It’s Never This Clean

CPR
Image via Wikipedia

A code last week reminded me that the biggest problem with classroom ACLS is that it is too clean, too managed, too un-chaotic.  Here’s a couple of recommendations to the AHA for inclusion in the next set of guidelines for ACLS curricula.

1.  More people, smaller rooms.  Codes almost never happen in big rooms, so you end up with 20-30 people cramming into a 10×10 (or smaller).  I swear besides the code team, everyone else tends to show up.  Housekeeping, dietary, looky-loo nursing staff with nothing better to do, extra docs not involved in the case, maybe a couple of pharmacists and an administrator.  To best simulate that feeling of claustrophobia and having to work under such conditions, the schools hosting the classes should hire extras to crowd around you so there is barely enough room to work.

2.  Auditory competition.  It’s usually a cacophony of noise as people are barking orders, shouting back values, yelling at each other and general noise in a code.  ACLS mock codes are just too quiet, like a quaint afternoon tea in the country.  They’re full of thoughtful contemplation, “Hmmm…we gave Epi, CPR is in progress, let’s see what the next step should be.”  Where usually it is, “What!!!  Did you give EPi yet?!!!” and “GET ON THE CHEST!!!!”  To solve this, using the extras mentioned above, have them loudly carry-on conversations to provide a sort of white noise effect and teach students to think with 10 different voices giving you information all at once.

3. Smell-o-vision.  Think it through.

CPR training

Image via Wikipedia

4.  Realistic dummies that either poop, pee or vomit during the code.  Ever done CPR while trying to keep your scrubs out of vomit?  Yeah, it’s difficult, the hands slip off of their position as the gloves slide over the vomit on the chest so it’s kind of like hitting a moving target.  Also, the training should incorporate  identification of emesis into the H’s & T’s differential diagnosis.  Maybe call it T-H-Es?  We’re trying to look for a causative reason, ID’ing dinner might be a good start, it’s usually easily viewed.  One of the extras could smear chocolate pudding on the dummy with each rhythm check to add that extra layer of realism.  To make it better, the manufactures of the dummies could add an optional module that uses the force of the compressions and triggered by breaths to spew liquid material out of the dummy’s mouth.

5.  Re-organize the algorithms by using a drunken dart toss for each step, say every 2 minutes.  Many times the actions are just so random it is like that.  This way by using the toss method, random changes to the procedure would be accounted for and awaited thus allowing practioners to think ahead.  Besides, wouldn’t playing darts in ACLS be awesome?

Finally,

6.  Teach clean-up as part of post-recusitation care.  We’ve all seen rooms after a code.  Wrappers everywhere, boxes from meds strewn about, random pieces of detrisius tossed to the side of the bed, pieces for the intubation tray lodged in the computer keyboard, sharps hiding under piles of plastic and the puddles of body fluid.  What should be taught is that everyone goes on break, leaving one person to clean up the mess.  That job should be assigned with as much if not more importance than the compressors to ensure the rest of the team gets to take a break post-code.

If the AHA would consider incorporating these elements into ACLS training, it would make the providers so much more capable in handling the realities of the true in-hospital codes.  Just sayin’.

 

editors note:  your results may vary, data is compiled from triple-blinded, beer-goggled, non-placebo, peer un-reviewed observation of events on medical/telemetry/geri-psych nursing floors over a 5 year period of time.

10 Long Seconds

You’re talking to the patient, carrying on a normal conversation whilst finishing some mundane task.  Abruptly in the middle of a sentence they stop talking to you.  You turn in time to see their eyes roll back in their head and them slump lifeless back into the bed.  What goes through your mind?

First, denial:  “Maybe they’re just messing with me.”

Sternal rub and nothing.

Second, more denial:   “Oh Hell no, they better not be playing with me now.  Wake the Hell up!”

Third, even more denial:  “That was a  twitch…ahhhh shiiiiit.”

Slam the head of the bed down, take one more attempt at noxious stimuli.  Nothing, nada, zip.

Finally, acceptance:  “Someone call a Code!!!!!”

All in less than 10 seconds, probably only 5.  The longest 10 seconds of the night.

Rapid Response Teams: Excuse or Tool?

I know this has been discussed ad nauseam already, but I had to weigh in.

Thanks to an article out on Medpage Today, Rapid Response Teams Sign of Poor Bed Management, the whole idea of Rapid Response Teams has been brought into the spotlight.  The article’s premise is that poor bed management is the cause for Rapid Responses to be called.  Bullshit. 

Code Blog sums it up nicely by saying,

I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care.  I think they are called because stable patients just stop being stable sometimes.

Are there times where over-crowding and poor bed management are the cause?  Yeah, if it is crazy busy, the nurse might miss subtle signs or the patient is sent to a floor of lesser acuity, but these are the exception rather than the rule.  I can count on my hand the number of times I’ve called an RRT, of course now I’ve now jinxed myself, but each time it was from a rapid change in patient condition.  There have been times where I could have called an RRT, but managed it with judicious use of critical thinking and calls to the doc.  I think that some nurses use them as a crutch instead of critically thinking a situation through, but not because a patient was wrongly placed.  Like I noted above, there are times when the patient is placed wrong.  When our observation unit opened we had several times where they went from Obs to the Unit in a very short amount of time.  But again, these we patients who rapidly de-compensated – and a couple that never should have gone there, but those are the exception.

Have the authors forgotten that a hospital is an acute setting?  It’s not like these folks are healthy!  And thanks to the rise of observation (outpatient in the hospital) those who are admitted in-patient are the sick of the sick.  Having a resource to get help quickly is a godsend.  Sometimes all you need is some stat meds, or imaging and labs , or just someone to look and say, “Yeah, they’re sick!”  And sometimes you just need to have the ability to transfer to a higher level of care without jumping through hoops.

Even if we have the best patient flow possible, appropriate bed placement each and every time and proper resource management, there still would be a need to the Team.  Patients crump.  The article never addresses that simple fact.  It’s far easier to point out structural issues than the reality – of course structural issues are somewhat easier to fix.  Schedule better to make better use of the nurses you’re already overworking.  Staffing plays an important role in this as well.  A nurse that is stretched too thin can’t take the needed time to adequately assess their patients.  When you 5, 6, 7 or more patients at a time, you’re running and even the most perceptive, mind-reading nurse can catch a patient decline if they’re stuck cleaning and doing a massive dressing change because the wound is saturated in stool of a 400lb quad with the 3 other nurses on the floor because it takes at least 4 to move the patient safely.  That’s when the easy things to fix fall through the cracks, hence why we need a team to “rescue” the nurses.

It’s a complex multi-layered issue to which there are no simple and easy answers.  It impacts staffing, scheduling, patient flow and the vagaries of the human condition.  But would I choose to work somewhere without the back up of a RRT?  Not easily.

The Shakes

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By the time I got home the adrenaline was finally starting to wear off, the shakes trailing off.  I don’t really remember the drive, it was an automatic drive home.  I was aware, but detached as the images of what happened to my patient just minutes earlier kept running through my head.  Those images were accompanied by the snippets of conversation, the shock and fear, the cool, clammy sweat sticky back of my t-shirt as it clung to my back.  Numb, but not comfortably.

How quickly things can change with our patients.  One moment you’re waking up not feeling well, but OK, waiting for surgery, the next you’re vomiting up copious amount of blood and huge chunks of clots.  How strange it must be to not understand what happened because you went totally unresponsive right before you vomited.  Did you hear your nurse yell out in fear “Can I get some help in here?!  Someone call a Code!!!”

How odd it must be to open your eyes and see 15 people swarming your bed, frantic in their energy asking questions, asking you how you’re doing, sucking something out of your mouth.  Do you feel it when you vagal out, go asystolic, vomit more blood and have someone start pumping on your chest?  And when you ask, “Did I throw up?”  the the nurses tells you that you did, but all you can worry about is that you might have lost control of your bowels.  What goes through your mind when the nurse who has taken care of you for the last 2 nights is asking you to “Stay with me!”  Do you know when your blood pressure is 60 palp?  That you’re pale, diaphoretic and ashen?

Does riding in a bed moving like the furies are after it down the hall cause motion sickness?  I’m guessing that the worried looks, the terse simple descriptive language the nurses and docs are using, the speech of people under pressure must worry you.  Does your mind rebel at the unfairness of it all?  Did realizing you had stomach cancer make you mad?  You were a healthy guy.  Sure you drank, but you sobered up years ago.  Yeah, you smoked, but otherwise, healthy.  No chronic medical conditions, just some elevated lipids.  In fact your doc at your last yearly check-up said you were about the healthiest 80 year old he had seen in a long time.  Or is the only thing you’re thinking about is your wife of 50 some odd years and whether you’re going to see her again?

I know that when you got to the ICU you vomited more blood and clot chunks.  You looked incredibly pale, blood pressure barely registering.  There was blood all over the floor, all over you, all over the bed.  I wish you could see the cluster of docs outside your road, the 7 nurses around your bed, the cluster of medical knowledge all focused on saving you.  I wish I could tell you that it was going to be OK, that we’re going to take care of this, but deep down I know I can’t.  You’ve lost a lot of blood, it’s got to be close to 3 liters, blood and huge gelatinous chunks of clot, like something tore loose inside of you.  But you were in the best place and I was in the way.

It was the fastest 30 minutes I can remember in a long time.  The adrenaline was still surging as we brought the bed back upstairs but as I began talking to my colleagues the shakes started.  I knew they would, was waiting for them.  The shakes, the weakness in the knees, the self-doubt came crashing down, barely held back by an iron will.  It’s odd how I can remember bits and pieces, little flurries, but not a seamless narrative of the whole thing.  Maybe it’s a protective thing.  I remember the looks on my co-workers faces, the awe, the respect, the one who said, “I want you in my code, you were so in control.”  If they only knew.

If they knew that I spent the drive home going over every little bit of the previous 12 hours.  Could I have done anything differently?  Should I have checked your vitals at 4am instead of letting you sleep?  You had been rock-solid stable all day, all night, no sign that anything was amiss.  I know rationally that this was a quick thing, bright red blood spewing out is a rapid thing.  The clots?  Well the EGD pics were beyond nasty, huge masses of clot on the wall of the stomach.  It is like something broke open.  Still I wonder if there had been a sign early, if there was something I missed, or if it just came down to when you went unresponsive and started to vomit up blood.  You should know though, that I went home, and even though I’m not a religious guy, said a prayer for you, knowing you needed all the help you could get.

I just looked down at my hands, the shakes are gone.  Finally.

Disappearing Nurse

I looked up from my charting that night as an incessant stream of words kept drawing my attention.

“Mrs. Smith?  Mrs. Smith?  Can you hear me?  C’mon open your eyes for me!”  incessant pleading, repeating quicker, voice rising in timber and urgency.

I look over at tele, nothing ringing, nothing out of the ordinary.  As I walk across the nurses station I see two colleagues at the bedside of one of our new admissions.  Like a tag team they’re trying to get Mrs. Smith to respond.  And it isn’t working.  She is just laying there, limp, barely moving any breath into the shriveled shrunken chest.  I start to get that sinking feeling in the pit of my stomach.  Something is definitely not right.

“Hey, what’s going on?”  I ask walking into the room.  Looking around I see a manual BP cuff, fluids up and going, oxygen on, but no purposeful signs of life.

“She’s not responding to us.”  says Not-so-New-Nurse (NsNN).  She’s good, a little lacking in confidence in herself, but usually when she asks a question these days she already knows the answer, but is not yet confident to believe she has the correct answer.

“Merly was trying to get some vitals but the Dynamap isn’t reading so I came over from my patient in bed 2 to help her out.”  she continued.  “Now she’s not responding to us.”

I look around, Merly is nowhere to be found.  Not surprising.  It always seems that when her patients are going bad she finds reasons to step out.  It’s “Oh I need this”, or “I went to call RT.”  She’s been at this a long time and is a very competent nurse, she always seems to disappear at the worst times.

Outside the room another charge nurse and the house supervisor have come over.  “Do you need anything?  Want us to call the RRT?” they ask, worried looks directed my way.  They both know my reputation as a black-cloud.

“Not quite yet, let’s see what’s going on.”  I say.

I step up to the side of the bed, grab a frail limp wrist feeling for a pulse.  It’s there, thready weak, fluttering away under my fingertips.  “Mrs. Smith…”  I say squeezing on her nailbeds.  Normally I would be rubbing my knuckles along her sternum, but as I look I can count the ribs, I might snap them if I rub too hard.  Mrs. Smith is a dictionary definition of cachectic, eyes sunken, skin a wan yellow almost waxy pallor, thin stringy hair, the look of someone who has not eaten much, if not anything in a long time.  She had come in right before shift change with a diagnosis of hypokalemia and failure to thrive, or otherwise malnutrition.

As I’m thinking this through I’m inflating the manual cuff, fingers still on the radial artery.  I watch as the dial creeps lower, lower, still not feeling the tell-tale pulse, then faintly it comes.  64 palp.  Not a good thing.  As I’m feeling I’m watching her chest rise and fall.  Shallow halting breaths.

“I think it’s time, call an RRT will ya!”  I holler out the door.

Merly’s back, dragging the Code Cart.  “Tell me what’s been happening,” I say as the overhead page goes out, “Rapid Response 5NW.”

“I don’t know.  I checked her at midnight and came back to check on her fluids and she wasn’t responding to me.”  Merly says as the code team starts to fill the room.  Furniture is disappearing out of the room as we make room for the extra bodies.

Fave ICU charge nurse is first in, “Hey Wanderer”  she says.  We’ve been through this before more times than I would like to count.  I look around, Merly has disappeared once again.  “Uh, 78 year old female, found unresponsive, BP 64 palp, pulse weak and thready, resps shallow…”

“Uh Wanderer, she’s agonal…”  Fave ICU nurse says, “Call a Code!” she hollers out the room.

I look over, Mrs. Smith is surely agonal breathing.  Erratic, shallow breaths separated by pauses that are far too long.  I kick the brakes off and pull the bed away from the wall.  Someone tosses me a BVM, I pull it out and crank the O2 up.  I’m looking for RT as they are just slightly territorial, but no one’s here yet.  Head tilt, good seal on the BVM while I start to bag,  hearing the code page go out in the background.  Now people are streaming in.  It seems that with RRTs they don’t go balls out, they move fast, but not like when you call a code.  RT arrives and offers to take over the airway which I gladly let them.  I’ve seen RTs fight each other over managing an airway and I know they would just run me over so I leave it to them.

The ICU residents have arrived and not surprisingly, Merly is gone.

Once again no one steps up to talk, NsNN stands silently in the corner, fixing up IV fluids so I jump in.  “Uh, yeah, 78 year old female, admitted toady with hypokalemia, failure-to-thrive, we found her unresponsive with a BP of 64 palp.  She then began agonal breathing and we called a code.”

Mrs. Smith is just laying there, not even fighting the bagging.  We get her on the code cart’s Lifepack, and the monitor comes up showing sinus tach in the 130s.

“Let’s get some labs, draw a rainbow.  Anyone know what her K was on admit?”  the resident starts giving orders.  We’re lucky tonight, Dr. And actually wants to go into critical care and has her act together.  “You guys think we need to tube her?” she asks the RTs bagging her.

“Yeah, she’s not even fighting us nor helping a bit.” one of them says.

“How about some fluids?” says the resident.

“NS up and wide open.”  says NsNN.

“Y’all need to leave her alone!”  I hear from the other side of the curtain.  Then I realize that her neighbor has been adding her own commentary to the proceedings.  “Hey NsNN, can you talk your patient down a bit?”  I ask knowing that we’re only starting to rile up her demented roommate.  The comments she has been making would be funny in any other situation, but not tonight.

“Do you guys want to tube her or should I?”  asks Fave ED doc as he enters the room.  “Go for it.” says Dr. And.  Fave ED Doc grabs some gloves, tosses his stethoscope in the corner and starts talking to a freaked out looking guy in  a short white coat that came with him.  “Normally I would let you try, but not right now.  I’ll show what we’re going to do though.”  A visible wave of relief spreads across the poor guy’s face.  Tubing someone is one thing, tubing some one in front of an audience of hundreds is another.

“Uh,”  he says looking down, feeling the throat and jaw, “How about a #3 Mac and a 6.5 tube.  Do we have drugs?”

“Yeah, here!”  pipes up the pharmacist standing by the door, just on the edge of the chaos.

“OK, she’s what 50 kilos?”

“40, soaking wet.”  I say.

“Right, let’s do 15 of etomidae and 40 of succs.  Suction ready?”

I’m standing at the IV site, guarding it like it was the last beer in my cooler against a thirsty horde.  The pharmacist hands me the bottles of meds and a couple of syringes.

“15 of etomidate, 40 of succs, right?”  I ask, just to make sure.  “Yeah.” comes the distracted reply.  He’s face down with the scope looking into Mrs. Smith’s mouth.  I glance over at Fave ICU Nurse and quietly ask, “Etomidate first, then succs, right?”  I ask, then add, “It’s been awhile.” to qualify my question.  She nods.

“Alright, every body ready?”  Fave ED Doc asks.  “Let’s do this.”

I push the first,  “15 of etomidate in…” flush it wait a breath and push the next, “40 of succs in.”

A brief moment of action and then “Got it…someone want to listen?”

Fave ICU nurse and I, plus about 3 others start putting scopes on.  “Equal bilaterally.” is consensus.

“Let’s get her packaged and downstairs to the Unit.”  says Fave ICU nurse, “I’m going down to let them now we’re on the way.

Sometime during the preceding 5 minutes Merly showed back up, carrying a handful of supplies, fluids, tubes, IV miscellany.  But at least she’s here.   Since the start we’ve had about the same for blood pressure, in spite of the fluids .  Her roommate is still muttering at us, telling us what to do and adding her own running commentary and answering questions along the way for her obtunded roommate.

Transferring a critical patient to the ICU is a exercise in logistics.  We have an RT at the head of the bed breathing for her, trailing along is the residents, the IV pole, Merly and assorted other folks.  And naturally the elevator that comes first is the small one.  We fit.  Barely.

We pull into the pod where she’s headed.  This time I managed not to drive by feel getting the bed into the room.  Thankfully Merly is here with us.  One of the ICU nurses pulls her aside for report.  We get Mrs. Smith over to her new bed.  40 kilos was a guess, but it was pretty damn close, she’s so light.  I gather up the stuff that goes back with me upstairs and look over.  They’re about to  turn her onto her side to pull out the extra detritus under her and she pukes.  She’s on her side quicker than one would think possible.  “Suction!”  someone yells.  I get a glimpse of the vomit.  It’s brown.  It looks like poop.  Then the smell hits me.  It is poop.  Really not good.

Knowing there is nothing else I can do I crib a page from Merly and disappear myself.  NsNN and I are pushing the bed back upstairs, musing over what we just saw.  “Merly and I are going to have a talk I think.”  I say.  “This isn’t the first time we’ve RRt’d or Coded one of her patients are she isn’t around.

“You did good though,” I say to NsNN.  “It’s like I’ve been trying to tell you:  you know what to do, you know the answer, but you just have to believe in yourself.”

“Thanks, I know, but it’s so easy when you’re around…”  she says back.

Back on the floor I start relating what transpired on the way there.  “That was fun wasn’t it?”  I asked sarcastically.  Then we all went back to what we were doing before.  Because that’s how it is.  We fix them enough for them to be someone else’s problem then go back to what we had been doing.  It’s hard.  You go over it in your mind, wondering what did we miss early on, did we do everything right, are they OK?  And even though it wasn’t my patient I muse if it had been.  She was where she needed to be.

I found out a week later when I came back to work that they took Mrs. Smith to emergent surgery the night we shipped her down.  On opening her they found a belly full of poop and a perforated bowel.  Evidently Mrs. Smith had undergone a gastric bypass-type surgery in the 70’s and they think her anastomosis had finally failed.  With a belly full of poop she went into severe septic shock and came out of surgery maxed out on pressors while they searched for any family.  Mrs. Smith had lived alone, we didn’t even know if she had family.  Through some digging and a little bit of luck they were able to find some.  She held on long enough for them to say it was OK to let her go.  And then she was gone.

Keepin’ the Beat

It looks like I’ve broken my streak.  I actually had almost 3 months without a Rapid Response or Code Blue on my shift.  It’s no more.  At least we didn’t have to do CPR on this little 40kg bag of skin and bones, just some airway support and off to the ICU.

But it got me thinking.  Thinking led to rooting around in my “book o’ fame” (my morbid collection of EKG strips of “bad things”) which led to me finding a couple of strips related to CPR.  Strange how a mind works.

Evidently, per the post-it note, these had been grabbed during a code last year where I did a TON of CPR.  Remember kids, a bad thing about being a big strong dude is that you get to do a lot of chest compressions.  I’m not dissing the ladies, I’ve seen many a round done by y’all, and you’re fierce, but for some reason whenever there is a code on my floor, yours truly gets roped in to do compressions.  Needless to say I had no need to go to the gym after that code.

My tele tech knows my predilection for interesting tele strips so he printed a couple for me.

First, near the beginning of the code:

CPR is in progress with a rate around 100bpm, stop to check for a rhythm, find VT, resume CPR, then shock.  This is why you resume CPR right after the shock.  That heart ain’t doing nothing.

Second near the end:

We’re still going fairly strong, figure the rate is around 80bpm, then nothing.  We called it about a minute after this strip was run.

In all fairness, they were dead from the get go.  Never once did we get a rhythm stable enough for transport, never a pulse, pupils were fixed pretty much from the beginning.  Morbid?  Probably.

But on to the beat.  They say 100bpm is the speed we need to keep when doing CPR.  It allows for adequate refilling of the ventricles with blood before the next compression.  In the midst of the controlled chaos of a code, keeping that speed can be tough when adrenaline gets the better of us.  So what do you do?  Keep the beat with a song.

We’ve all heard of “Stayin’ Alive” by the Bee Gees as the “perfect” CPR song.  Heck, I have it on my header.  My BLS instructor the last time around had a thing for “She’ll Be Coming Around the Mountain”.  There is the slightly more darker “Another One Bites the Dust” by Queen that fills the 100bpm measure.  Thanks to the American Heart Association, there is a large list of songs that fit the bill of 100bpm.  Some notables include:  “Kickstart my Heart” by Motely Crue (they would know), “Paradise City” by Guns N’ Roses. “Heart Attack Man” by the Beastie Boys and of all things, “Back to Life” by Soul II Soul.  The entire list can be found at Be the Beat, which is a website dedicated to educating kids about CPR, but here’s the playlist.

Will this help me set a new streak?  I doubt it.  As the rule of three shows, I have 2 to go before a new streak can start…