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Failure to Rescue

A flight nurse illustrates her definition of best practices.

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"Daryl! He is going to puke on you!"

In the seconds before I blurted this hurried warning to the flight physician, I watched my patient make the retching motions I am all too familiar with.

We were 2,000 feet above the ground, headed to the rooftop of an urban facility with a 50-something male patient diagnosed with a STEMI [myocardial infarction] at a rural hospital emergency department. He needed a cardiologist and a cardiac catheter lab as soon as possible if we were to save his heart muscle - and his life.

As I reached for the anti-emetic stored in the drawer at my right elbow, I glanced at the cardiac monitor. The patient, who not 2 minutes before gave me a 'thumbs up' while glancing out the window of the helicopter, was in ventricular fibrillation.

He was trying to die in front of me.

I jumped from my seat, knowing if we didn't shock him immediately his chances at living narrowed by the second. My airway and medication bags exploded in a cloud of tubes, syringes and vials as the two of us began running a code in a space the size of a small closet, tipped sideways.

I'd like to report it went as neat and tidy as an ACLS mega code performed in a non-stressful educational environment with an entire team simulating most of the steps. But oh no, this was a real patient who, in the moments before he died, smiled at me because his first helicopter ride was no longer something he feared.

In the course of about 5 seconds, the anxiety level in the aircraft reversed from patient to crew in a metaphorical and actual bolt of lightning.

Life Savers

When people learn I am a flight nurse, I frequently hear, "Wow! How many people have you saved?"

The question still surprises me. During my time as an orthopedic trauma nurse practitioner, or as an intensive care nurse working at the bedside, I never received that type of reaction to my job description.

Why the difference? Don't all nurses save people?

Most nurses have heard the term "failure to rescue," coined by Sean Clarke, PhD, RN, CRNP, FAAN, and Linda Aiken, PhD, RN, FAAN, FRCN, from the Center for Health Outcomes and Policy Research at the University of Pennsylvania, who in a January 2003 American Journal of Nursing article defined it as "a clinician's inability to save a hospitalized patient's life when he experiences a complication (a condition not present of admission)."

In understanding failure to rescue is based on a myriad of root causes including staffing levels, I began to wondered why, when faced with an obvious patient emergency, med/surg nurses did not feel an instinctual sense of urgency. Why did they wait so long to intervene or ask for help? More importantly, why didn't they apply the basics of airway, breathing and circulation once they recognized the emergency?

Two obvious things dawned on me.

First, the same nurses who were incredible at their jobs when things went as planned weren't taught what to do when things didn't go according to the textbooks. Second, nurses are subtly mentored to believe we don't actually save lives.

Saving lives is the job of the paramedic working on the street rolling with lights and sirens, or the doctor, called to the bedside after the 'code blue' button was hit by, yes, I will say it, the nurse.

This is where academia and bedside nursing collide. This is where the simple phrase, "failure to rescue," moves from being an academic, mental exercise into the daily practice of nurses.

Balancing Act

An obvious chasm needing to be bridged exists between what we declare is important to our profession (caring for our patients) and to what we actually dedicate most of our time (documentation).

It is essential we continue to approach our individual practice with the goal of preventing the need to rescue a patient. That is where nursing basics including, but not limited to, pain management, appropriate medication administration, assessments and adherence to procedures remain such a vital part of our role in patient care. However, the ability to deal with the few patients who, despite our best nursing efforts, still become critically ill is one of the most important skills we possess.


Failure to Rescue

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