Sunday, December 7, 2008

If All You Have is a Hammer...

“No open heart patient, especially a fresh open heart, dies in this unit with a closed chest - that’s our motto.” This is from my orientation tour by an assistant nurse manager of another CTICU (Cardiac / Thoracic). She was pointing out which code carts were equipped with “chest trays.” I have not seen this so far, but a chest tray will be including some kind of scissors for cutting the sternum and an instrument for spreading the ribs. The idea is to have quick access of the heart in case a complication develops after surgery. The motto is about the ones that die. You can add something like, "whether there is any chance it will help or not," if you like. It is there silently already.

“When all you have is a hammer, everything looks like a nail.” That is my motto. I have noticed that all codes are not equal. In MICUs (Medicine), the codes are generally chemical codes – the doctors look at the patient’s labs and inject drugs to try to get the heart going and to correct any imbalances that may have caused the problem. I favor these over the other types because the doctors are more able to determine whether or not there is any point in continuing. MICUs tend to have the highest mortality rates in their hospitals because they get the endstage, inoperable cases. When death is expected, there is less need for dramatic gestures or heroic attempts.

In case my readers are not aware, I should mention that the statistics for meaningful survival of a real code are dismal – like why do we even bother dismal, maybe we are doing more harm than good dismal. By “meaningful survival” I mean a return to anything approaching normal consciousness and by “real code” I mean when there has been full cardiac or respiratory arrest. If memory serves, it is under 5% of those who are “saved” who ever leave the hospital (just like on TV).

In SICUs (Surgical) the surgeons seem to feel compelled to open the patient’s belly. This makes the least sense to me of all the interventions, but I gather they are looking to release pressure that may be constricting the lungs and for bleeds. I have seen this done a few times with no impact of the final outcome.

Trauma ICUs seem to favor chest tube insertion and their codes tend to go on and on. I saw one where the patient’s heart was stopped for fifteen minutes. We finally did get it going again, but what was left after that I would not care to speculate. After the code the charge nurse, Matt, gathered the rest of the nurses on the unit in another patient’s room to debrief. This is the only time I have seen this, although it really ought to be done after every code. I guess Matt was trying to seize the moment, but the choice of venue was unfortunate. The patient was totally out of it, but a relative was visiting. Matt had his back to the family member, who was standing just behind him. I have often wondered if the Matt realized the family member was there or not. The woman was so close to him, it is hard to believe Matt did not know. Maybe he thought it was another nurse.

Matt asked if anyone saw room for improvement. Not wanting to be too obvious with the visitor right there, I held out my arms and pantomimed ineffective chest compressions. Two male nurses and two female nurses had been doing the compressions. The patient had an A-line, so you could see the blood pressures they were generating. The men were generating systolic pressures in the 60s, which is pretty good for chest compressions, but the girls were only going through the motions, not even putting their weight into it, and they were not generating any pressure at all.

If you are wondering, I did not say anything during the code. I was just there for the day and the attitude was that trauma nurses were better than anyone else. Matt had been in there (he was one of the men who had given good compressions) and if he was not saying anything there was no place for me to. I was glad of the opportunity that came with the debriefing, but Matt just nodded and acknowledged, “The chest compressions,” without elaborating. Apparently he did not feel up to confronting the girls either. He moved on, listing his observations.

We had taken too long to put the back-board under the patient (this gives a solid surface to do compressions against instead of the bed mattress), and we had taken too long to bring the chest tube insertion tray. I watched the discomfort grow in the expression of the family member.

It had taken about ten minutes for the chest tube insertion tray to show up. The fellow who was going to do the insertion had called for it repeatedly with mounting frustration. Apparently it had not been in the usual place, but the task had also not been properly assigned and no one had taken ownership. Matt tried to put some gentle pressure on the nurses to do better next time, but the nurse who had brought the tray in the end felt accused and became defensive. Matt met her forceful renditions of various versions of “It wasn’t me!” with versions of “I am not trying to assign blame, we are just doing this so we can improve…,” but the nurse could not back down and the debriefing unraveled. The family member now seemed even more unsettled, but had no one to talk to. We disbursed and went our separate ways. I guess that is why we do not do the debriefings more often. Too much headache.

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