A “code” is the term that medical professionals use to describe the orchestrated chaos that surrounds a patient that is on the brink of death. Depending on the facility a code may be called a Code Blue, Code Red, Code CPR, or sometimes Code 99. They all mean the same thing. A person is about to die unless there are medical interventions made immediately. Sometimes it means that death will come no matter how hard we try to stop it.
A few months past graduation I experienced my first code on my own patient. The man had been verbally abusing me all day. I had been running around trying to make him happy and also care for my other five patients. He was bellowing from his bed that he was going to die. A lot of patients speak in that way, but something about the way he said it terrified me a little. All his vitals, physical assessment findings and that he was able to yell with so much energy all assured me that he was stable. I called the physician anyway. He agreed to assess the patient. I went to check on my suddenly quiet patient. When I walked into the room I knew something was different. I will never forget how grey he looked. I froze in a moment that felt like eternity while I listened and looked for breathing. It only took a few seconds to confirm. I reached up above his head and pressed the small blue button.
I was the person yelling now.
I called above the alarm sound for help. Help came. Almost before I could lay the patient flat in the bed, a nursing aid, with a football player build, began chest compressions. Respiratory commanded the head of the bed, bagging and preparing for intubation. A metal crash cart clanked into existence, pushed by my charge nurse. The emergency room physician and intensive care nurse rushed in together. The ICU nurse asked who the primary nurse was. All I could think was ‘Oh Crap! That’s me.’ She told me to grab the chart (that’s back when patient’s records were big, clunky, 2-ringed, plastic folders stuffed with a ream of paper printouts and handwritten notes) and call the patient’s physician.
I ran to the desk and called the doctor again. He was just getting off the elevator. We met at the patient’s bedside. I calmly answered questions about history, vitals, and labs, all while the resuscitation dance continued. I was calm only on the outside. Inside my mind raced, searching for what I might have missed. This man had been screaming at me all shift. How could we be coding him now? I couldn’t think of anything I could have or would have changed. Even now looking back, with much more experience, I know gave him appropriate care. I watched the code continue, clutching the hard plastic chart. I optimistically observed that his color was pink again. Surely that was a good sign, I told myself.
As if someone had flipped a switch, everything stopped.
The ER physician called time of death after nearly 40 minutes of trying to coax my patient back to life. I watched as my patient lost his rosy color while the team waded through the open package wrappers that had been hastily discarded on the floor. The CNA stayed and helped me to clear the debris and prepare my patient for the morgue. The aftermath of the code was over quickly. I think that is what stunned me the most. The physicians and nurses went on caring for their patients. Housekeeping came and cleaned the room for my next admission. I did not have time to cry or sit in disbelief or process what had happened.
The shift went on and so did I.
I have since been to countless codes. Sometimes I am doing the compressions. Sometimes I am the nurse directing the chaos. Occasionally I am the primary nurse questioning every action I did or didn’t make that shift. Luckily one aspect of patient codes has changed since I was a new nurse. It is now an expectation in many hospitals that a debrief occurs after a code, regardless of the outcome.
A debrief is conducted as soon as possible after the event. All available team members are expected to attend. It is a confidential and non-discoverable group discussion of the event. The purpose is to discuss the facts, problems, barriers, needed improvements and to acknowledge and share feelings. This is not a time to place blame or try to find fault with one another. This opportunity to discuss the event and acknowledge how we feel about it is a valuable practice. I never want to feel that losing a patient is business as usual.
Debriefing is the pause that we need to take to acknowledge, gain knowledge and make adjustments for the next time we press that little blue button.
1. Introduction: The facilitator establishes the group goals and rules and reinforces the need for confidentiality about anything that transpires within the group.
2. Fact gathering: Each staff person describes what happened and facts are gathered.
3. Reaction phase: Led by the facilitator, the group examines its feelings, thoughts, and responses to the event experienced. If the debriefing session happens soon after the event occurred, there might not be any symptoms.
4. Symptom phase: If some time has elapsed since the event, group members may be experiencing symptoms. The facilitator helps the group examine how these reactions have affected personal and work lives.
5. Stress response: The facilitator teaches group members about their stress response.
6. Suggestions: The facilitator offers guidance on how to cope with stress related to the incident.
7. Incident phase: Group members identify positive aspects of the event.
8. Referral phase: The facilitator concludes with this phase, whereby specific individuals who require additional support are referred for individual follow-up.
Adapted from: Hanna, D., & Romana, M. (2007). Debriefing After A Crisis. Nursing Management (Springhouse), 38-42,44–45,47.
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