code blog: tales of a nurse

I've been a charge nurse now for almost 5 months. It's been quite a learning experience in several ways. Until the other night, though, I had not been responsible for being "code leader" during a cardiac arrest.

Whoever's in charge on CCU has the responsibility of responding to any code blue's called in the hospital to be the "leader." They run the code by assessing the situation, deciding which meds to give and when, etc. until the ER doctor arrives to take over. I've participated in several codes, but not really ever as a "leader" - there has ALWAYS been someone more experienced than me around. Furthermore, when codes occur in CCU, I'm surrounded by nurses that know exactly what to do and we all sort of fall into our roles. There's almost no need for a leader - people just show up in the room, determine what's already being done, and start working on a task.

During a code blue, there needs to be a person doing each of these steps, and some can be done simultaneously: the patient's nurse gives a brief history to those responding to the code, hopefully someone has grabbed the crash cart by this point and is working on hooking the patient up to it, IV access needs to be established - if all the IV lines are being taken up by medications, it needs to be decided which medication gets stopped to give code drugs. There are people who continuously assess the heart rhythm, give drugs, defibrillate if necessary, do compressions, ambu-bag the patient, intubate, assist with intubation, hook up suction, call the primary MD and fill them in, draw labs, and write down what's going on - minute-by-minute documentation of the patient's status, blood pressure, medications given, etc.

Over these last 5 months, I have sort of lived in fear of hearing a code blue called overhead while I was in charge. If I did, that would mean that someone was coding on another floor, where I didn't know the nurses. It could be on a floor where patients were already being monitored continuously, and that would be best - the RN's working on that floor would be very familiar with typical code heart rhythms and their treatments. But it could also be on a floor where patients are NOT monitored - and those nurses would not be as familiar with them. I was more concerned about the latter.

The other night, I was in charge and checking on the 2nd CCU unit. Overhead, I heard "Flex nurse stat to surgical floor." Uh-oh. That's a warning. When a patient's going bad and looking like they're about to code, the floors usually page the flex nurse to help out. I'm thinking very strongly that I do NOT want to code someone on the surgical floor because that is not a monitored unit. My very strong thinking was not heeded however, and a code blue was called shortly after.

Fortunately I was only one floor away and when I got to the room, several things were already going on, so I just jumped in. I found that I was still surrounded by more experienced nurses, but my particular role was as "code leader" and I was supposed to be making decisions. Gulp. I'm used to having things just sort of happen though! I'm usually the one responding to orders, not giving them! What else to do but continue on and hope the ER doc got there super fast?

As luck would have it, the ER doc DID get there super-fast and immediately had to intubate the patient. This made him fairly unavailable in deciding which drugs to give, whether or not to defibrillate, etc. Even so, I thought things were going very well, but I had a nagging feeling in the back of my head that we were forgetting something. I did a mental checklist and realized that no one was giving drugs! So I grabbed an amp each of epinephrine and atropine, and had the nurse standing closest to the IV push them in.

Eureka! Our asystolic patient finally had some heartbeats here and there, and then an actual perfusing heart rhythm! Woo hoo! All of this transpired in less than 8 minutes. We transferred the patient to the CCU, where she remained on a ventilator, unresponsive.

The next day, I went to work fully expecting that she would still be on the vent, maybe still unresponsive. Although her arrest was caught very very early, chest compressions aren't as good as the real thing. I found her not only extubated, but sitting up! Brushing her hair!! Later in the evening, she put her call light on to be helped back to bed. I answered and told her that she looked much much better than the day before. She was a little surprised to learn that I had been at her code and said that she was feeling pretty good. She made a special point to tell me that besides chest soreness from CPR she was no worse for the wear for her ordeal, and there was certainly nothing wrong "up here" as she tapped her temple with her index finger.

I was completely blown away. Never have I seen a patient with cardiac/respiratory arrest make such a fast and apparently complete recovery, and never would I have expected one from an octogenarian. I cannot even begin to describe how ecstatically happy I was to see her practically put herself to bed when not 24 hours prior, she had been completely unresponsive without a breath or pulse. I used feel pretty hopeless about post-arrest patients - even if they came around, something was bound to be affected by the lack of circulation or oxygen.

Finally I've seen the outcome that we work so hard to achieve. Hallelujah!