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!
The nurse followed them into the room, pulled the curtains, and hooked the patient up to the monitor. Heart rate in the 40s. Blood pressure 120s systolic.
The tech was entering the patient’s information onto the computer when the nurse walked out of the room and told him “Hey. You got your wish. There’s a code.”
I looked up from the admission orders I was writing.
The tech got an excited look in his eye and says “Really?”
The nurse tossed him a washcloth and said “Yeah, really. Code Brown. Get wiping.”
via Be Careful What You Wish For | WhiteCoat’s Call Room.
Having been the cause (not literally) of 2 codes, first by saying the “q” word in a not-so busy ED one night, the second by saying, “We haven’t had a code in awhile have we?” I have learned my lesson. Pretty sure that the tech will have learned his!
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.
In booming announcer voice…
“Ladies and gentleman, boys and girls children of all ages…welcome to the Interwebs Arena for our main event of the Summer…”
“Fighting out of the Doctor’s Corner wearing the red trunks, the contender from a big hospital somewhere in America. With a record of 200,000 and 0, years and years of residency training, thousands of sidebar ads and an ego a mile wide, Happy “I’m a Medical Doctor and have my own way of running a code” Hospitalist! …”
“And out of the Nurse’s Corner, wearing the blue trunks, the challenger from a big ER somewhere else in America. With a record of a million saves, years of being at the front lines of American health care, a chip on her shoulder and Dr. Bloody Gloves in her corner, Nurse “The Snarkinator, can’t believe Happy runs a Code like this” K! …..”
crowd goes wild…
“Let’s get ready to ruuuuuuuumble…..!”
referee…
“OK you two, let’s have a clean fight. No low blows, no crayzee talk…oh whatever, just come out swinging.”
announcer
Happy and Nurse K are at it again. Sit back and enjoy the show.
Not going to say who’s right, who’s wrong (although Nurse K is right dude, either wake the patient up for fucks sake, hello, sternal rub ‘em! or pull the cord for the code team), but it sure is turning out to be a real smackdown. I mean between Happy’s smug aloofness and K’s snark attack, you’ve got a real read on your hands.
Happy’s Post: Michael Jackson May Have Died From Fibromyalgia
Nurse K’s Rebuttal: How to resuscitate a patient Happy-style
Happy’s Attempt to hide the fact he got pwned: Is It Reasonable to Stock Every Room With Emergency Resuscitation Supplies
Would you two just get a room or something…
Edit: K just posted up a rebuttal to Happy’s rebuttal (a double butt-al?) Face it bro, you’re getting pwned. Throw the towel.
I was looking at me stats to see that this last March was my best month ever with somewhere around 2300 visits. I know some get that in a day, or even hours, but this is just me doing what I love.
Another milestone of sorts, I re-upped my ACLS this week. And it is the same as it was last time. I just love some of the dead pan humor that pervades the classes. Like dosing atropine for example, the classic, “half when they’re half dead and full when they’re fully dead.” Besides that there is a feeling like it is almost pointless at times. Sure, if someone goes into a VF arrest in front of you and and you’re able to shock them quickly, there is a 90% chance the rhythm will convert, but besides that, the outcomes are dismal. And even that conversion may not guarantee survival. I’ve had one PEA code make it and that runs about the percentages. It makes you wonder if it is really worth it. Then you have one that makes it and somehow comes out of it fairly neurologically intact (or totally fine…) to go home to their family. And that makes it worth it.
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.
From msnbc.com: 1 in 2 believe prayer trumps doctor’s prognosis
I found it interesting that over 20% of health care professionals beleive so as well. Having been thru the hell of dealing with a medical tragedy I can say that I don’t. When I lost my daughter we prayed harder that we ever prayed before, but she still died. I don’t beleive in miracles anymore than I believe in the Easter bunny, which is to say, ain’t much.
This too ties into my whole theory of denying death that permeates our society. Are there “miraculous” turn-arounds? Could be. It could also be that the treatments are actually working. But I’m not one to judge. We so don’t want to die that in-spite of overwhelming evidence that the end is nigh, we press on. That’s why we have 90 year olds with ESRD, CHF, so demented they don’t know their own name and a host of other conditions that are full codes. If medicine can’t fix them, maybe prayer can. We put our loved one through the torture of a code and expect them to come out bright and shiny, happy that they are still alive. When you hit a certain age, that just isn’t going to realistically happen.
It reminds me though of a story I heard from a colleague it goes like this: the patient had passed away in the due process of their disease. It wasn’t a total surpirse, but it was quicker than expected. The whole family, all members of the same church piled into the room and began to pray. For 2 hours. And what did they tell the nurse? “We’re going to raise him from the dead by the power of prayer!”
It didn’t work.
Getting the snot beat out of me… I don’t know if the guy who gave me this as a prize was commenting on my masculinity (or lack thereof…) or that maybe, he instinctively knew I was a nurse and knew the true roots of “Girl Power!” My second thought was, “Is it that obvious I work with all women?” He must have been a psychic as well as a carnie.
The coolest thing though happened to me at work this morning. I always feel weird around those who I’ve performed CPR on – those that have survived. So imagine my surprise the other night when our Code from the Night of Many Codes came back to the floor. As committed team member I went in with another nurse to get a patient cleaned up for the day. It was a bit odd, as laying here was a patient who last time I had seen them was quite nearly dead, if not truly dead. That night his pressures had been dropping all night and just didn’t look good. Respiratory status diminishing, really working hard. I pop in to see if the the nurse needs anything and end up finding the blood pressure as 60 palp. Things progress to a full blown Code. Luckily, being a fresh post-op heart, the wires were still in place. But until we got them hooked up to the temporary pacer, we had to do CPR. On a fresh heart. At least we didn’t have to worry about breaking ribs. The strange thing was the supple compliance of the sternum being held together by surgical steel wires. CPR was downright easy on this patient.
Now imagine my surprise when they’re pretty much neurologically intact, granted they stayed a month in the Unit and their kidneys went to hell, but they’re alive and talking to us. As we go about the tasks of turning, moving, sliding, rearranging linens, getting a new sling positioned (did I mention they can’t help much with care..) He says, “Hey,watch out for my chest!” pointing at their sternum. “It still hurts, had a lot of trauma to it.”
The other nurse looked over at me and we both grinned and chuckled. He continued, “What’s so funny?”
“Nothing,” I say, “We know you’ve had some trauma there. And let me just say I’m sorry about that.”
I didn’t fill him in on the fact I had been pumping on his chest 3 weeks ago or anything like that. Just took the opportunity to say sorry!
Someone asked for an update on the six codes from the night into Friday the 13th. I don’t know a whole lot as most of them were not even on my floor, but here is what I do know.
They lost one, after and hour and a half of work. The others I do believe are still in the Unit. The guy we sent had been extubated by the time I came back the next time, but was still still on multiple pressors. I will say though that we have been incredibly busy, full many nights. The other night, excluding L&D, the only open bed in the house was the code bed.
At least we haven’t had a night like that since, and hopefully won’t for awhile.
Anyways, my Internet connection has been and is kind of spotty so if it seems like I disappear for days at a time, I’m OK. Plus, I have 6 days off, and the weather is going to be AWESOME! Who can argue with blue skies, a slight breeze and temps. in the 70-80’s?
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.
