How a code actually works in the hospital

A lot of people have this idealized version of how they believe a code, or CPR, is done. We largely have medical shows to blame for this. Although entertaining, they are incredibly inaccurate. For example – they practically violate HIPAA regulations at least once every episode.

During my shift last night, I was involved in a code for the first time in a while. It was not a perfectly, smoothly run code. It made me question my abilities and the abilities of those around me. I’ve been reflecting on it a lot since it happened, because I want to be the best nurse that I can be for my patients and colleagues.

It started after I helped another nurse give her patient a bed bath. I remember asking him, “Are you comfortable?,” as I always do before I leave a patient’s room and after I’ve finished repositioning them in bed. He shook his head vehemently, looking troubled. Then, his arterial line (a real-time blood pressure monitoring device) readings started decreasing, as did his heart rate. His nurse insisted these changes on the monitor “weren’t real,” and I listened to her and ignored my own instincts to pull out the crash cart, paddles, and stool (this is used to stand on for doing accurate, deep compressions) faster. I also ignored the warning bells going off in my own head because I believed her senior position made her opinion more valid than my own.

Another nurse came in when she heard the alarms going off that indicated low pressure. While original nurse was fiddling with the arterial line, second nurse began taking a manual blood pressure. The manual pressure matched the arterial line, so compressions were started while I brought out all the supplies. Bewildered and overwhelmed, I mostly watched the action going on around me from where I stood cornered in the room, behind carts and equipment. I wanted to jump in but I didn’t know how. A third nurse began recording the code process (i.e. how long compressions lasted and what medications were administered). This nurse intimidated me, so I became even more of a mousy observer than I already was, now placing my value in this situation as below three people. A team of doctors arrived, and other nurses and technicians came to assist with compressions. I observed and grabbed what was needed when it was shouted. I still felt mousy.

Finally the code ended and the patient resumed normal pressures. But that doesn’t make this a success story.

After the code, a debriefing huddle took place. The purpose of the huddle is to review with all parties involved in the event what went well, what could have gone better, and to gather a general consensus regarding the event. While the nurses and technicians were all gathered at one table, the doctors sat at another. The doctors stayed at the other table even after the nurse in charge of the debriefing huddle called for them to come join us. Finally everyone picked up their charts and documents and things to move over to the doctors. I muttered under my breath “why don’t the doctors just walk over here….” and some people laughed. I hadn’t even meant for anyone to hear, I was just so subconsciously bothered with the doctors, but after other nurses looked at me knowingly and were in agreement with my remark, I was glad I had been heard.

The huddle was quick and dry, checking or not checking items in simple rows. The last question, “what could have made this code better?” was answered jokingly by the patient’s original nurse with “well if the patient had been DNR-CCA…”. True, yes, this would be a more appropriate code status given this patient’s medical background, but the question was asked with the intent of being answered seriously. And after one joke was made, it opened up the opportunity for people to make additional jokes. The casualness of this bothered me deeply.

20 minutes later, the patient coded again.

Again, family members were called during the code to determine if they would like the code status changed from “full” to “DNR-CCA” (do not resuscitate, comfort care arrest).  More information about that HERE. They insisted on keeping him full code, which was frustrating from a medical view, as there is an immense level of work to do when keeping up with a code while it’s in action and after it’s happened. During a code, everything seems crazy, people are moving and sweating and shouting to get things done, but it doesn’t seem like a lot of actual “work” because adrenaline keeps you going. Afterward, the heaviness of it all hits you. Then, there are basic tasks to still do in order to complete the code process, such as cleaning everything around and within the patient’s room, calling downstairs to change the code carts (you replace the used cart with a new cart so that the available code cart is always fully stocked with the necessary medications), sign off on the charting for the event, and complete a code de-briefing huddle.

Besides the “work” aspect of it all, there is an emotional and logistical component regarding organization of the patient’s family. I always think, if the family was physically here watching what a code fully entails, they would be much more likely to change their minds and to change the patient’s code status. Seeing the intensity of compressions and the pain in the patient’s eyes throughout the process make you wonder if it’s all really worth it. And, the patient’s quality of life will likely be much lower after it all, even in a best-case scenario, should he/she survive a CPR event. (This is a heavy and complex topic which I feel strongly about, and will likely write more about this subject of suitable end-of-life care measures.)

To sum up the patient’s part in this story, his family eventually did arrive on the unit to see him, and they did change his code status to a more appropriate DNR-CCA category. The night was only half over for me, it being my usual 12 hour shift. I was physically exhausted and shaken after doing compressions for so long, and emotionally unstable because I had really gotten to know this patient and his family over the past few nights. But still, you move forward, because you have to. Even in these trying times, I love my job, because I know that what I do matters.

Final reflections I have:

1) trust your gut instinct. If something is wrong, it probably is. Before anything happened, the patient knew something felt wrong. I ignored this and I ignored the monitors, because I didn’t believe in myself enough to stand up to that nurse. They always say in school that your first priority is to be a patient advocate. This means following your patient’s wishes, even when you, their family, or their doctors don’t agree with those wishes. But after tonight, I learned that it also means standing up for your patient to even your coworkers. As hard and heavy as it is to admit, something was wrong with my patient last night, and I didn’t act on it fast enough, because I didn’t want to offend my coworker. That’s stupid. I need to get over it.

2)medicine is a team sport. I don’t know why people still feel as though they have to act like they are the smartest in the room, like they have something to prove. This isn’t just doctors – nurses do this to other nurses, techs do this to other techs. We should build each other up, not tear each other down. Feeling confident makes you want to learn more and do better. Tearing each other down not only personally destroys you but it decreases your ability to provide the best patient care. Helping each other learn and being patient with each other in stressful situations will only lead to better outcomes.

3) Every life is valuable and valuable subjects should not be treated with such a nonchalant, joking, insensitive, inappropriate attitude.

4) Adrenaline helps, but it won’t last. You have to reach somewhere deep within yourself to be strong for a long period of time when you’re working in this field. It’s easy to become exhausted and jaded with the work you do, because you do it so often. Being exposed to a highly medical, monitored, structured environment in the hospital is not something most people are familiar or comfortable with, and you need to remember that when you feel like breaking down or slipping up and making insensitive remarks.

5) Confidence is a responsibility owe to yourself, your patients, and your colleagues. People are going to expect you do to things, and to do them right. If you don’t believe in yourself enough to do them, you are letting down a lot of people, not just yourself.

6) The importance of family meetings, establishing a common plan and doing so in a timely manner, preferably when the patient him/herself is mentally well enough and can also be included in the discussion (for a future post).

~Thanks for listening, and I welcome any questions and thoughts.