Frustrated over a code

1 I had to code a pt today, only my second code. My issue is for the 30 minutes before there was a ultrasound tech in the room and prior to that pt was in MRI. Family states reporting concern to the tech but nothing was reported. Pt was dusky and sats of 40%, when I went to go give meds. I know they are there to do a job but pt was clearly not doing well. Am I holding the techs to a higher stander then I should or did the ball get drop in a big way for the second time leading to the code? First was the 24hr chart check was not done right, medication dose was triple what it should have been.

Also how do you calm down after a code. I feel horrible and just have a list of what ifs and mistakes. It does not help that I was the one that gave the medication that ended up causing the code. Oh and family was throwing around the sue word well before this.

I'm emotionally drained and needed to vent.
I think everyone employed in a hospital, even the janitor, is to be held to a standard of patient care. Holding the door for a patient for example. Anyways, those techs are CPR trained...there should be some sort of assessment...MRI people can assess anxiety, why can't the assess the opposite? Unless the patient's family is just batty, I listen to them and the patient...because they are more familiar with "normal" for the patient. The other issues, all people who work in high-risk areas have the what-ifs...it's hard. And of course even in the best circumstances, later you'll think of something that could've been done better...or something forgotten...but maybe you should take a hot bath and have a few benedryl - Then reassess yourself in the morning.

To say "congratulations" seems bizarre and yet, you are to be praised for becoming involved. Codes are frightening for new nurses but, as you know, inevitable. I always recommend to new nurses that whenever any code is called they can become involved in the code (write events) and they will become confident - they will learn the ropes.As far as seeing that a code is coming, sometimes you get a little hint, sometimes you don't. Sometimes you are sitting with them waiting for their wife to bring the car to the door and they simply die. Most often, you develop that little "voice" over time. Always, always, always listen to that voice. I would prefer to look the fool but save the patient. If you have issues with a tech (remember they are techs) please do the professional thing (chain of command) BUT you should take the time to get to know them and their habits/assessment skills. They are there for assistance with the patient - NOT to do your job (not that you implied that) - I'm just covering all the bases.If you blame others or yourself, that's silly. If you did your best, hold your head up high - try to learn something from every code.Please remember we are here to help - anytime.

I don't know if I would expect an US tech to notice a patient's color, they're looking at the monitor screen rather than the patient. But I would expect anyone in the room to tell me if the patient or family expressed concern about the patient's condition: tech, dietary, housekeeping, chaplain, anyone.Time and experience will help you calm down afterwards. It's especially hard when there was a medication error that you were involved with because you'll be busy beating yourself up about it. That never helps though. The what if's can be helpful if you use them in a non self punishing way. How would you handle a similar situation in the future? What did you learn from this one? What will you do differently? What will you do the same?Your patient survived. That's the bottom line. In my area I've had to deal with very few codes, but I've never had a patient survive one either. You're way ahead of me.

I would write up an incident report in regards to the lack of training by the MRI/ ultrasound staff. Any person in the hospital should know that sats of 40% is not acceptable. They should have called you for an assessment. As for calming down after a code, that just comes with more practice. I was told once that the first thing you do at a code is check your own pulse . That goes along way to keeping yourself calm along with the code team if needed.

Honestly if the family voiced concerns to the ultrasound techs a simple "Let me hit the call light for you so you can alert your nurse" would have been appropriate. Hunting down the nurse would have been the best response, but our phlebotomists will frequently just hit a patient call light if a patient has a minor concern and that is something that I am fine with.

Speaking as a tech in my senior year of nursing school....We have a vitals policy on my floor. We report any abnormal vital signs to the appropriate nurse immediately. We are supposed to page from the patient's room. Not sure how your hospital works, but when the patient presses the call bell, the call actually goes to a call center and they send out the page based on if it needs to go to the nurse or the tech. With me so far? We page from the room because the patient's nurse can come directly to the room to address it immediately. We page for any systolic over 165 or over 95 diastolic, any low BP or SAT, or any elevated temp. The same goes for blood sugars. It works well for us because it is reported immediately. The only time we do not page is if we hear or see the nurse in close proximity and we can just grab her in the hall and report. Sorry you had a bad day. I hope your next shift is better! meredith

Tech definitely should have noticed and/or reported a patient that doesn't look like they are in stable condition to someone that could take care of it, if that patient isn't being appropriately monitored already. In the tech's defense though -- ultrasounds are often called up to the ICU to be done on unstable, critical patients. The tech may very well have thought that you were aware of the patient's condition and were watching him. As well, the tech is not responsible for the patient's overall condition -- he is there to do some testing the physician ordered. You are the one responsible. If this wasn't an extremely sudden event and you saw the patient slowly deteriorating, I feel that it was your responsibility to cancel the MRI and the ultrasound and watch/treat the patient. Even in the ICU, we don't allow testing to be started with sats in the 40's (you didn't give much info, so I don't know what the patient condition was when he went to all these tests -- just speculating.) That value right there is enough to tell you that the patient is going to arrest if you don't do something ASAP. I wish I knew more about the chain of events on this one -- patient's dx? What med did you give in triple dosage that you think caused the code? Did patient survive the code? What were the families concerns re: lawsuit? I have gotten pretty good at putting the pieces together of what happened in a clinical scenario but there isn't enough here for me to really get a good feel for who dropped the ball here, but from what you said, it doesn't sound like it was just the tech. Probably the patient should have been being watched closer prior to this event happening.

Do you work on a busy medsurg floor with a multiple patient assignment?

I don't think anyone (here on the internet- knowing very few facts) is in a good position to judge your or the tech's actions or lack thereof. I can only offer some observations from my own experience and some suggestions.1. Some techs (CNA, Xray, etc.) are very task oriented. They go from patient to patient to do their job without any thought of the bigger picture. Ominous signs (i.e. unstable vitals, unresponsiveness, labored or agonal breathing, etc.) should be reported by anyone - it's a no-brainer, right? Unfortunately, there are those individuals that are just there to git 'er done. Everyone with patient interaction needs to be formally oriented to recognizing ominous signs and who they should report them to- including how to call the rapid response team (RRT). And if a family is voicing concern to the tech, he/she should absolutely be reporting that back to you!2. Speaking of the RRT, on admission, the patient and family should be instructed in how to request the RRT. I think it is even a JCAHO requirement now. (And yes I realize this is a can of worms, in and of itself ) And as for yourself, have you ever requested an RRT for a second look at a patient who has you worried? It's best not to wait until the patient crumps. It takes time and experience to recognize early, subtle signs of decompensation. You'll get there- a good RRT will be very supportive and help you learn some good knowledge and skills that can really best be learned in that situation.3. Monitoring alarms (like a continuous pulse ox- for example) need to be set appropriately and alarm audibly enough to get attention. Turning off or ignoring alarms is risky, risky, risky. (Don't know if this applies in your situation, but it can't be overemphasized.)4. The instant that a patient or family starts threatening lawsuit, or the like- get the Quality department on board. Even if they are total whackjobs with no reasonable/rational concern or complaint.5. As a nurse, you are going to have those awful, awful dog days. Debrief and decompress with your family and friends. Just be sure not to violate confidentiality. It also helps to have good friends that are nurses. I tell ya, no one understands nursing highs and lows like other nurses. Good luck to you.

I work on a med/surg with 6 pts per nurse. Pt was there for a minor diagnosis another nurse saline locked pt prior to going down for MRI as I was at lunch, pt assessment WNL when I handed her the MRI check list, just prior to going to lunch (after the code that RN reported pt being tired but interacting appropriately so no major flags there). Pt came back from MRI and US was there with in minutes to do their exam. I visualized pt coming back from MRI in wheel chair as I was entering another pts room and nothing seemed out of line for further assessment. I entered room about 30 minutes later and observed pt as dusky and family reported concerns (pt was breathing and pulse) and went to grabbed Charge nurse for another set of eyes and vital sign machine. We do not have continues vital sign monitors just every 4 hours. This is when the sats were observed as 40%. Medication was extended release narcotic. I am just very frustrated as this all could have been prevented if the proper checks were done correctly and the fact that I gave the medication that caused the code. We unfortunately rely on others to do their jobs correctly to do ours correctly (ie 24 hour chart checks). We work as a heath care team and to think the RN can have eyes and ears on each pt at all times is not realistic on Med/Surg and when concern is raised it needs to be passed on.

Done more codes than I can count. Sometime 4 or more per shift! Maybe 1 or 2 codes in my career were perfect. My philosophy is after the code think about what went wrong and judging the code by how well we dealt with the errors. Cracked plastic suction containers, missing equipment, dead bulbs on laryngoscope blades, no defib pads or gel, there are too many possibilities to mention. After a code relive it in your memory. What went good or bad. How it could have been better. Once had to code a patient 30 minutes after pronounced because the epi caused a spontaneous pulse and a resident just had to go check. 30 minutes of apnea, fixed pupils, but just the faintest thready pulse. Hope you find the answers you need, hope all this offers perspective, and glad you didn't mention qualms about your career choice. I may need you some day.

If techs were expected to assess patients then we'd be out of a job. An U/S tech doing a scan has no baseline to compare to and an ill appearing patient is not that unusual in a hospital. We learned our lesson a couple of years ago following a patient death in an MRI machine and we now send an RN with any patient who is leaving the floor who has recently received narcotics or other sedatives.