Happy Ending?

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.

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2 Comments

  1. Nice save. It doesn’t often work like that but it sounds like you guys had your act together.

    Reply

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