Working in a developing country has reacquainted me with why we do things the way we do in the US. You never realize how much thought has gone into the filling and organization of a crash cart until you ask for a saline flush and you get a blank stare.
Anatomy of a Code
I just left a code blue, a very successful one. Yes, the patient died; he never had a rhythm. But a list of the learning experiences we had this morning would cover two pages. At the beginning of the debrief, I thanked the patient for giving us this gift.
Where I work....
I work in a developing country in East Africa (not naming the country for anonymity's sake). But I don't work in a refugee camp or a primitive cinderblock hospital like those I used to see in the news; I work at one of the better-equipped hospitals in the region. When I first arrived a year ago, I doubted whether I was really needed, whether I shouldn't be somewhere where the need is more desperate. But not only has this hospital demonstrated some real gaps that I have tried to help with (it might be the best, but it is very far from a western hospital), but we are a beacon for the rest of the country, a small microcosm showing what might be accomplished with more staff, more supplies, more water and electricity.
The code blue, or "resuscitation", as we call it here, started the same way they do in the US: a patient's relative came out and said the patient wasn't breathing. I found out about it the same way I do at home: someone called for the crash cart (or "emergency trolley"). I left my office and went to see what was happening. I saw someone giving chest compressions without gloves on, so I put on gloves and took over.
There's no overhead paging system. Someone ran to the ICU and the nurse manager and charge nurse came over to be the code blue team. Doctors got wind of the situation and came in. The nursing students came in the room but hung back. My nursing students this week are experienced nurses with high school educations, in the process of continuing their educations to get a nursing diploma through a bridge program. Certainly they had seen many patients die, and perhaps had even attempted resuscitation, but they never had seen a coordinated effort with this kind of equipment.
What went well? Teamwork.
The nurses looked for unmet needs and moved quickly. When I participated in a resuscitation earlier in the year, it was chaos; some things happening, other things not. Mostly, I have been frustrated by how slowly the staff often moves in cases that seem urgent to me. Later someone might explain to me that no one moved fast because they considered it a lost cause. The nurse manager and I have been trying to change that way of thinking.
Compressions also went pretty well. It has been hard to train people in CPR without enough dummies; often for our CPR classes (taught by a local nurse; I'm just there to help with a practice station) we have three dummies for thirty people. But I saw that with some coaching, the staff is now pushing hard and fast. We just have to work on placement. There is a perception that compressions should be done over the heart instead of on the sternum.
When you do CPR in a different language, there are some surprises. The language of the hospital is English, but most staff are more comfortable in French, and most comfortable of all in the local language. Counting to thirty in the local language takes way too long--the number words are lengthy. Some count in French, but they are "supposed" to count in English (I couldn't care less, but that's how they're taught). Except remembering how to count to thirty in English is hard for them even when they aren't under stress; forget doing it in the middle of compressions, loudly. Typically, they count to ten three times in English, speaking under their breaths. Try being ready to give breaths in that situation!
So, what were the struggles?
One, and I include myself in this... those directing the action were trying to do too much. No one can do good CPR or give effective respirations if they're also trying to tell others what to do. I took myself and the ICU manager out of the patient's direct care, stopped a nurse from doing anything besides giving medications, and told the resident leading the code that he was not to be in line for CPR. I was the most experienced at BLS/ACLS, the ICU manager knows more about the contents of the crash cart and can speak the language if necessary, and the doctor needed to be free to make orders. I am used to working with an extremely efficient code blue team where everyone knows what to do and where to stand. I remember how unnecessarily perfectionist some of that seemed when we started the code blue team. The value has never been clearer.
We didn't start ACLS soon enough. Epinephrine was given somewhat regularly, but otherwise, we were really doing BLS. We started with an AED and didn't switch completely to the manual defibrillator. I have probed before about why, when outcomes are just as good if not better with the AED, we still use the manual defibrillator in the US. OK, I get it now. I didn't realize how much I relied on being able to read the rhythm on the manual defibrillator.
You know that ACLS algorithm that hangs off every crash cart at home? Usually I don't see anyone consult it, but we really could have used it and I definitely see its value. I asked the ICU nurse manager about the algorithm later; she told me it is posted on the bulletin board in every nurses station and then agreed that it would be better stored on the crash cart.
We disagreed about intubation. I asked (in the middle of doing compressions, oops) if anesthesia was coming to intubate. I was promptly told "the priority is compressions". This is a problem I run into a lot here... the nurses and doctors receive half the message but the whole story is lost. Yes, the compressions are the priority and I'm glad they understood that, but it doesn't mean intubation is just a "nice to have".
I think part of what played into that--once intubation was attempted, twenty minutes later--is that it was clear the doctors aren't very comfortable with intubation. Anesthesia wasn't available, so a medical resident tried, with some difficulty (we never made it). There were great delays in compressions while intubation was attempted. This is one of those things that the ICU nurse manager probably understood but didn't say; I was the only one who didn't know.
Supplies in the crash cart were severely lacking. We didn't have enough of any of the drugs; we had few options for suction tubing. The CPR board was attached to the crash cart with zip ties and we lost valuable time waiting to get it placed (no CPR button on the bed, of course). And when the first dose of epinephrine was given and I asked for a saline flush, I remembered immediately that we don't have that. I asked for a nurse to start drawing up flushes, and what was available was sterile water rather than normal saline. The nurse drawing up medications understood my point and began drawing up water flushes every time he drew up epinephrine, but another nurse might not have. And several people told me it was unnecessary because the patient had a running IV. Because flushing isn't common practice in any case, there isn't a great understanding of how fast a flush moves versus an open IV.
The doctor called the patient after half an hour of resuscitation. If we had known how ill he was (metastatic cancer, which wasn't what he'd been admitted for), we might have stopped sooner, but we never had a chance to talk about that. When the doctor said "Okay, we are stopping," I said promptly a variation of the words I know so well: "Does everyone agree that we are ready to stop this resuscitation? Does anyone want to try anything different?" Everyone looked at me in surprise. I made quick eye contact with all of them. "We've done everything," the ICU nurse manager said, puzzled. "I know, but this is the question we ask," I said. Everyone agreed to stop. I thanked everyone and, because this is a religious country and we pray together before starting shift report every day, I asked one of the nurses to pray for us and the patient before we cleaned up. This, too, isn't the practice and was a surprise to everyone, and yet it seemed like the culturally appropriate thing to do. I wondered if in trying to make resuscitations as streamlined and western-like as possible, the staff had come to feel like their own cultural practices were not welcome or appropriate.
The resuscitation itself was a straightforward one. Nothing unusual happened; nothing we did for the patient did any good. But it was yet another situation in which I learned and grew at least as much from being here as the patients and staff benefit from my presence as a nurse educator.
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