ICU: Our acuities were high, and staffing was low. Our ICU, with 24 beds, was already full. The staffing situation for that night was so poor that instead of our RNs having a 2:1 patient-nurse ratio, we were forced into 3:1 assignments.

Despite the challenging circumstances, we couldn’t have asked for a better team of ICU nurses. They were the best in their field, supported by two dedicated Respiratory Therapists assigned to our unit, along with a single ICU physician.

The night was incredibly busy, leaving no room for breaks. At 0215, the first EKG alarm went off, indicating V-fib. It was a code blue situation, and we immediately sprang into action. Each team member knew their role: One nurse manned the crash cart, another administered medications, while CPR was initiated. Our teamwork was seamless, functioning like a well-oiled machine.

Moments later, a second alarm sounded, signaling another code blue involving a second patient. We had to split our nursing staff, dividing the code team into two groups. The ICU physician, who had been intubating the first patient, quickly shifted their attention to the second code blue.

Incredibly, a third alarm followed, marking a third code blue in our ICU. We were now out of crash carts, and our staffing was spread thin across the three coded patients. Given the skeletal staff available, we faced a difficult decision: We couldn’t allocate equal treatment to each code.

We prioritized the patient with the fewest comorbidities, the one most likely to survive the consecutive onslaught of emergencies. Amidst the chaos, we raced from one code to the next, attempting the impossible. Unfortunately, within two hours, two of the patients succumbed to their conditions, leaving only one survivor.

The question arose: Was it due to our unit’s lack of nurses, ICU physicians, or crash carts? A week later, a conference meeting was called for a thorough review. The attendees included the director and manager of the ICU, risk management representatives, ICU physicians, respiratory therapists, and all the ICU nurses involved in that fateful night.

During the review, as we analyzed our actions and the resulting deaths, the blame game began. Our manager was the first to speak, focusing on what we did wrong and how we could have improved. It seemed possible that disciplinary measures or remedial classes on running a code might be implemented.

Amidst the intense scrutiny and criticism around the large mahogany table, one nurse stood up, displaying fearlessness and strength. She presented the facts, assuming a heroic stance. Her words resonated: “Throughout the 12-13 hours of nonstop work that night, not a single nurse took a break. When faced with three consecutive code blues in our unit, we had to divide our staff, neglecting the other ICU patients. With only two crash carts available, we had to share medications among all three patients.”

Ultimately, it came down to a matter of life and death. We had no choice but to prioritize the patient with the fewest comorbidities, the one most likely to survive the code. Despite our best efforts, running from room to room, performing CPR, administering stat medications, and conducting intubations, we fell short. We failed as a team, exposing the brokenness of our system.

The truth became apparent: We failed because our unit operated within a limited budget. Our manager’s failure to proactively address staffing concerns and maintain a safe nurse-patient ratio contributed to our downfall. We were casualties of a budget-driven system that denied us the necessary resources, including a third crash cart.

In the end, two patients lost their lives, and we were left facing the painful truth. The budget silently triumphed once again.

Debbie Moore-Black is a nurse who blogs at Do Not Resuscitate.