Code Blue. The two most anxiety-provoking words to any nurse. When you’re a new nurse, the thought of your patient coding is always a lingering fear. When’s it going to happen to me..? Will I freeze? What if they don’t make it?
If you think your patient is headed towards a Code Blue, keep investigating. The take-home is, YOU know your patient best. Trust your instincts FIRST, and then take other’s opinions second in regards to your patient. I learned this very well after my first code blue, which goes as follows.
It was 4 months after I got off orientation. Brand new little me struggling to stay afloat in the ICU. I don’t remember exactly what my patient was in for since this was years ago, but I believe he had gone for possible stent placement that day. He was an older guy, and they weren’t able to stent him. They compared his coronaries to concrete. He was stable when I came on, and I’m doing my little assessment while the family was in the room talking.
I overheard them saying how they didn’t believe the doctors when they said he was doing okay. The family knew something was wrong. To me, the patient appeared stable. Vitals in check, good mobility and strength, and was talking with his family. Alert. I told the family he was doing well (regret number one), and that he may just need some blood pressure medicine if his blood pressure were to drop.
The family left and as I expected, his blood pressure did drop. I called the doctor and we started levo. Problem solved.
Around midnight, he started complaining of pain. He didn’t speak english, but was pointing to his chest. I had someone translate and ask him if he was having chest pain. He shook his head yes. Okay crap that’s not good. But we have emergency standing orders so I’m good right? I know this. He needs a stat EKG and my girl MONA. But as a new grad, I went to talk to my resource nurse first about my plan.
She asked me why I would want to order an EKG. Um, what? “He’s complaining of chest pain…”
“Well what does he rate his pain 0-10?”
“Uh, i didn’t ask that, he doesn’t speak any English.”
I mean come on… he’s complaining of chest pain… whether the guys a pansy or Iron Man, if someone mentions chest pain it’s a concern. But being new, I went with her opinion that he didn’t need one at that moment. Regret number two.
Now it’s around 0530, my shift is almost over. The dude’s been okay throughout the night. Then he gets his morning X-Ray and one lung is completely whited out. Uh. So I call the doctor right away to let him know. He’s says he’s on his way into work and he’ll see the patient first. Then my patient starts getting kinda sweaty and restless (hello hypoxia). This guy does not look good. He had wiggled his way down in the bed so I asked another nurse to help me boost. The nurse was like, “they don’t look good.” I said “I know.” This was another missed opportunity for a nurse to intervene.
It’s past six, and I’m getting really nervous at this point. This guy might code. Ok what do I do. I check where the code pedal is on the bed. Got it. I ask him again if he’s having chest pain and he says yes. The dayshift nurse has arrived. At this point I’m done, I order the stat EKG myself and go to grab morphine. I tell the oncoming nurse that this guy is gonna code. I’m pretty sure that’s what this looks like at this point. I see the resource nurse on her way out. I looked at her and was like, “my patient’s tanking!” She said, “does this mean I have to stay and help you?” Uh YEAH. I have no idea what I’m doing. I had never felt so helpless. Why is no one doing anything?
I go to grab the morphine. While I’m in the med room I hear the code bell go off. Oh God it’s happening. The dayshift nurse comes running in my direction to the supply room, “there’s no ambu bag in the room!” Nice Marissa. I’ll never forget to check for that at the beginning of my shift ever again. Regret number three.
I run into the room and somehow I knew where I needed to be. I had practiced this. I became the med nurse in the code and things were going well for me. The code lasted and lasted. All I could think during was I’ve been trying to tell people, I tried. Should I have done more? I don’t even know what’s happening. Why did this happen again?
We call it. My patient was gone. The crowd of people in the room disappear as fast as they had arrived. And now I have to go give report on my other patient. The doctor who was on his way in shows up.
Just like that everything’s back to normal. This is so weird. I start giving report on my other patient. In the corner of my eye I see the family walking down the hall. Oh my god I told them he was going to be okay. They see the post-code mess and the patient lifeless in the bed and start shrieking. “What happened to him?!” I can’t find words. Another nurse steps in and puts her arm around the woman and says, “I’m so sorry… he just passed.” She throws the nurse’s hand off of her and the entire family goes into the room and starts wailing. I continue finishing my report.
At the end of report I went in to talk with the family. I felt terrible. There were so many of them crying and yelling. The grandson was like, pounding the countertop in frustration. People are asking me to control the noise. I went in and told them that this had literally just happened, and I was so sorry. They kept saying they knew something was wrong. I guess I did too.
What I learned
I kept replaying the night over and over again and thought about what I could have done differently. At the end of the day, they already said his coronaries were shit and he didn’t really have any other options. So eventually this guy would have died anyways. However, I believe there were a lot of opportunities for myself and others to intervene before it got to a code situation.
- I should have gotten the midnight EKG. If there were issues then I would have called and medication could have been given at that time.
- At that early point in my career, I felt like I had done everything in my power. I had gone to the resource nurse for guidance, I had called the doctors throughout the shift. Everyone was aware of what was going on. So I felt good about that.
- The nurse helping me boost could have stopped and talked through things with me. Experienced nurses should always investigate a situation like that, and help when necessary. It was the end of the shift, and it was crunch time. Gotta make sure canisters are changed and blankets are tucked for dayshift.
- Lastly, I learned to ALWAYS trust your instincts. I knew something was wrong all night and I was right about wanting the midnight EKG and medication. Today, I would have laughed when they said no to the EKG and ordered it anyways. But being new, it really is hard to stick up for yourself when someone with thirty years of experience is telling you what to do. Experience does not equal knowledge. Remember this.
Since that day, I have always been confident in regards to how I feel about my patients. Nurses get vibes you know? Trust them always. It’s better to be over-paranoid than too chill about critical situations. Be proactive and don’t second-guess yourself.
Codes get easier with experience. Get involved when you can, observe people’s roles, and debrief post-code. A code blue is only part of the end of life struggle we all see as ICU nurses. Stay tuned for a future post on how to deal with code status discussions and death/dying as a nurse.