The First 30 Seconds: What to do When Your Patient is Crashing
A universally applicable guide whether you're ICU, PCU, or med-surg level Nurse, regardless your level of experience.
You’re new here. Congratulations! You made it to the floor. A place where newness is often met with hostility and those "varsity" entrenched, embittered nurses wait with bated breath for you to fail. Hopefully your floor isn't a meat grinder like my first couple were. But if it is, this stupidly simple algorithm will make you look like a veteran, requires minimal conscious effort, and will have the Rapid Response Team and/or Code Blue team giving you a second look because you just did what 90% of experienced ICU nurses don't.
Keep calm and breathe. psych! You're body will be contemplating whether or not to release its bowels as you feel the threat of your patient dying. That's good, it means you care.
1. (really) Plan. Did your report sound ominous? Got some ST changes right out of the cath lab? Blood pressures or heart rate swinging erratically? Good for you for having the foresight to see these are red flags. Use your intuition. Does looking at this patient make you feel uncomfortable? Existential dread? Sinking chest? Listen to your body. If you answered yes to any of these questions, what can you do ahead of time for if/when shit goes down?
What kind of access do they have? You don't need to be an IV wizard (we'll get to that in another post). Simply know what they have and take a second to flush the line. Does it work? Excellent. That's the first thing the code team is going to bark in your direction. You can now answer this question with confidence, or prioritize getting a new line--just ask someone who is good. Everyone loves to show off their IV skills. You don't need to spend unnecessary time digging around in 3rd spaced arms for veins that are 1/2 inch under fat and fluid. A small note: If you're having a 200 IQ day, take a second to note where the CPR switch is on your patient's bed. It'll either be a pedal on the floor near the head, or a red lever near the foot. It’ll read "CPR" and get the bed flat in a hurry.
2. Defibrillator pads. You don't need to dramatically grab them and slap them on, but you can always sneak a set into your room. The closer they are to being attached to the dead body, the faster you can do all kinds of things to bring them back. If you have any suspicion at all of any lethal dysrhythmia, go ahead and place them. If the code team comes through and you've already got pads placed, you are god-tier in their eyes (mine anyway). If you are a new grad and you're doing this, people will tell you to go to med School (don’t go to med school).
3. Are they intubated yet? If not, Make sure they have suction available at the bedside. If they lose their airway, the first thing the intubating MD will need is to have all the goobers cleared. As a bonus, you may be able to keep your suddenly dead/dying patient from aspirating. Truly, it's great practice to have suction set up and ready to rip on every single patient you care for. 200 IQ bonus: make sure there’s a bag valve mask within arms reach.
4. Caught with your pants down? Did they just up and die without warning? There's no avoiding the panic at this stage. Everyone, regardless experience, will be stressed here. Best thing you can do in this moment? Smack that code button and scream politely into the hallway for some f***ing help! Then immediately step on that pedal at the bottom of the bed that flattens the patient out and start hammering on their chest. Much harder than you think. If you remember the mannequin in the BLS/ACLS class, its harder than that (90 year old full-code granny is the exception). The goal, truly, is to break the patient's sternum so you can better simulate the contraction of the heart. More on good quality CPR later.
5. When the code team arrives, expect calamity. People will start yelling for a background on the patient. You have that information. If you are drawing blank, that's OK too. All that really matters in this moment is that the patient is dead and the code team is there trying to make them not dead. You've already done more than 90% of experienced "competent" nurses.
6. Stay in the room. No matter what. Even if you do nothing but cower in the corner. You need to absorb this atmosphere. You need to learn this environment. You need to desensitize yourself to this reality. You're in the hospital. People die here. The better you get at acclimating to this chaos, the better you will be at helping people stay alive.
7. It's over. You can change your underpants now. Great job. You did it. Maybe they died. Maybe not. You showed up. You cared enough to read this so you can get good at doing hard things.
Cheat Sheet:
Plan. IV good? Where is the CPR lever on the bed?
Defibrillator pads? In the room or on the patient. Use your gut
Airway plan. Got some suction? Got a bag mask hanging up somewhere? Get it.
Oh shit they crashed before I could do any of this! Hit that code button. Flatten bed.
Hammer on chest.
Condensed Cheat Sheet:
Good IV
CPR lever location
Dfib pads
Suction and BVM
Code Button
Crack Sternum
Code Team chaos is OK
Stay with the code
Print the article, cut out the cheat sheets, show your friends