Monday, October 26, 2009

CPR Refresher

On Thursday we had to take our CPR first responder training. I was trying not to be bored out of my mind as we sat through 8 hours of "one-and-two-and-three-and-four-and" chest compressions and how to perform the Heimlich maneuver.

Interestingly though, when we pulled out the baby models for the infant CPR I felt my heart rate pick up ever so slightly and a knot tie itself in my stomach. At first I tried to step back and figure out what was happening...and then realised that it was just a little too much of a reminder seeing a lifeless looking baby in front of me. I briefly touched on the neonatal code that I was involved in last summer when I was working as an ER nurse in Canada.

It had been a very very busy day in the emergency department and we were short staffed as the connected ICU had two very heavy patients which required 1:1 nursing. Earlier a woman had walked in holding her soccer sized belly and we had directed her upstairs to the maternity ward. We hadn't paid much attention and were just happy we could tell at least one patient that they could be seen somewhere else. Just before lunch we heard the announcement on the hospital PA, "CODE BLUE...NURSERY....CODE BLUE...NURSERY".

My colleague and I were both standing in the nursing station when this announcement was made. For a split second we just looked at each other, the main thought running through my head was that I was pitying the nurses who had to deal with that situation. On the heels of that thought was the realization that as an emergency nurse I was likely responsible to respond to that code. One of the points that no one mentioned during my 4h orientation. My colleague who was in charge stood rooted to her spot with wide eyes and said, "Go".

I turned and ran up the three flights of stairs to the maternity/medicine ward. Remembering that I have only ever run once before in the hospital...years ago when a patient I had escorted to CT crashed during the scan and there was no bagger in the CT area. I got to the top of the stairs and took a moment to catch my breath and collect myself. There is nothing worse than staff who BURST onto a scene. What was that saying about taking your own pulse first?

Walking onto the floor I saw a crowd of patients, family members, and staff had gathered around the periphery of the nurses station. When I rounded the desk two of the medicine nurses pointed me to the room I was destined for.

Going in the first thing I felt was the heat. The doors were closed and this was during a very unusual hot spell--in a hospital with no air-conditioning. The warmer was also on and no windows could be opened. With 9 or so bodies in the room the air was thick and sticky. Two anesthetists were at the head of the warmer finishing up the intubation, one was already peeling off her gloves and saying, 'well you've got things under control here...' An emergency physician was standing to the side of them finishing up with inserting the umbilical line. None of the family was present in the room. The maternity nurse was getting the buretrol and IV lines going and the charge nurse was on the phone with the lab and xray department. I grabbed a pen and started writing.

Sometimes I like recording, especially when it is a patient that I know nothing about. Being the recorder allows me to go through what needs to be done (in my head) and gives me an opportunty to keep other nurses organized. Some people get a little 'chicken with their head cut off' in code settings (and I am certainly not excluding myself from this group) but I find if you say, 'hey what size catheter are you inserting?' or 'where is a second IV line going to go?' then folks seem to get on task and off the circular merry-go-round-wheel-of-stress.

This code was being run by one of our most pleasant and experienced ER docs. Even during arrests he uses the words 'please' and 'thank you', never raises his voice, and never looks ruffled. I instantly calmed down and was grateful for him and his demeanor. In fact, it was almost comical how he raised his eyebrows to me when a clearly very flustered nurse came running into the room with the syringe of broad spectrum antibiotic in hand...the door banged against the wall causing everyone to jump. It was sort of a 'hey lady, we're all cool in here! What's with the Grey's Anatomy entrance??' kind of look.

The baby was not doing well. I had finally gotten report and learned that mum had arrived with no previous prenatal care, and no physician following her pregnancy. She had a vaginal delivery a few hours ago at 32 weeks gestation. The baby was just over 2900gms and had gone into respiratory distress and then cardiac arrest.

The code blurred into the various stages I was used to in adult situations...the arrival of the lab and attempting to work around them...the x-ray technicians and the portable machine forcing us out of the room for a momentary breather...then the hurry up and wait aspect until some reason for all of this happening presents itself.

The x-ray came back showing the 'ground glass' appearance to her lungs. My role in the code had shifted to providing ventilation with our neonatal bag valve mask. Along the side of the bed with the warmer heating my already sweaty neck I counted out respirations and watched the monitor for her wildly fluctuating oxygen levels.

Now my memory shows me only slices in time from the rest of the event. I can see the surfactant bubbling around the ET tube and I can hear the gurgling hiss. I can see the flushed cheeks of the maternity nurse and the two bowls of untouched tomato soup sitting on the bedside tray. I see the rise of that tiny chest with each squeeze of my hand on the bagger. It is strange to feel that tenuous line between life and death strung between yourself and another, another very helpless individual. Where else in the world does that exist? When in our lives do we feel that responsibility and connection to another human?

I remember feeling very in the moment and calm, detached and interested from a medical point of view but not sad or upset. I remember thinking that I found the differences between being in an adult code vs a pediatric one very interesting...and I wondered if I shouldn't dismiss pediatrics for my future.

A nurse from the floor came in saying the ED was a zoo and they had phoned up to see if things were under control so I could go back downstairs. The child was as stable as she'd been for the past couple of hours so the mat staff said they could take it from there. The infant transport team was due to arrive shortly anyway so I was relieved of my duties. I headed back though the doors of the ED and picked up the first chart with orders on it;

IV ancef 2gm
dressing
Td IM

On I went into the room to find a cheerful man with a sailors lexicon who had traumatically amputated his right 2nd finger just past the knuckle while he was at work. And from there the rest of the shift swallowed me up in the usual more mundane presentations and chief complaints.

When I wrote about this event before I mentioned that I drove home and sat in my car parked in the driveway for quite some time after the shift. I looked at my feeling of detachment, I thought about how intriguing it was. Another example of professional self-preservation? I replayed in my mind how frustrating it was trying to use equipment I wasn't accustomed to and made a mental note to familiarize myself with the pumps and lines we had stashed away for peds cases.
It wasn't a good night. I talked about it at length with a friend via skype...one of the downsides of travel nursing is you don't necessarily have the people you need around you to informally debrief with.

Then the incident travelled to the back of my mind until this CPR exercise.

And so it goes, the recall. The questions that almost never get answered--the long term outcomes, if our interventions were effective, if we gave the best care possible? The images arrive in your mind and the present is abandoned for a few moments while someone talks about how many compressions per minute and someone else makes a joke about having babies in medical school. No one really wants to hear about the fact that your last code was a pediatric code so you tuck all of it away again and allow time to do its job. Moving right along..

4 comments:

Old MD Girl said...

That must be weird, having so much clinical knowledge already, but being surrounded by people who don't.

Albinoblackbear said...

It is weird and it's hard to not cite a clinical example with everything we are learning day in and day out during PBL sessions.

I was told by one of the residents on my volunteer trip last year just to keep my mouth shut for the first 2 years of medical school or else everyone would hate me for coming off like a know-it-all. :)

I do share some clinical context when people are waaaaaaayyy off base with something or just spouting misinformation...which seems to happen more often with certain members in my small group. I know one guy definitely has a voodoo doll of me at home.

My anatomy study partner actually encourages me to tell him clinical examples because it helps him with recall---his anatomy knowledge is stellar compared to mine so it works for both of us.

Old MD Girl said...

That's excellent advice. It's gotta be hard to bite your tongue though. I know I have a tough time with it....

Keet said...

Oh Ebsco... Thanks again for sharing. Amazing stuff. Next time, you'll be the cool ER doc, politely asking for the novocaine or epi. I'm so proud of you. Tomorrow Nurse Practitioner Keet is H1N1 Vaccinating. Wish me luck.