April 15, 2018

Crashing Patient | Chaos & Panic Not Necessary

So, you were doing your assessment, and your patient starts crashing. This is becoming a common occurance for me, and I wanted to offer my two cents on how to manage these events. I've noticed some nurses going into a full-on panic mode when their patient start crashing. He or she starts yelling commands to random people in no particular order, starting five things but finishing none, and finally calling the provider but unable to answer common questions because of their lack of investigation. I get it, someone is about to code or is in the process of coding and it's frightening. I've been there, but you must understand that panic mode is unproductive and serves no purpose. You must also understand yelling random things out in a hallway will get you nowhere. This is your profession, your career, take a breath and do what you already know you need to do...

Initial Event 
Okay, your patient is in respiratory distress or severely hypotensive, what do you do? Elevate the head of the bed, apply a non-rebreather mask, auscultate those lung sounds, check cuff blood pressures q5 minutes, get some labs (a rainbow, perhaps), get an arterial blood gas or maybe a chest x-ray (depending on what items are nurse-order driven), and let's do this! You already know what needs to be done. It's the emotions that get the best of some people. Yes, a crashing patient is terrifying. You replay the entire shift in your head, trying to remember if you did anything wrong. But you need to be focusing on the current problems and manage them BLS/ACLS style until the provider arrives. Nursing isn't rocket science, and no one expects you to make unilateral decisions. You have the toolkit within yourself. You just need to focus on the right things in times of crisis.

You remember the primary survey right, ABCDE (airway, breathing, circulation, disability, exposure)? Whenever my patient is crashing, I go into primary survey mode and work my way down. I assess my patient and lookup pertinent information while in the room. If your patient is unstable, you need to stay in that room until the cavalry arrives (if feasible). Because when the provider comes, he or she will want to know the background and not just the event specifics. Your patient is in respiratory distress, huh? Well, has the patient been tachypneic all day or is this a new finding? Any fever in the last 24 hours? Any history of COPD or lung disease? Yes, all this seems unimportant, but decisions are based on the patient's background, as well as the current clinical picture. The provider is attempting to whittle-down to a few differential diagnoses. To do that, he or she needs information. The faster you can access this information, the sooner your crashing patient can get the care he or she needs.

Once you have your orders, you need to execute them in a timely fashion. Your patient is unstable, right? So getting that bolus hung and infused is essential. Getting that BIPAP order and calling respiratory therapy is critical. If a provider is giving me tons of orders, I get out a pen and napkin or glove (because who has paper) and I start writing (verbal orders in times of crisis). Once you read back the orders, you then need to begin your closed-loop communication threads. Screaming random orders down a hallway will get you nowhere fast. You need to find a particular person and say, "Amber, can you grab me a 1-liter normal saline bag and some primary tubing, please? My patient is crashing." You then wait for her to say, "Yes, I will get you a 1-liter normal saline bag with some tubing." You need the confirmation. You need the feedback! You then know she is working on it (hopefully quickly). You can scratch it off your list and continue. So many people scream things during a code, and you know what happens? Nothing, because, umm, who is getting what? What did you ask for? Your command was non-specific, so you got non-specific results. Do you want help? You need to command people's attention and ask properly. This isn't the time to be coy. Ask for what you need and get confirmation someone is working on it. You can't be mad if no one does what you're asking if you're asking the ceiling.

Follow Through 
Once you have the orders, it's on you. It's on you to execute these orders. And if the patient keeps deteriorating, providers are expecting you to update the team. You gave the bolus, what is your blood pressure? Still 60/40? You need to call the provider (again) and update him or her on the intervention's outcome. You must update the provider, and you must follow through on hemodynamic instability, change in a patient's condition, or abnormal vital signs. This is where some people fall off completely. Some folks will complete an intervention (a bolus given r/t hypotension), but then chart a blood pressure of 65/35 for four straight hours. Are you insane?! If the response was unsuccessful in keeping your patient hemodynamically stable, your job is not finished. You need to update the provider on the completed intervention and seek additional orders. This isn't a middle school soccer game. You don't get an award for merely showing up. I know, we get super busy. But you must finish what you started. And updating is as significant as the initial event. No update to the provider means the initial intervention worked and you no longer need an escalation of therapy. Understand that providers can monitor an upward of 30 patients at a time. No call from you means the issue is resolved, certain parameters were met, and the intervention was successful. No news is good news.

That's really it. It all comes down to proper communication and feedback. Yeah, it seems self-explanatory but you have no idea how many times people do not communicate properly and things are missed. Assess, communicate, implement and follow through. It's that simple. Managing a crashing patient doesn't need to be convoluted. You just need to be clear in your instructions and evaluations. You know what you need to do, just get in nursing rockstar mode and do it.

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