Critical Care / Emergency / Trauma

From our readers: My first code—A retrospective report of a premature promotion and a crisis situation

The elevator’s walls were covered in bronze and silver raised metal squares that gave the appearance of a magic eye puzzle and smelled of the stainless steel cleaner that was probably wiped on that morning. I remember thinking that if you spun around in here too fast the vertigo would be unimaginable. Fumes from the cleaner were so thick that I had the feeling that someone had placed a nickel under my tongue. As I continued to perform compressions on the elderly woman who had just arrested for the third time, I thought, “How did a new nurse wind up in an elevator with a critical patient and a first-year medical intern at a major trauma center?”

The beginning

The situational norm of initiating a new nurse to the floor through weeks of orientation and extra training was superseded by the hospital’s initiative to transform the facility to an environment of electronic charting. A brief IT background and a knack for understanding computer applications made me “appear” on par with the most seasoned veterans of the unit. The reality is that most of the time the satisfaction of keeping my patients alive for 12 hours was the only thing that gave me the courage to come back the next day.

A vast majority of experienced nurses now found themselves charting on the computer, scanning medication, and printing forms from various databases. These same nurses never had an interest in getting an e-mail address much less working on a computer so these core tasks seemed to consume the entire shift leaving tasks like scheduling and staffing assignments to people like myself who were more technologically savvy.

It wasn’t long before I was placed in charge of the unit because of my apparent, albeit false, ability to function so efficiently.

The crisis

Norma M. was well known throughout the hospital. She was 91 years old and had a history of metastatic lung cancer. She was a pleasure to be around, and the staff liked her. After every hospital stay, each staff member would receive a handwritten thank you card in the mail and a box of candy to pass around the nursing unit. She would never call unless absolutely necessary, and every request was preceded with please and followed by thank you. Every day her daughter and son-in-law would visit after work, and on the weekend her grandchildren sat by her playing cards while watching the clock to ensure an appropriate amount of time had passed before they could graciously escape back into their lives. To an outsider these visits might have seemed perfunctory or regimented but her family never missed a day.

I had been a nurse for a little over 3 months and the letters A C L S meant almost as much as the ink it takes to write them when one evening at about 5 p.m., an LPN came out of Norma’s room with a look of pity and sorrow on her face. She asked me how long Norma had been so confused. “She’s been fine, just short of breath last night so she came in,” was my honest response. Before the LPN could finish saying the words to describe her current appearance two of the nurses that I had considered inept (due to their difficulty with the EMR conversion) ran into the room and found the patient in acute distress. Her breathing was shallow and tachypneic, she was diaphoretic, and her responses were slow and incomprehensible. One of the nurses yelled for a vital sign machine and the other yelled out to call for a rapid response. As the equipment arrived—along with the doctors and what seemed like half of the hospital—the two nurses began connecting equipment and both commanding and following orders to and from everyone else in the room. I was the one who felt inept now.


The response

The parade of equipment that was being brought into the room seemed endless at the time. I have reflected on this event and pieced everything together to the best of my ability so a better picture can be painted. Being a new nurse in a crisis situation can be likened to transferring high schools in the middle of your junior year. The vital sign machine was wrapped around Norma’s right arm, but was ordered to be moved to the other side due to a central line; the pulse oximeter was placed on her left index finger but fell off every couple of minutes. A tall, serious doctor flipped angrily through Norma’s chart in the corner of the room occasionally asking why this wasn’t done or why did this happen. Embarrassingly, I had very few answers, which seemed to make the doctor more agitated. When the code cart arrived I placed the defibrillator at the foot of the bed and began to fumble with the leads that had been either improperly wrapped or had been tangled by myself when I was moving the machine. One of the physician assistants said to a hospital aide that Norma needed a “finger stick.” In an effort to run and hide I volunteered to go get the glucometer to read the blood sugar.

For the first time since I was hired, there was nobody in the hall. If there was a closet close by I am certain that I would’ve curled into a ball and hid out until my shift was over. At the end of the corridor the secretary was at her desk looking at me as though she was waiting for me to bark the next command that she would need to carry out such as a blood draw label or to page a specialist. If only she knew that even though I had just come out of that room, I had less of an idea of what was happening than she did. To avoid conveying my feelings of uselessness and panic I asked her in a stern and confident tone for the glucometer. She informed me that it was already in the room.

As I reluctantly made my way back into the room I glanced at the foot of the bed to find that the defibrillator had been attached and was reading a heart rhythm. The hospital aide was getting the blood from Norma’s finger to test her blood sugar while another nurse worked over her head stretching on her tippy toes to attach a suction set to the wall. On the other side of the bed were countless medical students easily identifiable by their short white coats and the stern doctor who had been reading the chart who I would later find out was the attending physician. To either side of him were two younger doctors who seemed eager to get involved but like me had no idea what to do. At Norma’s side were a physician assistant and a nurse practitioner, both of whom seemed to be autonomous and well versed in everything that was happening.

The glucometer takes 30 seconds to analyze the blood sample and beeps like an old Casio watch three times when complete. After the third beep there is a pause that can’t be more than a second but in this instance felt like an hour. “Thirty two,” the aide said with coolness in her voice that I would have killed for at that moment. The nurse standing at the code cart began digging through one of the drawers and removed a blue box. She opened the box and assembled the dextrose 50% for administration and handed it to the nurse practitioner. The nurse at the code cart immediately reached into the cart and began to assemble a second system.

Almost right away Norma’s eyes opened as blood rushed to her cheeks, giving her complexion a rosy undertone that transformed her from what appeared to be a zombie back to somebody’s sweet grandmother. In my mind a round of applause was bellowing through the room but as I looked up from our sick patient all I saw was a sea of white coats leaving the room unfretted by what had just happened, discussing lunch and other patients they were off to see.

The rerun

In the midst of the crisis, finding a spot to stand in the room is what I imagine floor seats to a Grateful Dead show in their prime must have been like. However, the moment that the patient was stabilized, I found myself left alone to clean up the mess. I began picking up the gloves that were thrown on the floor and making small talk with Norma. There was a stethoscope on the windowsill, and the bedding was thrown in the corner. For every piece of equipment that is normally in high demand, such as suction sets and IV pumps, I removed at least two.

After about 5 minutes of conversation and cleaning I approached Norma to remove the defibrillator. As my right hand touched the white lead on her chest a loud beep pierced my ears and felt like a screwdriver had penetrated my brain. I jumped back in time to see her eyes roll back in her head, and the color that had just come to her face disappear. The defibrillator showed a wavy line that I would later discover was ventricular fibrillation. I was frozen! All I could do is muster one word: “Doctors!” I yelled into the hall. I remember thinking immediately how ridiculous I must have sounded and that even though this woman in front of me was in great distress I was able to find joy in the fact that my voice didn’t crack.

The parade of healthcare professionals returned almost instantly as most of them were still in the hallway. As I sat in the corner of the room watching the nurses I had once considered lazy or inept performing CPR and injecting different medications every time the picture on the monitor changed, I prayed that I wasn’t going to wake up in the next bed with another nurse telling me that I passed out.

The house supervisor’s voice was barely audible when she asked which nurse was taking care of Norma. Finally an out, I thought, as I made my way to the hallway so the supervisor could tell me to call the ICU with a report. The patient was going to be transferred if she survived this code. Even from the nurses’ station the sounds of the nurses yelling clear before they defibrillated and the cadence of doctors calling for various meds gave me an eerie chill.

In retrospect, the report that I gave must have aggravated the nurse in the ICU to no end. My lack of medical terminology, knowledge, and understanding couldn’t be hidden here. Perhaps the only saving grace was that I was in front of a computer and was able to navigate through her chart with ease to provide information. Once again my computer background helped me fake a sense of competence.

The transfer

The young intern who had earlier been standing next to the attending physician came up to me and asked, “Are you ready to transport?” I hung up the phone in time to see the bed exit the doorway, pushed by more people then I could count in the mayhem.

In the narrow transition from the room to the hall there is only room for one person at each end of the bed so in an attempt to keep up the façade of being a useful nurse I grabbed the Ambu bag that had been temporarily laid down next to Norma’s head and started squeezing oxygen into her endotracheal tube. The intern and I pushed her to the elevators where a security guard was holding the door open. Mentally, I placed this person on the long list of people who were more prepared to help than me as I squeezed the bag at a rate that now I am sure was too fast and deep.

The intern got on the elevator first, followed by me, standing on the patient’s headboard area of the bed. My positioning didn’t allow the bed to be pushed completely into the elevator thus preventing anyone else from fitting in. The image of the tall angry looking attending physician handing to the intern what I would later find out was a Carpuject filled with 1 mg of epinephrine remains one of my most vivid memories. His message was somehow both simple and calming, “She is paced, if anything happens use this, I’ll take the other elevator and meet you there.”

What could go wrong in five floors?

The same elevator that usually travels fast enough to induce vomiting and that I complain about everyday seemed to be taking forever. The intern looked scared. Not a word was spoken between us until the defibrillator alarmed the same way it did in the room so long ago. Not that it would’ve helped but I couldn’t see the monitor to decipher the rhythm. The look on her face assured me that the intern had no idea what caused the disturbance. She extended her arm with the pre-assembled epinephrine as she asked me in a very soft voice if I thought the patient needed the medication.

Looking at the Carpuject from the head of the bed, I realized that I didn’t even know how to attach it to the IV system. My only thought was to mimic what I had just seen. Giving one last squeeze of the Ambu bag, I abandoned my post at the top of the bed and jumped over my patient to begin chest compressions. Almost right away the doors of the elevator opened where I found several others shocked to see the rapid decline. We were wheeled into the ICU where I jumped off the bed and stood back for a moment as the team worked.

The aftermath

I took the stairs back to my floor where I was met with pats on the back and congratulations for the excellent job that I had just performed. I wondered whether they were so busy with everything that was going on that nobody noticed my inadequacies or whether everyone was being polite so I wouldn’t feel bad. I contemplated everything from a career change to never taking an elevator again. The entire ordeal continues to replay in my head as it did that day. I will always remember that moment as the moment that I decided that being able to complete the task wasn’t enough; a good nurse understands why the task is being done in the first place.

Because of my background in computer information systems I was able to excel in a field that is based on caring for people. I erroneously had the opinion that those around me who were less computer savvy were less capable. My perspective has changed since that day. Now, when I am asked to teach a nurse how to use a new computer application or where to click the mouse I do so with the greatest patience. I imagine how difficult it would be if I was told that I had to provide patient care without the assistance of computers.

I have been able to carry that lesson into the field of nursing informatics and will never forget Norma or my first code as a new nurse.

Note: Norma never regained consciousness, but she survived long enough for her family to arrive and say goodbye.

John A. Copas, Jr., is a nursing informatics specialist at Niagara Falls Memorial Center in Niagara Falls, New York.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

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4 thoughts on “From our readers: My first code—A retrospective report of a premature promotion and a crisis situation”

  1. Anonymous says:

    Maybe I am missing something here,but why is a 91yr old woman with metastatic cancer being coded?? Thelessonlearned is valuable however,and worth passing on.

  2. juliemsn says:

    Be scared, because your job is to prevent the code by assessing and treating before the patient codes. Unless, of course, your pt arrives in this condition. 25 years later and codes still scare the heck out of me. It’s good to hear others feel this way as well.

  3. SARA, RN says:

    You know, I am a relatively new nurse and have not yet had a code on any of my pt’s. I had a revelation, however. If the pt has gone to this point of calling a code, they are either dead or nearly dead and anything and all we do is only going to help!! So why be so scared?

  4. TerryJ says:

    Thank you for your story. I have been a nurse for 17 years and still remember “my” first code blue. I still remember my feelings of inadequacy and being scared out of my mind. I don’t know that these feelings will ever leave me, but it is comforting to know that other RNs share and understand the experience.

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