Nursing Home Codes

I did another nursing home code this weekend. We have five nursing homes in our town. Two are very nice and are the final stop in larger retirement communities where residents start off in the own cottages or apartments, move to their own rooms and then go to skilled care before they pass on. The only codes I have ever done at these places are patients who drop in their apartments or on the grounds. I can’t remember doing a single one in the skilled nursing section. I think the patients must all be DNRs. Both of these facilities have very affluent clientele. Most of the calls they generate are falls with hip fractures or head lacs and on the medical side lots of pneumonia and COPD exacerbations.

The other three nursing homes are the more generic types. I do lots of diabetics, sepsis, respiratory failure, aspiration pneumonia, and of course, lots of codes. Most of the codes are poorer patients with train wreck medical histories. The one this weekend was typical. Obsese, IDDM, dementia, HTN, COPD, CHF, CAD, depression, hypo this and hyperthat.

We used to transport all these patients in arrest, but then when we got permission to cease asystole rescusitations after twenty minutes of ACLS, including intubation, IV and three rounds of cardiac drugs), we stopped transporting most, but now with the new CPR, we are back transporting because they keep coming back from the dead, or at least their hearts do. Get some rounds of epi in them and circulate them with some solid hard fast deep CPR and that flat line starts getting some blips and bleeps. I walk in, take a glance at the person whose chests the nursing aides are pounding on, hear a snippet of their medical history and think no way are we going to end up transporting. But then sure enough. Way.

You stare at the monitor. I don’t believe that I am seeing that. Maybe someone is shaking the wire. You would think that getting a rhythm back would make you excited, and it does only to a point. Then you remember your patient’s eyes are fixed and dilated. And their bodies are wracked by disease and years of living, followed by more disease and years of laying in their nursing home beds. And all the rhythm is is the drug you put in to their veins as part of your ACLS protocol. Anyone would says epi doesn’t work is wrong. But of course they are just saying epi doesn’t help with the outcome and I would have a harder time disputing that. Epi certainly can produce electrical activity on a monitor and sometimes even a pulse and blood pressure.

On this day it just produces PEA. We continue to work the patient, even going to the point of getting all 300 pounds of the patient on our long board and strapped down and ready to go, but then the patient goes asystole again. We make the decision to stay and fight the battle on the bed, rather than trying to do the over to the stretcher, out the room, down the hallways, and out to the ambulance, and bump all the way to the hospital routine. We’ll do that if we get the rhythm and a pulse back. After a total of 40 minutes with just occasional PEAs, I call the hospital and ask for permission to stop, which is quickly granted.

One partner picks up all the wrappers and waste from the floor and put it in a big red biohazard bag, and then zips up our IV, med and intubation kits and place them in the house bag. My other partner and I unstrap the man from the long board and gently ease him back onto the mattress. We set a pillow under his head, cover him with a sheet up to his neck and then with my finger tips, close his eyes for the last time.

On the way out I glance at the roommate in the next bed. Sound asleep.


  • Tom B says:

    When is this madness going to end?

  • Jonathan Rosenfeld says:

    Thanks for sharing your nursing home experiences. Too often nursing homes are slow to notify paramedics when they are truly needed. Nursing homes are under the impression they can handle many critical care situations when the reality is they are not.Jonathan Rosenfeld

  • Tom B says:

    Really? My experience has been the opposite. Sure, there are times that you’re like…. Umm… how long has this patient in acute pulmonary edema been lying flat? But for the most part, they abuse the sh*t out of EMS because they are not competent to handle routine care situations, let alone critical care.

  • Medicmarch. says:

    This reminds me of something one of my paramedic instructors told me, three long years ago.”Isuprel? Fuck, that could make jello beat.”As you have stated, getting a nonprofusing rhythm typically doesn’t mean much in the long run.-MM-MM

  • Anonymous says:

    I had a similar code two days ago. Asystole x 20 mins with BLS doing CPR before ALS arrives. A good 4 minute gap in the middle with no CPR when he had to be carried up a bunch of stairs. After 2 mins of CPR with epi, he gets a PEA rhythm (narrow complex tach) that degrades back to asystole. After 6 more minutes and another 2 mg of epi, he gets a pulse back for awhile, but eventually bradys down and dies. Surprising what that epi can do, although it isn’t making a difference in their end outcome.

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