*Original post released on 6/10/2020
**This photo is NOT of the room of the patient discussed in this situation. It is likely a photo of an emergency room setting, however most code blues end up looking like this in the end regardless.
Walking into my shift last Thursday night felt just like any other shift. It was my first of three shifts in a row, and I was even relaxed enough to have made a dessert to bring into work that night. I checked my patient assignment, put my things away, grabbed all my nursing gear and headed over to get report from the day shift nurses. One of my patients was currently in the process of receiving dialysis and was mechanically ventilated, on vasopressors, hemodynamically unstable, and also on an insulin drip. After getting report and increasing his Neo dose, I left the patient with the dialysis nurse and went to get report on my other patient. This patient was actually one that I had admitted the week before when they arrived to the ICU to recover from an abdominal surgery. I was surprised to see he was still here because he had been doing so well. Apparently he was still in the ICU due to increasing respiratory issues. Trust me, those respiratory issues were very apparent the moment you walked through the door. You could hear audible gurgling noises as he breathed.
Once I received updates on that patient, I ran back to check on the hemodynamically unstable one. At that point in time, the dialysis nurse had just gotten off the phone with the nephrologist and it was decided to terminate dialysis for the day. Luckily, this made them more stable. Thinking more of my time would be spent with the dialysis patient, I went and did my thorough assessment with my old patient first. I knew them well after having already taken care of him for a few shifts.
As expected, his respiratory assessment was the only abnormal finding. He was alert enough to respond with a “yes” when I asked if he wanted me to try and deep suction his airway (example pictured above). I gathered the necessary supplies, explained the procedure and made two passes through his nare while allowing rest time in between each pass. He didn’t like the procedure but I was able to suction a small amount of thick, yellow/brown sputum. Afterwards, the audible gurgling was reduced and he seemed to be breathing more comfortably. I left him to rest.
By now it was about 8:20pm. My charge nurse for the night approached me so we could obtain telephone consents for my ventilated patient for a bronchoscopy procedure. Just as we were about to make the call, I noticed the respiratory therapist (RT) about to enter my other patient’s room. Typically, I like to introduce myself to the RT and let them know that I’m the nurse for the patient. Something in me urged me to go in the room with the RT and walk her through my assessment findings. Usually I only do this if absolutely necessary or if I am unfamiliar with the RT. We walked in the room and the gurgling sounded worse again. It hadn’t even been a full thirty minutes since the last deep suction! I offered to grab supplies to do it again, and she (the RT) agreed with me that he needed it. I usually try to avoid repeated passes as it can cause trauma to the airway, but he wasn’t coughing any of the phlegm up on his own so it was necessary.
She tried to get the suction catheter to pass through his nare but it wouldn’t advance for her. I offered to try since I was successful with it earlier on. As I was able to get the catheter to pass through, we nearly immediately hit the “secretions.” It was a mixture of reddish brown output and it was filling the suction canister FAST. It was alarming to me, so I ran out of the room to get the surgeon’s number. As I’m calling the surgeon, the RT stayed in the room and I ran to update the charge. In the background, I faintly hear a few of the other nurses asking what’s wrong but I don’t respond. I should have. In just a mere 60 seconds, I return to the patient’s room to find him hanging over the edge of the bed railing with minimal consciousness and the other nurses helping hold him and suction his airway. At this point, the drainage is coming out of his nose and mouth a continuous rate. A fellow nurse drops an NGT and hooks it to suction to assist with preventing further aspiration.
While my amazing colleagues are managing his airway, I’m on the phone with our critical care intensivist, getting approval for intubation. The ER doctor was notified of the emergent intubation and another nurse and I gathered the intubation tray and RSI (rapid sequence intubation) box. The patient had a moment of increased LOC as the output stopped, but this did not last long at all. Around the time the ER doctor arrived, he became unresponsive again. So far, he was still vitally stable though. After intubation, it was as if his body finally caught up to everything that had happened.
He became incredibly hypotensive with systolic blood pressures in the low 50s. We bolused him with three liters of fluids, which was what I estimated he lost in output. I requested an order from the surgeon to give blood, but he wanted data from the patient’s updated CBC first. So a STAT CBC was entered. At this same time, the ER doctor was placing a triple lumen central line catheter so we would have additional access for fluids/blood products/vasopressors. Orders for Neo, Levo, and Vaso were entered and pharmacy was called. In those 3-5 minutes waiting for meds and the line to be inserted, I was praying that the patient wouldn’t code.
To everyone’s relief, the line was placed, labs sent, and pressors started without a code. My colleagues helped clean the room and the patient while I updated the physicians. The hemoglobin came back with a four point drop from 11 to 7, so the surgeon decided to go ahead and order 2 units of PRBCs along with additional labs for coagulation studies (PT, INR, aPTT, Fibrinogen). I put those orders in as STAT orders and got the blood tubing primed and ready. The blood was given as fast as he could tolerate. The coags came back elevated which was not shocking to me. For a little history, this patient was taking Eliquis for his A-fib. When he had surgery, he had taken the Eliquis that same day so they gave him a med called Kcentra to reverse the med’s effects prior to the procedure. It was now suspected that the patient had a bleed somewhere in the GI tract from the surgery and from taking this medication.
I passed my 10pm meds to my hemodialysis patient within the time frame for administration, and then returned immediately to my other patient. My three amazing neighboring nurses assisted me throughout the night in monitoring my dialysis patient. Since he was on an insulin drip, he required hourly blood glucose checks and insulin titration. I would not have made it through the shift without their assistance with both patients. I notified the surgeon of the coag study results and he ordered an additional 2 units of PRBCs and 2 units of FFP. When these were done being administered, I updated the surgeon and he requested two more of each product to be given with follow up labs to be drawn with the morning labs. I gave Lasix in between the products to help with fluid overload but his urine output had already drastically declined to less than 30 mL/hr. I also slowed down the rate of administration now that his blood pressure had improved and the doses of the vasopressors were being weaned down.
We finally began to think we were out of the woods! There was no more output from the NGT or via in-line suction of the endotracheal tube. Vitals were stabilizing and he was off all but one of the pressors. However, at approximately 3 am, he started to mildly desat. Your first thought with desaturation while mechanically ventilated is to check all the tubes and lines, assess for secretions/mucus plug, and if all are normal, increase the FiO2. However, he was desatting on 100% FiO2 and 14 PEEP. There wasn’t much else we could do. He was on the mode of ventilation that allowed for the best respiratory assistance. Eventually, once the patient’s saturations reached the 70th percentile, nitric oxide (pictured to the right) was added to the oxygen being delivered through the vent. This brought him back up to the 90s. We thought this might just give him the time he needed to recuperate and improve.
Again, we were wrong. He maintained decent oxygen saturation with the addition of the nitric oxide until about 5 am. At that time, his saturations began to decline by 1% every 5 or so minutes. I knew that it was a matter of time before he coded. His family was contacted multiple times to explain what was going on, what had been done, and what would be done if he lost a pulse or stopped breathing. Family decided up until the end that they wanted all measures taken.
Finally, it was time to give report to the oncoming day shift nurses. I quickly gave updates about the dialysis patient and returned to the crashing patient. The same nurse who had him the day before walked by in utter disbelief at the patient’s current presentation. I began explaining everything that had happened and been done for the patient. In the middle of report we were discussing the falling oxygen saturations and noticed the pulse began to become brady as well. We paused and held our breath. The pulse consistently dropped from the 60-70s to 50s to 40s and then to the 10s and nothing. The code was called at approximately 7:10am. After about 10 minutes of compressions and emergency medications, we were able to get a pulse back and stabilize him.
The family was called again. This time there was disagreement among the family members about whether or not he should remain full code status. Until the POA could prove he was in fact POA, the decision remained full code. We resumed giving report for about 5 or so minutes until his pulse started to trend downward again. As soon as we hit the high 40s for pulse, I recruited additional nurses in anticipation for the code and asked someone to grab another med tray for the crash cart (this would be the third used for the patient so far). 30, 20, 10s, nothing. The code was called again, compressions were initiated, and the ER doctors and surgeon arrived again. We coded the patient for a total of 10 rounds (~20 min) until time of death was called at 8am. I was the last person to compress his chest as they called it. I looked down to actually see my patient. His frail little body was covered with empty medication vials/syringes, defibrillation pads, and an Ambu bag that had been tossed aside. His extremities and head were bluish purple from lack of oxygen and his abdomen was incredibly distended with what I assume to be pooled blood from internal bleeding. His chest caved inward slightly from repeated rounds of compressions. It was a sobering sight.
For those 12 short hours of my life and career, I gave that patient EVERYTHING I had. I hardly left his side. I cleaned him, medicated him, resuscitated him, held his hand. No one he recognized or knew was by his side when he passed away. No one was even in the hospital for him, despite his family being notified of his critical state. This man died alone. The moment I threw my gloves in the trash and stepped into the supply room, the tears flowed out of me like a river. I gave him every ounce of myself that I possibly could in those twelve hours together and it felt like it didn’t make one bit of difference.
As a nurse, this is part of our job. The loss. No one can prepare you for how difficult your first loss is. Even now, I go through every moment of that night over and over in my mind. I can’t find something that I would have done differently that would have made a difference in the patient’s outcome. Even so, the loss doesn’t hurt any less. My head knows that I did everything I could have, should have, and was ordered to do. However, my heart aches for the fact that we can try our hardest and it still may not make a difference in the end. My take away? Be there for your patients as much as you can. Make them as comfortable as you can while you can. Work every shift as if you were going to lose your patient so that when you look back, you can say with confidence that you did everything within your power to be there for your patient in every way possible. It may just be the only thing that lets you sleep at night while we continue to work in this profession.