Despite years of life support classes, starting with BLS in high school and then graduating to ACLS and PALS towards the end of nursing school, I never had to do compressions on a real patient. The occasional code happened on my other units but I managed to slide out of participating, and if I was involved, I gravitated towards roles such as recorder or comforting the family. I never rushed into the action. This piece comes from right after I did compressions for the first time in the CVICU.
On this day my coworker in the next room had a very sick teenage patient who came to our unit with heart failure. She was getting ready to send him to the Cardiac Catheterization Lab. Since my patient was ready to transfer to the step down nursing floor, I helped my coworker consolidate IV pumps, unplug cords, and prepare medications for their trip. The CVICU physicians, concerned her patient was too sick to tolerate the trip to the Cath Lab without cannulating onto ECMO (the machine that does that work of the heart and lungs outside the body, connected to the patient via a cannula into the carotid artery), decided to intubate this fifteen year old and put him on ECMO preemptively. After rearranging the room and his bed to make intubation and cannulation onto ECMO more optimal, roles were assigned: the attending physician would call instructions, the fellow would intubate, the primary nurse would push meds, the nurse practitioner was in charge of the defibrillator machine if needed. Outside, the operating room nurses were wheeling their supply carts into the hallway, setting up for the planned ECMO cannulation after the fellow inserted the breathing tube. Other nurses and doctors stood in the hallway, if other roles or supplies were needed. I was standing next to the bed adjusting some IV tubing when the attending physician assigned me a role: compressions. The heart failure physician would be the second compressor. I panicked inside, but in the midst of the chaos, I took some deep breaths and just hoped my role might not be needed.
Our “soft” code started. The attending gave instructions in her soft yet authoritative voice. The nurse pushed paralytic and sedative medicines to make the patient comfortable. The fellow measured the patient’s airway in preparation for intubation then I listened for his breath sounds. As they got ready to insert the breathing tube, the patient’s blood pressure started dropping: 80/40…60/30…then 40/15…
“Sarah,” the physician instructed, “Please start compressions.”
So I did. I climbed up on the bed, balanced my knees on the edge and put my hands on his chest, one of top of the other between his nipple line, and started. “One, two, three, four, five, six…, “ I counted out loud, not really sure why, but that’s what we always had to do in life support classes. I wasn’t really listening to myself, maybe someone else would keep track and figure out how long I did them for? If I was doing at least 100 per minute like the guidelines suggested? Did we even assign someone to record since it was a soft code situation? These worries flew around in the head as I continued, “fifteen, sixteen, seventeen, eighteen…,” How long was I supposed to do this?
Two things stood out:
First, my ID badge swung like an angry pendulum from my scrub top as I compressed; my knees on the mattress, my body leaning over this fifteen year old, up and down up and down up and down, pumping his blood. I should have removed my badge before I started, I thought.
Second: Outside in the hallway, I saw the patient’s mother fall apart, collapsing into her husband’s arms for support as she watched me compress on her son’s chest. I felt embarrassed that I was up there, causing her this anguish.
I have no idea how long I continued but at some point the attending instructed me to hold compressions. His blood pressure had skyrocketed and they had successfully intubated. Part one complete, the surgical team took over to set up for ECMO cannulation.
Another nurse took over my helper role and I got to escape to my patient’s room in order to get him ready to transfer out of the ICU. But for the rest of the shift, it was hard to shake off the sensation of pressing repeatedly on a teenager’s chest, pumping blood to his brain.
A few weeks later, this patient, now off of the ECMO machine and extubated from the breathing machine, was steadily improving. I was assigned to take care of him. His mother immediately recognized me as the one was was “pounding on her son’s chest that day.” And I admitted to her how terrified I had been, how glad I was that he was doing well, and that I had no desire to make that experience part of our day again. She agreed.
Compressions are usually part of a greater resuscitation plan, one that we re-certify at life support classes every two years to know, but that doesn’t make it any easier to perform them. At least not yet. Maybe over time this will change. As compressions become less awkward and I do them more often, I’ll remember to remove my badge, and ideally explain to the family member beforehand what to expect, if this type of planned code arises again. Looking back, I have to remember that these few minutes were all part of a bigger picture plan, one that thankfully had positive results for this patient and his family. This is not always the case.
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