I’m calling staffing right now to make sure the ICU is well staffed and checking with Materials to get an extra cart up to my floor, just in case. Let’s hope the universe got it all out of its system last night and things will go smooth.
I’ve been at work all last week, so I haven’t had much of a chance to post.
Here’s the denouement to “Let’s Play A Game…“
According to the labs drawn at the beginning of the code, her potassium was 7.7mEq/L. Yes, a lady with hypokalemia, had a K of 7.7. I came to understand her renal function was (is) incredibly screwed up and since they had been fighting hypokalemia, she got a large dose of KCl before bed. Hence the PEA episode and subsequent transfer to the Unit.
Here’s the cool part: by the end of my shift she was awake and following commands. Two days after the code (my back still hurting) she came back to the floor with zero(!!!) neuro deficits. She complained her head, neck, chest and back hurt, but other than that, fine. She walked out (well, was wheeled out) 2 days later.
Now she’s coming back twice a week to get puffed (pure ultrafiltration dialysis) for both fluid and from what I heard, for even worsening renal function. And she’s doing well.
You’re helping turn your patient in bed as a nurses runs past going, “Where’s Mitch, I can’t find him. 87’s in trouble.” It settles in for a second…”Oh shit! I’m covering for Mitch!” You then run for 87.
The patient is face down on the ground, legs splayed under the bed, maintaining an airway, but only briefly. So, now what? With the RT maintaining C-spine, we turn her over and start help her with her airway. By this time, the room is beginning to fill up. Someone asks, “Anyone have a history?”
“Ummm, she’s not mine, but I know her,” I say, “30 year old, history of part-partum cardiomypathy, s/p ICD and pacer implant. Issues with hypokalemia and fluid retention. We found her face down.”
“You guys have a pulse? We have a rhythm…” a resident asks. I feel around the area where a femoral pulse should be…nada, nothing. I’m digging into the layers of subcutaneous fat and feel nothing. “No pulse! Starting CPR.”
So what do we have? PEA. Pulseless Electrical Activity. A tele nurse’s worst nemesis. The monitor looks good, but no perfusion. The AICD isn’t firing beacause it sees a rhythm. The pacer is just going along all happy, but the heart ain’t working. So, we all remember the famous H’s and T’s from ACLS, right?
Warning: Educational Content
Hypovolemia
Hypoxia
Hydrogen Ion (acidosis)
Hyperkalmia
Hypothermia
Toxins
Tamponade (cardiac)
Tension (pneumo)
Thrombosis (coronary or pulmonary)
I couldn’t remember these for the life of me, so I found a couple others, just to keep the mind fresh.
ITCH PAD
Infarct, Tension/Tamponade, Hypovolemia/hypothermia/hypo-hyperkalemia/hypoxemia/hypomagnesia, PE, Acidosis, Drugs.
PATCH MED
PE, Acidosis, Tension pneumo, Cardiac Tamponade, Hypovolemia/hypothermia/hypo-hyperkalemia/hypoxemia/hypomagnesia, MI, Electrolyte imbalance, Drugs
So there we are, performing CPR on the floor. She gets tubed. Draw labs, slaine running wide open. We get a pulse back. Then we lose it, start CPR. Give Epi, get it back. Hang dopamine. Monitor shows wide-complex beats with pacer spikes. Get a backboard under her. Lose the pulse again, re-start CPR. Get her to the Unit and they start working her. Levophed, dopamine cranked up, vasopressin, D50 w/10units of regular insulin – just in case, bicarb, as I leave the docs are there starting an arterial line in her femoral.
So what happened?
Brief synopsis:
Dilated cardiomyopathy, renal insuffciency, fluid overload, chronic hypokalemia secondary to diuretics (today was 2.2, got 60mEq of KCL x2 and doses of Lasix and Zaroxlyn), urine output over day was low, found down after complaining to nurse about shortness of breath. Has implanted AICD/Pacer.
I’ll post the end result in a day or two after I finish my stretch of days on. Or if people are begging…
No. Not that kind. But a happy ending to a code. It’s rare. I’ve seen it now only twice (and a third may be underway, but that’s for another post). Most of the Codes we have on the floor do not end well. It either ends in the patient being pronounced on the floor, or later on that night, or sometimes week in the Unit. Our Rapid Responses seem to have better outcomes, but then again, folks usually aren’t dead when we call a RRT.
The other night was going along as planned. Assessments and vitals, med and insulin being handed out like candy when I walk out into the station from the med room. You could tell something was afoot, there was just a buzz, almost an anticipatory buzz that something might happen. Hoping not, but sometimes you just know something bad was coming. We knew one of our co-workers had a patient who was starting to decompensate, badly, but was still stable. I had run into her in the med room about an hour back and learned what was up, but she was holding her own. John, as I’ll call him, had been admitted for pulmonary edema, spent a night in the Unit and come up to us in the afternoon. He was going for an angio the next day, but was becoming increasingly short of breath, and his BP was way up, like 190’s over 100’s. So I decide to go check on her. Sometimes just having someone pop their head in to check on you when you’re in a situation can be stressful (see the landing scene in Airplane), but in others, it’s comforting to know you’re not alone.
I get in the room and look over at John. He does not look good. He’s sitting up at the side of the bed, in a semi-tripod sort of position, non-rebreather mask on, and working pretty hard. I glance down at the portable pulse oximeter on the bed beside him; it reads 78%. On 15L NRB. Not good. Angie, the nurse looks at me, “Let’s get him back into bed, see if we can get him breathing better.”
We move him back, but as we’re getting him settled, he lolls his head back. “Shit!” I think. “I’m going for the cart, you might want to call an RRT” I say as I dash out the room. Luckily, John’s doc is still at the station, as I blow past him, “You really need to go see John, he’s crashing quick!”
Down the hall as I hear the clarion call of the overhead calling out for an RRT. I look at the other nurse’s station and make eye contact with my charge nurse and say, “You might want to join us, we’re having a little fun down here!” Totally calm, totally collected. Her jaw drops, but I’m already down the hallway with the cart. Twenty feet down I hear a Code being called overhead and see the unit secretary gesturing violently to “get my ass down here, now!”
The other staff are pulling furniture and family out of the room as I run the cart inside. The doc is at the bedside as we hook John up to the monitor. We’ve got a pulse, but his beating is getting worse, more wet, more ragged and he’s working very, very hard. By now the room is filling up with people; RT, ICU nurses, our charge, dietary, other nurses, housekeeping and a couple of residents. Break the cart open to grab airway supplies. The doc calls for a Mac 3, which I hand over to him. Funny thing, I only worked in the ER as a student for 3 weeks, but knew exactly what to hand him and even checked to see if the light was working, almost by reflex, weird.
He tries to intubate, but no joy, tube’s in the stomach. He calls out, “Can I get some roc (rocuronium, a paralytic)?” Someone else pipes up, “Don’t you want some sedation first?” John is bucking now, he was fighting the tube on the first pass and now his pressure is through the roof, 220’s over 120’s, but with a strong pulse and good rhythm, his body is just in survival mode. Dude was a rock. The rest of the room was pretty much chaos. Pharmacy didn’t have Versed with them, so it had to be raided out of Pyxis. The portable suction machine was about to die. RT is trying to maintain a patent airway and bag John. Calamity. Then anesthesia steps up ad takes over. Like a captain of a foundering ship, he takes control. It was intense to see. Totally cool, calm and collected, he starts giving orders.
He asks for vitals. The ICU nurses can’t seem to figure out how to cycle the automatic BP cuff and are getting increasingly flustered. I can’t do it, I’m guarding the only site of access available at the moment. I look over and my buddy Ken is next to me, contorted taking a manual blood pressure. He’s tucked under my arm, craning his neck to see the dial on the wall behind anesthesia, and in spite of everything, gets it. We push nitro and labetalol to bring down his pressures, then Versed to knock him out and now, some rocuronium to paralyze him. I’m juggling syringes and flushes, wishing I had an extra hand, but somehow keeping them straight.
Now sedated and paralyzed, he gets intubated. But when the stylus is pulled out, a stream of pink frothy liquid comes shooting out of the ET tube. Massive flash pulmonary edema. The look on anesthesia’s face is priceless: a mix of awe, wonder and sheer terror, as he had been in the line of fire seconds before. More meds, start running a nitro drip and we get John packaged for transport. RT is bagging John sporting the oh-so fashionable face mask provided to them to protect from flying froth. And off to the ICU we go.
We get John settled into his new bed in the ICU and one of the ICU nurses, who had previously been, well, freaking out, looked over and said, “You guys did a great job up there.”
“Thanks,” I said as I grabbed the bed and our transport monitor along with the other little bits we needed to return and headed back upstairs. Waiting for the elevator I feel the adrenaline slowly staring to fade and the post-rush shakes starting. When I get back upstairs, anesthesia is still there writing his note, looks up and says, “You guys did a great job in there.” Wow, twice in five minutes, I guess our floor does have it together. Talking about it later with Ken, he says, “Y’know, we (our floor’s nurses) were the only cool heads in that room. You totally calm, it was awesome.”
Fast forward a week.
I figured John had been in pretty bad shape. I wasn’t expecting to see him sitting in bed as I walked into one of my rooms to introduce myself as his nurse for the night thought. I said, “You look a heck of a lot better than the last time I saw you!”
“I’m sure” he replied, “But I really don’t remember all that much about it. Just glad I came out of it OK.”
Well they had done the angio and found he had severe triple vessel disease only correctable through bypass and was schedule for surgery in the morning. I made sure I spent a little extra time with him that night, just making sure he was comfortable and ready to roll. He was up bright and early to get prepped for surgery, and for once I didn’t forget to do anything off the checklists. I wished him luck as he slid over to the gurney on his way to the OR and said, “I’ll see you when you get back up here.”
And you know what? He sailed through surgery and recovery like a champ. Last I saw him, the day before discharge, he was up, walking around, weak, but doing well. He ended up going home the very next day. Like I said, a happy ending.
I know that it sounds like the classic FDGB (Fall Down Go Boom!) syndrome, bu in my eyes, it’s something different. I’m talking about DNR status. Lately some of docs, most notably residents, have been writing rather bizarre and oft-times confusing DNR orders. Our DNR sheet has four sections. First, is “Full Code,” simple, classic and easy. Second, is “Do Not Resuscitate, no interventions, comfort care only, let them pass in peace. Third is “DNR with Limited Interventions” meaning no extreme measures, no transfers, but not just leave them be. Finally there is my favorite, “DNR with Advanced Interventions.” A fine catch-all that allows the docs and patients to fine-tune exactly how much we can do. And does it every get creative from there. Here’s a fine selection:
“Defibrillation OK, No intubation, vasopressors and antiarryhmatics OK, CPR for 2 minutes.”
You had better choose your drugs quick ’cause you only have 2 minutes to get them into circulation. Hmmm…what’s that? ACLS guidelines? Right, we don’t even give drugs until at least a round of CPR has been done . So we burned up our CPR and really who is paying attention to time in a code? We’d going hell-bent for leather and someone will pop up and say, “Oh, minutes are up.” It wold be like when you’re walking someon with nasal cannula on and they run out of tether, you get that jerk back, where their head snaps back and they’re pulled up short like a fish on a hook.
“No defibrillation, no intubation, no CPR, vasopressors and antiarrythmatics OK.”
Hence why I call it a gravity code. Push the drugs in, give it a good 20ml saline flush and hold that extremity up in the air and let gravity get the drugs into circulation. Seems like it would work fine. Maybe do a little massage to puch it down the vein back towards the heart while you’re at it. Kind of like external counter-pulsation…technically it’s not CPR. I mean who cares that we have to overcome capillary pressure, much less bridge the gap from that antecubital IV site to the heart and then into circulation.
“CPR OK, no drugs no defibrillation, no intubation.”
Right, so we have nothing to shock the heart back to an organized rhythm. Studies (which I’m not going to go Google now) have shown that electricity is the best treatment after good CPR in event of a cardiac arrest. The American Heart Association considers this top-tier evidence based practice, and adjusted the algorithms for VT and VF to include a shock quickly after start of he event. Sure, we can perfuse the body with CPR, but if the heart is acting all crazy and not maintaining an adequate perfusing rhythm, all that CPR will do for naught when you stop. Maybe in cases like this we should all line up and yell, “BOO!” at the heart in order to shock it back to rhythm. I can hear it now:
Team Leader: OK, let’s have a rhythm check. Still Vfib? OK, I want a verbal shock…who’s turn is it?”
It would be like the scene in Airplane where we’re all be lined up yelling at the chest, “Get ahold of youself…”
Again, doesn’t seem all that effective.
Finally, my favorite. Wait for it…
“Ask patient.”
Yes. You read that right. Ask. The. Patient. In the middle of a code. When technically they’re dead. I’m sure that’s going to work very well.
“Umm…excuse me sir. Even though you’re unresponsive, have no pulse and are not breathing, per your DNR orders do you want us to code you?”
Let’s just say the resident and the attending had a long discussion about the appropriateness of their orders.
I know that it stems from the worry that by being a DNR it means we won’t treat the problem. DNR does not mean Do Not Treat. Infact, we will do what we can to avoid a code situation. It also stems from the belief in American society that death is not a natural extension of life, but something to be avoided. And by declaring you’re a full code it means that you (or your family that it wracked by feelings of guilt for their mistreatment of you) are not going to give in the Reaper. Even it that means spending your last days intubated, on multiple pressors, being fed through a tube, in pain from cracked ribs earned in the massive code, in renal failure on CVVH and never regaining consciousness to talk and explain your wishes to your family. It’s the lack of understanding that death is as much of a a part of life as birth is. But with the prevailing dream of living forever coupled to classic American arrogance has led to a multitude of ridiculous and untenable wishes. We don’t want to die because we cannot accept that we can’t be fixed. We don’t want to leave our families. But in this denial of death, we leave our families in a lurch, left adrift and controlled by their own emotions on how to proceed. Unless you put your wishes in writing, we will do everything we can.
I leave with a contrast.
Case A, younger, but with end-stage CHF due to a life of hard living. Coded for 40+ minutes, multiple attempts at intubation, central line placed, labs, 2 shocks, 30+ minutes of CPR, 3/4 of all the drugs in the code cart and never maintained a pulse and never woke up. Traumatic, intense and in the end still despite our best efforts died.
Case B, end-stage COPD, DNR on supportive and comfort measures, i.e. morphine, oxygen, eating what they wanted, found on early rounds dead. They had passed peacefully in the night, quietly, without trauma, calmly but the end result was the same. We knew whe was going, it was just a matter of time. Family had accepted it, they accepted it and we as staff accepted it.
Which on was better? I know where I stand.
If you listen closely you can hear several things…
You hear the charge nurse watching the monitor at the tele station go, “Oh shit!” Jump up, grab the code cart and go hauling ass down the hall. Then the nurse at the station right next to him calling the operator and the overhead announcing “Code 99 to XXX.” Next you hear the page go live and pagers going off and nurses running down the hall with the COde Team hot on their heels.
He was down on the floor, half in, half out of the bathroom, all 300+lbs. of him. No time to move so they worked him on the floor, half in, half out of the bathroom. One nurse was standing on the toilet with their butt in the face of the one in the shower. The floor was covered in the miasma of body fluids and blood as the guy came to a little and started tearing out IVs. They shocked him once and got a rhythm back and like a bat out of hell, off to the unit. If memory serves, guy came back up to our floor about a week later, in pretty good shape all things considered.
Looking at the strip several things strike me. One is that this the last time I ever want to see a R-on-T phenomenon live and in person. Second, dude was damn lucky he was in the hospital, on a monitored unit with ACLS-certified nurses caring for him and a Code Team 30 seconds away. If he had been out in the regular world, things might not have turned up so rosy. I guess this could have been a case of Sudden Cardiac Death, but he was lucky. Third is that how quickly life can turn on you. One moment you’re getting up to take a leak in the middle of the night and the next you’re on the floor after having died for a couple of seconds. Kind of brings things into perspective. Finally, that tele tech who the charge nurse was covering for while they were away at the bathroom? Yeah, they don’t get a bathroom break ever again. This was not the first time. No, this was the third or fourth time that they stepped away and something unfortunate goes down. It’s just bad luck.
I wish I had saved my other favorite strip from a while ago. It was sinus with an 7 second pause. All you saw were these little P-waves, but you could call it asystole. Like above, they were dead, if only for about 7 seconds (isn’t that the length of a champion bull ride?).
