July 15th, 2008 | The Blog
My first patient flight of the day was a “stable myocardial infarction” that we needed to take from an outside hospital to the Big Hospital with a cardiac cath. lab. I’ve flown dozens of these patients and normally they only require a bit of pain medication, IV drugs monitored, and reassurance that it’s better to fly than go by ambulance.
Standard Operating Procedure when transporting a patient to the cath lab is to attach hands-free defibrillation pads to the patient, then plug the pads into the defibrillator. Although it isn’t necessary to turn the defibrillator on, just having the “shock” pads ready and plugged in helped keep the bad juju away.
I’ll give you one guess as to where this is going. I forgot to plug them in… again!
A mentor once taught me to “check my own pulse first” when things get ugly on an accident scene, or when a patient starts going bad. If you aren’t aware of yourself and your surroundings, you can’t do a damn thing for the patient.
He also taught me to always, “practice like you play.”
I’m bad about plugging in the pads. Usually, I would get busy, distracted with other things and forget, just as I did this time.
Apparently, three strikes and I’m out.
I don’t care who you are, or how long you’ve worked in healthcare, when your patient’s heart stops right in front of your eyes, you can’t help but want to panic.
The doc began chest compressions and I pulled out and turned on the defibrillator. At that time we flew with two monitors. One, our primary, didn’t have defibrillation or pacing capability. Our secondary monitor did, though and I flipped it on to shock the patient.
Now, at 160 miles an hour and 2,000 feet above the ground, when I needed the pads I fumbled with the pigtail, unable to figure out how to use the adaptor so I could plug it in.
I fought with the adapter cables for just a moment and thought I had them connected correctly. The monitor charged, so I got the doc off the patient’s chest and punched the shock button.
I rechecked it, trying to control my panic.
Then the inner voice started in on me.
How could you forget to do something so simple? This mistake could very well keep you from saving your patient.
As a flight nurse, I’m required to be prepared for the unexpected. I truly do believe that complacency kills. Although the outcome of this flight was positive, a simple oversight could have cost this patient his life.
While working in the hospital, I saw this kind of oversight on a daily basis. Running a code, especially on a medical-surgical floor, was a challenge. In general, nurses are minimally prepared to handle a stable patient who codes.
Hospitals are following a trend of “Rapid Resuscitation Teams,” who are available for consultation when a healthcare provider (nurse, medical assistant, etc.) feels that a patient is unstable. Rapid resuscitation and code teams in some hospitals have critical care or emergency room nurses, and physicians. In other hospitals, they actually staff with at least some paramedics. That’s important, medics are taught from day one how to handle a crashing patient.
Why aren’t nurses?
On the medical-surgical floor where I worked as a nurse practitioner, I often randomly asked the nurses about the code cart. Many had no idea where it was, let alone what was on it. When a code occurred, I often watched a nurse fumble opening the patient’s airway, and stare blankly at me when I asked for the bag-valve-mask.
Not all floors or ICUs are like this.
My guess is, however, that more resemble this than don’t.
Each nurse needs to take responsibility for their response and own ability to handle a “code.” Some problems are, I believe system issues. However, this one boils down to each one of us learning a few, somewhat-simple things.
Where is the code cart, and what is in it? If you don’t know where the important stuff is before the panic ensues, you won’t find it when you really need it.
How do you call a code? There are usually buttons at each bedside. You should know where they are and who will respond to help you.
What do you need to do before the team arrives? Airway, Breathing and Circulation. If you do nothing else, go through your CPR algorithm. That’s 50% of ACLS anyway. Lay your patient flat. If they are in bed, put a compression board under their back, and begin pumping their chest. Don’t forget to open their airway and check for a pulse as well. A bag valve mask works almost as well as the patient being intubated, so do good CPR and begin to think about where your IV lines are.
What does the code team need to know? Have your patient’s history, diagnosis, allergies, and hospital course ready to report. Only give the important information, ignore the rest, or the critical information could get lost in the shuffle.
Mock-codes, a common way to train, are a good idea, when done properly. Nurses have a way of not running at full speed during training, though. Getting participation in a training session is also difficult when it’s a busy shift. Run through mock codes on a consistent basis, and as the teams get better, increase their intensity. If you can run a code when practicing, you have a much better chance of doing it right when it matters.
Regardless of job requirements, try to take an ACLS class. Although you may not be responsible for running a code, knowing the basis for treatment and the algorithms makes you a much more effective team member.
Take the time to run through the basics and picture yourself grabbing that BVM, or running to get the code cart. Knowing what you will do ahead of time can make all the difference. Don’t let something simple trip you up and make a bad situation worse.
When all else fails, don’t forget: check your own pulse first.