Vital Signs Absent

For some the heroics of a code are what some nurses live for. For me, well, I would rather see the patient living.

It was 0600 and I had drifted off into a nap in the staff lounge. It had been a busy night on the floor: answering callbells, wheeling commodes, admitting patients, and dishing out meds. We were one staff member short, and the substitute staff member who agreed to come in, peaced out after 30 mins of work. Things were just settling down after my 0500 snack of apples & peanut butter and orange pekoe tea. Charting was complete, and I didn’t have anything else to do but a blood sugar check before breakfast. I figured it was time for a quick snooze.

I awoke to the paging system overhead: code blue, emergency room, code blue. Then I heard some nurses shouting my preceptor’s name, and him running downstairs. I snapped out of my slumber and started running after him. I entered the room and a woman laid on a stretcher collared, the paramedic was frantically doing chest compressions, while the other paramedic briefed us on the situation. Pt was in a MVA and became trapped between the airbag and the dashboard. Firefighters got her out, and she was alert. EMS was transporting her to the hospital when she went VSA. Then a nasopharengeal airway was inserted, ambu bag used to delivered oxygen, and chest compressions commenced. The emerg nurses were trying to get an intravenous line in her, but no luck. Someone started writing down times and what was going on. Then she was called to find another IV site, and I assumed the position as recorder. I figured I wouldn’t be much help doing anything else; this was the very first code I had participated in.

The defibrillator pads were placed on her chest and her clothes were stripped off. The monitor revealed that our patient was in asystole. No one could get an IV line started, so we used an intraosseous drill and had an intraosseous infusion running normal saline 0.9% with a pressure infuser bag. We put another IO line in the other tibia (shin) also running N/S. The doctor and her resident ran into the room and took over the code. We started pushing 1 mg of epinephrine every 5 minutes. It was my job to make sure the team knew what was going on, and when to give the next epi.

The resident attempted intubation, but no luck. The anaesthetist was paged, but she still hadn’t arrived. Then my preceptor was asked to give it a shot — success. The team had to take off the collar around the pt’s neck, but at this point we were grasping at straws.

The lab tech came in and managed to get a few samples of blood. She came back with the results, and it looked like our patient was in metabolic acidosis. The doctor ordered 1 amp of bicarbonate to be pushed. But at this time we had been running the code for 40 mins. The nurses had inserted a nasalgastric tube which was draining blood from her stomach. A catheter was inserted, but only clear coloured urine came out. We double checked her hips, but they were even and aligned; no sign of a pelvic fracture.

The doctors tried to reason out what could be happening. Was it a pneumothorax/hemothorax? Two needles were inserted into the chest to try and draw out any air or blood — nothing.

The patient was still pulseless after an hour of CPR. One of the doctors decided to do a bedside cardiac ECHO, to detect if the heart still had any electrical activity. From his clinical judgement, he saw cardiac activity and a dopamine drip was ordered 10mcg/kg/min. Chest compressions continued for another 2 rounds, and the pulse check still was negative. At this point another cardiac ECHO was performed and no activity was present. The monitor showed asystole and the CO2 capnometer decreased.

After 1 hour and 10 minutes, the code was called.

In hindsight, I think being the recorder is one of the hardest jobs in the code team. While I was debriefing with my preceptor afterwards, he told me I handled myself well. The recorder has to be focused, vocal, and observant. I wasn’t afraid to ask questions, and have people repeat medications or doses back to me. If I wasn’t accountable, then my role as the recorder would be irrelevant. In the end, my documented notes will be used in the investigation.

A sombre mood took over the department, and we covered the pt’s body with a sheet. All the lines and equipment had to stay in place for the police to document. The body would be later autopsied. The cause of death is still unknown. Perhaps it was head trauma or a c-spine injury.

I hope that this patient finds peace and my condolences to her family.

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