Moving to the issue of life-support equipment, supplies, and qualified personnel, having those available in case of emergency is vital indeed. When you arrive on a hospital floor as either a patient or family member, do you think about whether all the paraphernalia needed for lifesaving measures is immediately available? If you are like most consumers, that would be the furthest thing from your mind. After all, who are we to tell the health-care professionals how to do their jobs? Although for the most part there are systems in place to check the supplies and equipment at the beginning of every shift, people sometimes fail to perform routine rudimentary tasks. Sometimes the nurses report a broken or missing piece of equipment to management and nothing happens. The other problem is that usually there is only enough emergency equipment to manage two simultaneous crises on anyone floor. Thus if a third emergency arises, the nurses have to waste time borrowing from another floor or ordering from the pharmacy or central supply.
The following is a list of items needed on every floor, which should be contained within a standard crash cart:
cardiac rhythm monitor (sometimes built into defibrillator)
endotracheal tubes of all standard sizes
emergency drugs such as sodium bicarbonate, atropine, epinephrine (adrenalin), diuretics, antihistamines, antiarrhythmics, antihypertensives, insulin, and others
bladder catheters with drainage bags
syringes of all standard sizes
needles of all standard sizes
sterile kits containing gloves, tourniquets, gauze pads, disinfectant solution, antibacterial ointment, and tape
intravenous catheters of all standard sizes
intravenous solutions of all standard types
blood specimen containers for laboratory tests
You should never stay on a floor without receiving assurances that someone checked the crash cart to make sure that it has all required items in good working order.
A case to illustrate this point is an incident involving seventy-three-year-old "Sadie". She was seriously ill, but she might have had more time in relationship with her forty-seven-year-old daughter, "Norma", if not for the shameful fiasco that occurred during the attempt to save her life. Sadie entered the hospital with congestive heart failure. The heart loses its effectiveness as a pump in that condition. Moreover, fluid begins to back up, causing swelling inside the lungs and elsewhere in the body. Sadie's doctor admitted her because she was having some difficulty breathing, and he felt that a thorough workup and medical management would likely help her to avert a catastrophe. The reasoning was that if she were to encounter a crisis during this period, being in a hospital would assure her of having qualified personnel with lifesaving drugs and equipment at the ready. Little did the physician suspect that his patient would have been better off staying home with her daughter and relying on the paramedics responding to a 911 call.
Soon after she settled in, with her daughter at her bedside, Sadie gasped for air and collapsed in bed. Norma called out for help (she was near the nurses' station), and within seconds, there were four doctors and three nurses at the bedside with the crash cart. The cardiac monitor showed a straight line. Two members of the team started cardiopulmonary resuscitation (CPR), one providing respiration with a mask and ambu-bag (manually operated air pump) while the other administered chest compressions. Then the doctor in charge ordered sodium bicarbonate, epinephrine, and atropine. Up to this point, everything was well coordinated, and each member of the team knew exactly what his or her job was. What happened thereafter was a series of delays due to missing supplies and faulty equipment. A few minutes into the code, the on-call anesthesiology resident showed up to intubate (pass a tube into the windpipe). This was the only way to assure that the air pumped in would go into the lungs and not the stomach. The anesthesiologist called for a certain size tube. There was none on the crash cart. One of the nurses had to run down the hall about forty or fifty feet to the other crash cart and run back with the tube. This was a loss of three minutes. While the nurse was running, the ordering doctor decided to defibrillate in an attempt to convert the heart to normal rhythm. One of the other doctors applied the paddles and fired-nothing happened. One of the other nurses hit the recharge button, and the familiar high-pitched squeal sounded off indicating the recharge was taking place. The doctor applied the paddles-and again nothing happened.
By this time, the first nurse had returned with the tube but then had to run back again to get the other defibrillator. This was another three-minute loss. In the interim, the nursing supervisor had arrived and immediately went to the adjacent floor and rolled in another crash cart as a backup. The second defibrillator did not work either until the supervisor pointed out that someone had disconnected the paddle unit. One quick "click" and the paddles fired off the power needed for the conversion. The heartbeat returned, but the rhythm deteriorated to a lethally slow rate of twenty beats per minute. The doctor ordered another bolus of atropine, but there was none on the cart. The supervisor produced one from the extra cart that she had brought with her.
The code proceeded for another thirty minutes, with the charge physician saying early on, "This woman is too far gone for us to do anything for her. Technically, she is already dead. We're just going through the motions for the benefit of the daughter, who is at the other side of that door."
Meanwhile, Norma was pacing in the corridor just outside the room, thinking all the while that her mom was getting the best possible care. Finally, the supervisor approached Norma at the doctor's behest, saying, "Your mother is gone. We did everything we could, and we were unable to save her." Norma's emotions changed from worry to disbelief and then to grief.
Retrospectively, it is impossible to know whether Sadie could have lived if the necessary items had been available when needed. Nonetheless, the loss of those costly moments forever robbed her of whatever prospect she had for survival. Ironically, Norma, being ignorant of the procedural chaos, accepted that it was her mother's time to die. It may have been her time, but the final botched attempt to save Sadie's life has to be characterized as sloppy.
The fact is that the potential for disaster in every hospital is an ever-present reality. When you first arrive as a patient or family member, it is vital to speak to the charge nurse and ask to see where the crash cart is located. Find out if the nurses are checking the equipment and supplies at the beginning of every shift. Ask the nurse to explain how long it will take the code team to respond when called. Finally, find out if any of the nurses on the floor have achieved certification in advanced cardiac life support (ACLS). Such questions would serve as a reminder to those who need it. If the answers leave you feeling unsafe, speak to the director of nursing and lodge a protest.
By comparison, whenever we board a commercial airliner or say good-bye to a loved one at the airport, we have confidence that the pilot and crew members will check all of their equipment and review emergency procedures before each flight. In this case, however, their lives are on the line the same as the passengers, so, to some degree, self-preservation motivates perfectionism. If all hospital personnel were like-minded at the start of each shift, there would almost certainly be much fewer adverse incidents related to faulty equipment, missing supplies, and/or bungled procedures.