Spiga


Trau·ma  Junk· ie  ( 'trau-m&  'j&[ng]-kE) n. Slang
  1. One who has an insatiable interest, devotion or addiction to responding and assisting people with serious injury or shock to the body, as from violence or an accident.

A Tale of Respiratory Arrest at Shift Change

At around 0415, the patient, a 52-year old male, was admitted to the cardiac unit, diagnosis A-Fib with RVR. The doctor ordered a Cardizem drip, "Titrate to keep HR less than 100."


Fast-forward now to 0600, and Mr. Smith was assisted to the bathroom by the nurse and CNA. Upon returning to back to bed, he stated he felt very weak, and was helped to the floor. He took a few agonal breaths, stopped breathing, and no sooner than a few seconds later, the operator comes over the PA, "Your attention, please. Code blue, room 518..."

The Code Team responded. The CNA (who also happened to be an RT student) was bagging the patient until respiratory arrived. The primary nurse gives a rapid report to the code team: "Pt is A-Fib with RVR, helped to the floor after leaving the bathroom. He is apneic but has a pulse of 40." The admitting physician, who happens to be in the emergency room at the time, rushes to the bedside.

"Call tele and get me a rate and rhythm, stat," he announces, speaking loudly over the nurses, respiratory therapists, EKG tech, and security guards.

A frantic CNA picks up the phone and dials the extension, "What do you have on room 518? I mean, what are they reading? I mean...we need a rate."

It was like the telemetry technician had been sleeping. She mumbled in confusion, "Do wha--? 518?"

This was normal for the tech, who is always working all kinds of crazy hours, so the CNA chalked it up to the fact that she was probably watching the patient who is coming in and out of SVT in the room next door. "Yes, 518. Give me a rate."

At this point, the tele tech heard all of the commotion in the background: "Just keep breathing for him. Don't start compressions yet. Open the crash cart, get the Atropine ready. D/C the Cardizem."

"Oh, 518. Sinus Brady at 40."

The CNA slammed the receiver down in hurry and yelled the reading over all the commotion. At this time, the RT had taken over bagging for about a minute. The patient came to, started breathing again, and complained over the worst headache of his life. "Where the hell am I?"

There was a huge sigh of relief and some smiles from the Code Team members, but they knew they'd have to do something about the heart rate or they could be doing it all over again in a few minutes, with compressions. The patient was put back in bed and hooked up to the monitor on the crash cart. Atropine IV push, and the rate increased to 60. A minute or so later, and the patient was in sinus rhythm at 65.

The commotion cleared the room in a matter of seconds, as the staff on the unit returned to what they were doing and the code team quickly dispersed down the stairs and back to the ICU, ER, and the doctors' lounge. It was a job well done, due to the quick response of the staff. They all knew that if they hadn't gotten there in the first 3-4 minutes, the chances of the patient's survival would have decreased by about 70%.

The primary nurse and the charge nurse were outside the room discussing the situation and ensuring that everything was documented. Once everything calmed down and they exited "fight-or-flight mode," their thoughts were redirected from saving the patient to discussing how this happened.

The primary nurse looks at the charge nurse, "Wait a minute... Telemetry said the patient was Sinus Brady at 40, right?"

"Yeah, and?"

"They came in with A-Fib, and I have been infusing the Cardizem since four-thirty."

Just then, I spoke up the measly CNA spoke up from around the corner. "You had me enter the orders in the computer, and I remember, 'Titrate to decrease heart rate to less than 100.' That can only mean two things: Either the tele tech didn't call you when the patient converted and the rate decreased to 100, or the rate dropped so quickly that she didn't have a chance to call." I he said, sharing what little bit of knowledge he had learned about the cardiovascular system in RT school.

"I didn't even think of that," the charge nurse stated, as the primary nurse agreed that it didn't ever cross her mind. "I'm going to go look at the strips in the monitor room."

Lo and behold, Mr. Smith converted to Sinus Rhythm, with a rate of 80, at around 0545, after an hour and fifteen minutes of Cardizem. Minutes later, about the time that the patient was helped to the bathroom, the rate dropped from 80 to 60, and the Code was called about 15 seconds later, when the patient stopped breathing.

If you've made it this far, I hope what you've learned is this:
1. The "little guys" can be pretty knowledgable at times, so don't just blow them off.
2. Whether you're a doctor, nurse, respiratory therapist, CNA, nurse practitioner, etc., always oversee the care that others are providing, be a patient advocate, and check behind others. Don't get so comfortable with the people that you work with to the point where you don't CYA (cover your ass).

I'm not a doctor, or even a nurse or RT, but it's easy to tell how this could have been prevented: If the nurse knew when the patient converted and the heart rate dropped to less than 100, she could have stopped the Cardizem and all this most likely would have never happened. It's scary to think that all of this almost cost a patient their life, and I'm afraid that would have been the outcome if the respiratory arrest went unwitnessed and the patient had been laying there for 5-10 minutes.

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