The Fight for the Code Cart

I love circulating and scrubbing liver transplants. Kidneys/pancs at great too, but the livers are fascinating. The organ does so much for our bodies and when it fails or is damaged, the multi system consequences are disastrously….fascinating? Yeah, that’s the word. I’ve learned my sickenly morbid enthrallment with pathophys is almost an industry standard. At least, most other RNs and MDs don’t give the sketchy side-eye when I mention how much I love things like HIV and liver failure.

I’m on call over night for the transplant team with my favorite scrub tech, and really my favorite team from anesthetist to residents to surgeons. Notified at 9pm, set up at 3am, roll back at 5am. Of course we’re delayed. Most are, due to either the donor liver transport if it’s out of house, or the recipient arrival, cooperation, or labs.

The week prior, this same team had run the smoothest code I’ve ever seen in any situation. It was beautiful, a work of healthcare art. And we were proud of it. The experience had brought the whole tam together in a way unparalleled throughout the unit. The transplant room is also one of the trauma rooms, so it houses a code cart 24/7. We check all code carts every 24 hours, regardless of use. Prior to a transplant, I double check the daily check. Another reason the OR allowed me to release all OCD tendencies I might have ever had.

At 6am, my patient rolls back. This guy has active LBBB and lives in afib. Regardless of heart history, the most dangerous part of most surgeries is intubation and extubation. With livers, repurfusion beats them out, but only barely. Anesthesia resident, propofol given, blade in hand to intubate, is disrupted as the OR door flies open. One of the night nurses, an overweight woman who will pay cash to other nurses to take her surgeries so she can continue sitting in the lounge, walks in and begins to unplug the code cart. She says nothing, makes no eye contact.

“Tom,” I said, holding my hand up to pause the confused resident. “Hold on and bag him for a minute.” He breaths for my completely sedated patient. I ask The nurse what she needs from the cart and inform her of the obvious, our impending intubation. She ignores me and begins to wheel the code cart out of the room.

I run across the room, intercepting her and stand between the cart and the door.

“Sandy (our manager), wanted the cart brought into the core.” I point out the three other carts we keep in the OR and relay my patient’s heart history. She seems unphased and repeats the managers request, pushing the cart past me. At this point, the phrase, “pry it from my cold, dead hands” might have exited my mouth, but it all became a haze. I ended up physically removing her hands from the cart, plugging it back in to the wall, adding an emphatic, “it stays. If the manager has a problem with that, she can come speak to me herself.”

She left. We intubated.

Shortly after, while anesthesia placed lines, I was inserting the catheter. Doing so left handed, I left my back to the door. So when I hear the door open, I make eyes toward my scrub and he interprets it correctly to keep an eye on the code cart. My manager walks up behind me.

Sandy always wears hospital scrubs, but I’ve never seen her scrub or circulate a case. Rumor has it she did open hearts about 15 years ago. Since then, she has suffered from the middle-management curse of forgettting all knowledge one learned at the bedside  but being forced by upper management to act as if they hadn’t.

“Are you ok?” Sandy asks. I pick up my patient’s penis in my right hand, holding it upright and refusing to make eye contac. The last thing this patient needs is a UTI from breaking sterile technique.

“I’m good. My patient’s pretty sick, but I’m good.” Still no eye contact as I twist the catheter until it pushes into the urethra.

“I heard there was a misunderstanding over a code cart.” I hit the prostate. More twisting of the catheter.

“No misunderstanding. She tried to take the cart, I explained the severity of my patient’s condition, and I kept my cart.” Up to the hub, no urine out. I take my non-sterile hand and push on the bladder.

“Oh. I knew the team had used this code cart last week.” Healthcare art. “And I wanted to make sure it was ready for the next transplant.” Seven days of scheduled surgeries and now she’s worried about it. What about the hip replacements all day yesterday? Those can bleed almost as much as a gunshot wound to the spleen.

“Sandy,” more bladder pushing, “we check those code carts every day.” Finally! Urine! It’s gross, thick and red-tinged, but urine. I hate to think what this guy’s creatinine is. “It’s been checked seven times since the last code, plus an 8th time by me this morning before the patient rolled back.” I secure the catheter to the leg, bend down to hang the bag on the table, and stand back up to finally make eye contact. “And we don’t have to move a code cart to check them.”

She looks at me. She looks at the catheter. The room is silent; everyone’s eyes down to whatever they’re working on. Her face morphs from chastisement to fake bubbliness. I get more nauseous from that than the smell of the liver being prepped. “Ok! Looks like you’ve got everything under control here!” Yes, now leave us alone, I say, internally impersonating Grumpy Cat.

As the door closes behind her, a slow whistle comes from the surgeon’s prepping the liver. “Oh shut up, Schmitty.”

No code that day.

The Come to Jesus Talk

The come to Jesus talk is a conversation in which you lay it all out there, expose the truth, the reality of the situation, and usually the direness of it. I’ve given these talks more times than I can remember and mostly to drug addicts. Although, patients with heart attacks and heart failure come in a close second. I’m blunt. “If you don’t stop smoking, you’ll be dead in three months.” That patient’s HF was so bad, his only option was hips surgery, which no one would do unless he stopped smoking 2 packs a day.

Most of these talks are met with feigned interest by the patient, some with serious looks, some with shame. 25% of people who have heart attacks make lasting changes. Only 25%. What am I working towards as a nurse? What difference am I making? Are these CTJTs making any difference? I do my job, both as a nurse and as a Christian, give these people the knowledge and tools to help themselves and improve their lives. And most of them blow me off. I’ve learned to let it roll off my shoulders. If I let it bug me, my own stress level would ruin me and be unmanageable. Self preservation.

“Broken wrist. Only history is positive for meth.” Greaaaat. Meth withdrawal. My favorite. My look of annoyance must have shown since the night nurse giving report quickly added, “he’s not your typical meth head. Really nice guy.” Sure. My skepticism proved unnecessary, since, while I can usually spot a meth user 60 ft away, I would have had no idea without that positive lab report.

After a few days of having this patient on the unit, we had developed a good rapport. He requested his family not be told about the meth, so the day I discharged him from the hospital, I waited till his mom left, pulled up a chair, and asked him what was going on. The twenty minute conversation that followed broke my heart. His out of control ADHD, leading to his meth addiction, it seemed miraculous that no one knew about it. He started and still ran his own successful business, functioning normally in society. And that’s after ten years of daily meth use. 

“It will catch up with you,” I told him. “Drugs leave a trail and you cannot hide from its devastation. It will take your family, your job, and every other facet of your life.” He didn’t roll his eyes at me. We talked about the next steps, how to fight it. I gave him the literature, hidden in his boots, so the family wouldn’t find it. 

I didn’t cry. Until I got home. This talk didn’t roll off my shoulders, it stuck there like a monkey. “He still had a good life, a life worth saving,” my then-boyfriend assured me. “Some people are more worth saving than others.” Whew. I hate hat explanation. All life is worth fighting for, worth saving. I truly believe that. That boyfriend and I eventually broke up due to our differing opinions on abortion and other end of life issues, so looking back on those statements, it makes sense coming from him. It wasn’t a good enough answer for me though. I don’t decide who is worthy of saving.  I simply save as much as I am capable of saving.

The question though, is why do some stick with us more than others. Was it the good rapport I had with this patient? Was it the similarities I saw between us, the common ground in life? Was it the impressive and unorthodox nature of his drug addiction? Was it the hope that he could be one of the few that survived? Is it my own personal level of empathy on any given day? If you have an answer, please let me know. And let me know how to combat it, how to continue letting that monkey roll off my back.