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Unanticipated Codes

February 20, 2013

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Love Song of Frank,” was published in the May (2012) issue of AJN. She currently has an essay appearing in The Examined Life Journal.

Code cart/courtesy of author

Code cart/courtesy of author

My mentor once told me that there are almost never unanticipated cardiac arrests in the ICU. I’ve found this to be true. Certain indicators, like laboratory abnormalities or particular cardiac rhythms, can foretell a Code, and sometimes subtle signs trigger an instinctual foreboding that I’ve learned never to ignore.

The conviction that a Code Blue can be anticipated provides a sense of security; if the arrest is anticipated, then it may be preventable. And when it’s inevitable, at least anticipation allows for preparation. I strongly believe this. And yet this weekend my patient coded and I was caught completely off guard.

I had just remarked to one of my colleagues that my petite, elderly Chinese patient (some identifying details have been changed) was looking so much better than she had when I’d admitted her earlier that day from the floor—she’d been in respiratory distress, in a hypertensive crisis, and in need of immediate dialysis. All of the various specialty consultants had seen her and collaborated and I’d had the thought that Ms. M’s day would end very well, that it would be one of those nursing shifts where I’d see a metamorphosis from dire straits and distress to comfort.

My shift was nearly over and I was standing at Ms. M’s bedside, monitoring her breathing, which had very suddenly become irregular. I was slightly distracted by her husband, who was standing at my shoulder and very upset. He was speaking in a heavily accented staccato that left me blinking, with a vague impression that he was angry at his children. Exactly why, I never did discern—for as he spoke, his wife took one last ragged breath, her eyes rolled upwards, and her EKG began registering electrical activity with no matching pulse to be found.

The respiratory therapist managed the airway while I started chest compressions. The rest of the Code team showed up; everything went as it should. Ms. M survived, intubated but responding. Mr. M, as a witness to what must have felt like mayhem, was traumatized. And I was rattled far more than usual—and more than I like to admit. I can only surmise that my stress response was related to my lack of anticipation in this case, for not only did I not see the arrest coming, I’d thought Mrs. M’s condition was moving in the totally opposite direction.

I discussed the situation with a good friend who happens to be a chaplain. I told her, not quite rationally, that I wanted to participate in a thousand completely unanticipated cardiac arrests in the hope that repetition would dull my emotional reactions, leaving automation and efficiency without distress. Perhaps then, I told her, I wouldn’t be as aware of family members while doing chest compressions and wouldn’t go home feeling like I’d watched a car accident play out in slow motion.

I also told her I wouldn’t be writing a post about this, as I felt my response was overdramatic. I was too experienced to be this shaken.

But she urged me otherwise, reminding me that nursing is not for the faint of heart, that years of experience don’t make certain difficult aspects of it any easier, and that it’s always good to write and to share.

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5 comments

  1. Another good reflection, Marcy :-)

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  2. I don’t know why the first, most immediate reaction to the realization that the patient is not breathing/pulseless is denial. I’ve seen it every time: the first nurse needs to nudge him or herself into action, as if we can’t believe what we are seeing. It’s okay, because our experience kicks in just short of the same time, and we respond with our training. Thanks for capturing this universal moment so articulately in your post, Marcie.

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  3. I vividly remember chatting with a patient who was sitting on his bed, waiting for family members to take him home after he had had a cholycystectomy. I was giving him final instructions when he looked at me with a puzzled expression and then just keeled over. CPR was futile (They think it was a massive embolism). This was before the days of VTE protocols and when patients stayed 5 days after surgery – long enough for you to get to know them. It’s never easy but the “out of the blue” losses stay with you a long time. I can still see his puzzled face.

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  4. Thank you for posting this! It will certainly help me in the future. Code blues are always nerve wrecking no matter how many you’ve been in. So anticipating it may actually make things a little less crazy.

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  5. Thank goodness a nurse is finally sharing one of the most intimate and emotionally shaking events we experience. Your post may at last give other nurses permission to experience whatever they experience. Feelings are not “right” or “wrong” they just are. When I worked in a surgical trauma unit in Dallas in the hood, I believe I came away with a form of Post Traumatic Stress Disorder fueled by my inability to be able to share with others what I experienced. I then began to find negative ways to numb my emotional pain. I don’t recommend that course for anyone! The more these types of patient experiences occur the more we have to share or they will build and build and build. Again, bless you for having the courage to share.

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