Thursday, October 18, 2012

Go Ahead and Shock Him Into Asystole, Then

So, it sounds funny to say, but codes rarely work out for anyone.  I mean, obviously it isn't a great starting point, but I didn't know til I became a real grown up nurse how seldom CPR actually does anything at all- and that when it does actually "work", we bring people back to the life of a week long, million dollar ICU stay after which they either a)die anyway or b)spend the rest of their life in some kind of long term care center with a trach and a hypoxic brain injury.  Maybe like, a couple times a year you will get someone who is a legit witnessed cardiac arrest where CPR is immediately initiated and the underlying problem is correctable and they get up and walk out a couple weeks later like nothing happened.  And boy, is it weird when those people check back in to the ER.
Unfortunately, this was not one of those cases.  Guy was older and had already been down around 30-40 minutes when we got ahold of him.  But okay, he's not that old and we've got some gung-ho paramedic students here who wanna do some compressions.  Let's give it a shot.  So we do a couple of rounds of CPR- asystole, asystole, what do you know-V Tach-clear!, asystole, that way too long of a pause in compressions for central line insertion that ACLS guidelines don't want you to do anymore,  PEA... asystole, okay, let's resume compressions, and okay, does anyone object to calling this now, because... yeah.  We've already been doing this probably longer than we should have given the circumstances.  Yeah, alright.  Let's call it.  Time of death is agreed upon, and we go to print the strips off the monitor, and WTF? The patient is in V tach again.  Recording nurse is distressed and tells the doctor we can't print off a strip that looks like this.  "That's a shockable rhythm. I mean, I know you called it, but I can't put this in the chart."
Doctor: "Okay, well, whatever, he's been pronounced, but I guess you can shock him into asystole if that makes you feel better." Walks out of the room.
Okay.  Clear!
Except, uhh.. now it looks like some kind of accelerated junctional funkiness on there.  And, holy shit, the patient has a pulse now.  And, could you hit that button please? A blood pressure! Um, can someone go stop the doctor and tell him before he delivers the bad news to the family please?
So yup, this guy is totally alive again.  Well, technically.  His pupils are non-reactive and he's down with no sedation.  His blood pressure responds pretty well to pressors when the epi finally wears off, but, uh, yeah. Here we are now.  The recorder was apologizing to everyone for the rest of the night, but I would have probably done the same thing.
It felt awful, to be honest.  He had a huge, super sweet family who were eternally grateful that we had saved their patriarch's life, and now we've got to find a way to break the news to them that he's still not really there.  They were on the fence about a DNR status.  They said they wanted everything done but they didn't want him to suffer.   I tried to gently explain that it's impossible to tell if he's suffering because there doesn't seem to be much there. The hospitalist pretty much laid it out how it was, but you could tell they were still grappling with all of it.  I'm sure it probably seemed like he had died twice.
That's the thing that kind of sucks about what we do.  Yeah, it's incredible when our interventions save and improve people's lives.  But so often I just feel like we're making it worse.


  1. yeah, i'm pretty sure i'd just like to be "let go" in this situation.
    especially if chances are brain damage // never recovering.
    i've seen it too, where pts are ACLS and i'm like - seriously??!! she's falling apart in our hands, and you WANT to keep her alive for YOU??
    selfish people.

  2. I can't tell you how many patients we have that do this. The whole refuse to die thing. Most of our patients are older but seriously will be asystole for minutes at a time and then everything comes back-pulse and bp better than mine at the moment. Over and over they will keep doing that without any help from anyone or drugs. I guess it just shows you the power of the body to adapt and want to keep living. The families freak out though especially if you don't do anything because you know it's not real.Couldn't she just have gone back and printed a strip from when he was asystole?

  3. My mom is a nurse too and we talk about this all the time. We put a lot of effort (and drugs/money/resources) into people and situations that really are futile.

  4. We've had long talks about this - the whole keep them on life-support lets the family say good-bye kinda thing. I still think that a) if people saw the effort of codes and knew the percentage of a quality outcome - no pt would want to be coded after 30 min - none and b) the whole getting them to the ICU for a two week stay before having to remove support only delays the family's reaction to the loss and imparts some feelings of ownership to the passing. I'm happy to code pt's as long as necessary, but the more times I see it the more times I am convinced of these.

  5. It's worse with peds patients. No one wants to let them go, so they go on and on for an hour or so. Then on the 25th dose of epi they get a pulse, then send the poor child's body to the children's hospital PICU for the brain death evaluation. By that time all organ systems are gone, and we don't even have the option of donation for the parents.

  6. Thank you for bringing this up. In my 3 years as an ER rn, I have never seen anyone come back and walk out of the hospital. Most of the times, dead is dead. Let them just stay dead.

  7. I don't know if you do this in the adult world, but in peds if we have a code that's going on for awhile and we're thinking about calling it, we will very often bring the family back into the room (if they ever left in the first place...our policy says they can stay as long as a staff person is available to explain to them what's happening and they stay out of the way). Usually once the families see the brutality of a code and the doctor explains that the patient isn't responding, they'll actually be the ones to tell us to stop. I think it's actually therapeutic for the family to see it, as hard as it is to watch, because then there's no doubt in their minds that we did absolutely everything we possibly could.

    I read about a study recently where they were trying to track what influences DNR decisions, and one group of patients was shown a video of real-life CPR along with a video of what a post-arrest patient in the ICU actually looks like...that group chose DNR much more often than the group that just got counseling from a doctor. They also explained the actual percentage of patients who survive to discharge after being coded and how dismally low it is.

    I think most people in the public just don't realize how hopeless codes really are most of the time.

    1. It's true. I think so many people watch TV shows where staff initiates CPR and the patient wakes up and opens their eyes after one minute. I really had no idea how shitty the odds were. I remember being APPALLED in ACLS when they told us that 90 percent of nurses would not stop to code someone in a public setting. I'd say in most cases I'd be one of those people. It just isn't worth it most of the time. I wish there was some way to educate people about this.

  8. In peds it is pretty bad. At my hospital they're giddy to get out the ECMO machine and stick them on that for a few excruciating days only so they can 95% of the time have a horrible outcome.

  9. Wow, this really touches home with all of us. I mean, why did we go into nursing? But it is the wise nurse who recognizes that not all interventions are for the good of the patient or family. When it's time to go it takes great strength and love to respect that nature has the last word. Nobody gets out of here alive and it's not the role of medicine to force the notion that a chemically sustained pulse qualifies as life. Brava my girl for speaking truth.

  10. Thank you for wonderful post! During my years as an ER rn, only a few were able to make it through but only through miracle I cannot able to explain. It's to believe but most of the times, it give me some creeps seeing someone pass-away.

  11. Interestingly enough, a friend of the family walked into her local hospital after seeing her MD for mild neck/jaw discomfort for a couple wks (yes, that's it!) and dropped dead on the floor of the ED waiting room. They managed to resus her and at one point a few days later, she coded in radiology....she was resussed for the second time, and after a week in the hospital (and a couple stents later) and she is now at home, living by herself (still has pain) but is remarkably - still alive. I am always a little apprehensive when I go over and visit her.....