Do you remember your first code and how you processed it? In this episode, our Med Student Over Easy hosts, Patricia and Molly are joined by Tanner, John, and Andy, to discuss navigating resuscitations and death. To set the stage, Patricia discusses an experience that she had with a new learner who was experiencing her first code.
“I was on shift when a patient was brought in by EMS in cardiac arrest. One of the senior residents was running the code and my job, as the intern, was to manage the airway. We had a third-year medical student rotating with us and I had her come to the head of the bed with me. EMS comes in with CPR in progress via LUCAS device. They have had PEA on the monitor on each pulse check. They have given 4 rounds of epinephrine and they report that the patient was down for an unknown amount of time without bystander CPR. Once we got the patient moved to our cot, we continued resuscitative measures. The patient’s pH was 6.8 with an elevated lactic acid and normal potassium. Despite 3 amps of sodium bicarbonate, 2 more rounds of epinephrine, and multiple rounds of high-quality CPR by the LUCAS device, the patient now had asystole on pulse checks without any return of spontaneous cardiac activity. After conferring with the team, the resident leading the code did one more round of CPR and decided to appropriately call time of death, followed by a brief moment of silence. As I was walking out of the resuscitation bay, I saw the med student out of the corner of my eye and I knew something wasn’t right. I asked her if she wanted to talk. Tears began to well up in her eyes and I took her back to the physician’s break room. It turns out that that was her first code and she had so many questions. Why didn’t we keep giving epinephrine? How did we know when to call the code? What could we have done differently to save his life? Why did he die? Then she told me how her heart broke for the family as she saw them crying at the bedside when we called time of death.”
How would you approach this scenario? Do you go back to shift? Do you discuss it with the student? What is your next move? What can you do if you are the student in that scenario?
In times like these, it can be helpful to those around you to recognize when things are not sitting well with them after a critical event like this. A good place to start is to ask the person what’s going on and what they are feeling at that moment. Another way you can start the conversation is to ask if this is the first code they have seen or if this is the first time they have witnessed a person die. This can help get the conversation started to better understand how you can support them. If you’re the student in this scenario, feel empowered to speak up and ask someone around you to debrief, whether that be a resident, attending, nurse, tech, etc. You’ll find that most people will be more than willing to chat with you.
We all know that codes can certainly be traumatic, even for people who have been through their fair share, but especially for new learners. One aspect that can be particularly traumatic is watching the LUCAS device give compressions. Most people have never seen anything like this device give artificial chest compressions to a person and it can be shocking the first time you see it. With the LUCAS device now doing compressions for you, people who would normally be doing them can now take in more of what is happening with the code, which can be both a good and bad thing. So many things we see on a day-to-day basis are not the norm for most and we tend to get desensitized to that.
Not understanding the why of the things that are happening during a code can also be traumatic. Debriefing to make sure everyone is on the same page and understands why the resuscitation was stopped can make a huge difference in helping people understand and better process the event. As a student, do not be afraid to ask questions. We want you to learn and sometimes your questions help us too.
When these critical and emotional events happen, it is important to take a step back and give yourself a moment to process everything. Sometimes it is hard to fight the urge to rush back to work because you know patients are waiting to be seen, however, this can be detrimental if you do not give yourself enough time to take a breath and process what just happened. It’s okay to step away from your chair and computer for a second to take a walk or talk to someone. There will be certain times when you have to jump to the next critically ill patient, but don’t forget to take some time after to debrief.
- All feelings are valid.
- If you have questions, ask them!
- If you just need to talk, ask someone!
- If you are a teacher, make an effort to always check in with your learners, even if you don’t have time for a full debrief.
Post by Shannon Caliri, DO PGY-3
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