Wednesday, June 06, 2007

Pediatric Code Blue

Let me say here and now, for all and sundry, that deathly sick kids just flat scare the hell out of me. They always have and they always will. I am glad we have established that. So bringing one back from the brink of death has the tendency to cause old goobers like me to pump my fist up and down and shout, "Hell yeah, woo-hoo!". And when a kid dies, it rips the heart out of the entire department and it takes weeks- sometimes months- to recover from the shock and grief. So we get pretty uptight when a sick kid comes in and we fight like cats in a dark bag with a snake in it to keep that kid alive.

A 4-year-old little girl was brought straight back from the triage desk. I mean, right now. She was the kind of case that flat scares the hell out of a nurse. She was sitting bolt upright even as she was carried in by her dad; her nose was way up high in the air, and the air she sucked down her constricted airway was honking, goose-like, as if forced through a pinched straw. Her eyes were watery and red-rimmed, and she looked septic and scared. One look at her and the horror-movie music started. This kid was Oh-My-God sick and about to crash and burn any second.

As soon as I saw her I stormed to the Broslow (pediatric resuscitation) cart and dragged it into the room, busted the seal, whipped out the measuring tape, measured the kid, and popped open the appropriate drawer. I rifled through, found the intubation tray, and plopped it onto the Mayo stand (a stainless steel bedside table). I just knew we were going to have to drop a tube into this kid.

I then dashed to the Med room and grabbed the Rapid Sequence Intubation (RSI) medication box and rushed back into the room. By the time I made the round trip (about 30 seconds), every extremity the kid had was covered by a nurse or ER Tech. The MD (who had just started here that night) was at the patient's head. Since I could not get to the kid, I stayed with the meds. We all donned lead aprons.

Dad was in the room, holding the girl's hand and saying soothing words. We put a lead apron around him so he could stay with his little girl while we snapped a portable soft-tissue neck x-ray and did really, horribly noxious things to his baby.

Respiratory Therapy was pumping racemic epinephrine into the kid's airway as the Xray was taken. One of the nurses managed to get a line in the kid's ankle and I immediately took station there. That was my IV site now and there was no way in hell I was gonna lose it.

I cracked the RSI medication box and pulled out the Etomidate (very fast-acting knock-out drug), Succinylcholine (fast-acting paralytic), and Vecuronium (another paralyzing drug). I calculated the doses of each medication based on the Broslow tape measurement. I drew up the meds, nodded to the MD, and stood by.

The X-ray tech brought in the film, parked it onto the wall screen, and snapped on the light. Sure enough, sticking out like a pimp in a monastery, was the thing we hoped not to see but knew we would- the "thumb sign," indicating that the girl's epiglottis was swelling and shutting off her airway.

[Cue Symphony of Oh Crap in D Minor.]

The girl seemed to be holding her own. Her work of breathing lessened for a minute or two. Then suddenly, she sat bolt upright, her eyes wide, wide open and panicked, and turned blue.

"She's hypoxic!" one of the nurses blurted. The oximeter showed the girl's oxygen saturation at 74 percent and falling like a cow off the high dive, with good signal. (We get worried if it gets below 89 percent.)

"Okay, either we drop the tube now or we cut her. Give her the Etimodate," the MD ordered. I pushed the drug into the girl's vein and said clearly, "Etomidate in at 0243." A nurse standing by the Broslow cart noted the time on the medication administration record (MAR). The girl went limp within seconds.

"Give her the 'Sucks' (succinylcholine) now." I pushed the drug and barked, "Sucks in at 0244."

At that point, the MD thrust the girl's jaw forward, inserted the laryngoscope, and said "I have a lumen. Gimme the tube!" A nurse handed an endotracheal tube to the MD, the MD inserted the tube, and the kids's oxygen saturation jumped to 100 percent within seconds. The RT slipped in and taped the tube at the teeth while another nurse began bagging the little girl.

"Vecuronium now," the MD ordered. I pushed the Vec and said calmly, "Vecuronium in at 0244." I stood back and took in what was happening. The little girl was pinking up rapidly. Gradually, everyone stood back and watched. Her vital signs stabilized. We visibly relaxed and started breathing ourselves.

Dad broke down and sobbed. The MD asked him to step out to talk. I collected the trash that I had generated and accounted for all my sharps. I noticed that my hands had started shaking (when did that start?) as I dropped the needles into the receptacle. On auto-pilot, I took the used RSI box back to the med room for Pharmacy to pick up and went to the nurses desk to sign off on the code sheet. One of the nurses who had trained me way back when I was a snot-nosed graduate RN threw her arms around me, gave me a big hug, and said "You were wonderful!"

That was my first pediatric code as a nurse.

I excused myself for a moment, stepped outside into the rain, and just lost it. I cried for just a few minutes, but what it lacked in time it made up for in intensity. I didn't feel sad- it was more of a release of tremendous tension and fear. I never did it before, and I haven't done it since.

When I returned a few minutes later, soaking wet and somewhat more composed, the girl was being prepared for transport to the regional children's hospital. The room was clean, and dad was again in the room. The primary RN was squaring away arrangements for transfer. The medics took her away, the dad thanked us and left, and we finished the remaining four hours of our shift in peace.

We got a card a couple of months later from the dad. The girl recovered completely and was doing great. I cried again. It still feels like it happened last night, although it was a long time ago.