Author: James Garrard
Editor: Antonia Clarke
Resuscitation is generally a messy business. Some go well, others go badly, but one thing they all have in common is a certain degree of chaos. Regardless of the outcome, being part of a resuscitation where the team has performed well is always a satisfying feeling, like your team winning at Monday night futsal. Obviously, when it comes to actually leading one, as a junior doctor you should be gradually exposed and gain more experience through simulation or observation. But what if you’re in, say, your first or second post-graduate year in a rural or regional centre, and find yourself running the show? Hopefully, if this does happen, you will only need to hold the fort for a few minutes until more senior help arrives. But a few minutes in such situations can feel like half an hour, and fifteen minutes can feel like an eternity. It sounds scary, but as anyone who has done a term at a regional or rural hospital will tell you, it is entirely possible to end up in a situation where you are the most senior medical officer on the premises. If you are going to do one of these rotations, I would strongly suggest that you are up to date with your Advanced Life Support (ALS) certification. When it comes down to brass tacks, all of the knowledge you need to run a code in its initial phase is on that single page ALS guide which is (hopefully) attached to the crash cart.
I write this article as an Intensive Care registrar having run resuscitations on the ward or in ICU. This is a different context to many of my Emergency Department colleagues, who are, in my opinion, the resuscitation experts. The ED experience of resuscitations benefits from having familiar staff and surroundings who are well drilled in carrying out their respective roles. Similarly, an Anaesthetist in theatre will, usually, be working within a familiar environment. Additionally, as a junior doctor, you (should) always have senior help immediately available if you are involved in a resuscitation in ED. I want to emphasize that there are “controlled” environments in which to resuscitate a patient, and that the ward is not one of them. Even simple things like getting the bed moved away from the wall so you can manage the airway can be a challenge. Simulation programs are tremendously useful in preparing doctors for the real thing; most newly minted doctors will have had some exposure to this during medical school. I would advise seeking simulation out and participating as much as possible, as this is the best way to drill yourself on the teamwork and communication components of ALS.
After attending a couple of code blues, you will very quickly get a sense of how things are going as soon as you enter the room. One thing you should never do is assume that someone is already in charge, regardless of how many people are present or how senior they appear to be. An increasing number of medical graduates are starting their medical careers later in life, so apparent age no longer reliably correlates to actual seniority. Even if there are other doctors present who you know are more senior than you, do not assume they are adept or confident in running a code. I have previously made this mistake when I arrived to a code blue to see two consultants, one a physician and the other a surgeon, already present and made the assumption that the most senior person in the room would be leading. Things appeared to be under control, so I took a minute or two to put on some PPE and gather my thoughts. As I entered the room, I asked who was in charge. They both looked back at me and said, almost simultaneously, “you are!”.
Asking who is in charge is also important to eliminate any confusion about who the team leader is and to avoid conflict. I distinctly remember running an arrest call for an elderly patient with multiple comorbidities who did not have a resuscitation plan. Fifteen minutes after the code blue team had arrived, I was about to stop the resuscitation when two other registrars entered, unannounced. They stood at the foot of the bed and started diverting people who had been allocated roles to give them a handover, and started giving unsolicited instructions to the team. This is not only poor etiquette, it is disruptive. Despite their good intentions, they ultimately only disturbed the team dynamic and decision making that had already occurred.
This is often an under-emphasised problem in resuscitations, especially those which occur outside of critical care environments. Resuscitations are almost always over attended; there will be multiple nurses, nursing students, seemingly every junior doctor in the hospital, cleaners, porters, curious members of the public, you name it. If you intend to lead the resuscitation, once you have allocated roles and got rolling with the ALS algorithm, you need to politely but firmly ask anyone not allocated a role to stand back. If things are really out of hand and you look up to see thirty people staring at you, blocking doorways and impairing movement, you need to politely but firmly thank people for attending and to kindly leave. An effective starting point is to ask every doctor in the room to raise their hand, and then ask for half of them to leave. Then do the same for nurses. After reflecting upon previous resuscitations, I have led, I now include this in my “allocation of roles”, particularly during resuscitations on the wards. It can be useful to delegate this role to senior nurses, ANUMs or bed managers – they will usually be present, and usually have the confidence to speak up to large numbers of staff with authority.
Do not over-think it
ABCD. Four H’s and four T’s. Shockable vs. non-shockable rhythms. They will be written down somewhere, and if not, then pull out your phone and google “ALS algorithm”. It will take you no more than five seconds. ALS is not overly complex, but as is the case in exam situations your memory can go on strike under pressure. Some junior doctors may have a tendency to want to prove themselves to a degree by finding a rabbit to pull out of a hat. There is no shame in reading off a checklist or quickly looking something up. You (hopefully) aren’t involved with resuscitations every day, so you won’t have a rolodex of drug doses and protocols immediately mentally available, nor should you be expected to. Look at it from this perspective: An airline pilot with thousands of hours experience flying a specific aircraft will still read a checklist before each critical stage of a flight, even though they’ve read the exact same list hundreds of times before.
I would advise against deviating from the ALS algorithm, as you will be taking yourself and your team into uncharted waters. Until you have more senior backup, your aims should be to keep ventilating the lungs and to keep blood circulating as best you can.
As with any other clinical deterioration, you shouldn’t feel compelled to attempt a procedure or intervention you aren’t comfortable performing or make a decision you aren’t comfortable making, especially if the things you are already doing are good enough. In resuscitation, perfect is often the enemy of good.
The thought of running a code as an intern or resident is very daunting to most. I remember the nerves I felt before going into simulation sessions with my peers as a medical student, so to me the thought of co-ordinating a team of colleagues you may have never met before was very confronting. I cannot overstate the value of thinking out loud. Verbalise your four H’s and four T’s and ask the team if they have any ideas or if they think you have missed anything. Not only is it a simple method of organising your own thoughts, but it will bring the team together and make everyone feel included. If things seem to be stagnating or there is an awkward silence, verbally recap the situation from the top, again asking everyone if there’s anything you missed / forgot.
There is no situation so dire that it permits you to be rude, dismissive or disrespectful to other members of staff attending the arrest. Sure, you need to be efficient in your communication which may come off as being abrupt with some people, but there is always time for please and thank you. Avoid swearing, not so much for the sake of avoiding offence but more because it gives others the impression you might be panicking. You need to refine the skill of masking your inner turmoil with a veneer of calm and confidence.
Phoning a friend
If no senior help has arrived within a satisfactory timeframe, somebody will need to get on the phone and call them in. You may try to delegate this to somebody, but if you assess that you are the best person to make the phone call, do your very best to keep it short. Don’t recite the patient’s admission note and then say “so they’ve arrested on the ward”, don’t even use ISBAR. All you should need to say is “such and such has arrested, please come now. Bed 14 on the medical ward.” Your senior colleague should be aware enough to leave it at that and allow you to get off the phone, but if they start asking questions you will have to stop them. Interrupt them and say “I’m sorry, I’m the team leader and I really need to get off the phone. We can talk more at the bedside.”
This is another important component of teamwork which is unfortunately often missed. It’s difficult to get the whole team back together to debrief after a code. People are busy, shifts are changing over, it is hard to communicate a time and place to debrief after the fact. There is, however, evidence to suggest that structured debriefing improves both survival and functional outcomes after in hospital cardiac arrest , so I can’t overstate its importance. Again, hopefully by this stage there is senior involvement and it should be you being debriefed and not you debriefing a large group of people. Facilitating a debriefing session is something that requires a certain degree of training and use of one of many structured approaches. This is a large topic in itself and falls outside the scope of this article, but I would encourage you to seek formal training in simulation to explore this further if you’re interested . You should at least try to debrief with a senior colleague who you might consider a mentor, even if they do not necessarily work at the same institution where the code took place. Your mentor doesn’t need to have a medical background; on several occasions I have sought the counsel of senior ICU nurses involved with a resus.
Lastly but most importantly, look after yourself. I have been and remain guilty of not doing enough of this, and I suspect the case is the same for a larger proportion of our colleagues than we’d care to admit. I consider myself extremely lucky to have a loving and supportive wife and people I know I can go to if I need help, but it wasn’t always this way. As a Junior Doctor you are in a constant state of flux. You are away on rural secondments, working unsociable hours, re-applying for jobs every year and worrying about shaping your career. I certainly found it on occasions to be a very lonely experience. This job has claimed the lives of far too many junior doctors, most recently one in my own specialty. It’s not an easy thing to do, but please get help if you think you might need it.
1. Wolfe, H. et al. 2014. Interdisciplinary ICU Cardiac Arrest Debriefing Improves Survival Outcomes. Crit. Care Med. 42, 1688–1695. DOI: 10.1097/CCM.0000000000000327. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/24717462
2. Monash university teaching resource for rural clinical educators – Debriefing learners. (2015). Available at: https://www.monash.edu/__data/assets/pdf_file/0006/998763/redissue30.pdf. (Accessed: 23rd October 2018)
Oliver, Matthew (2014). Arrest calls on the wards – Tips for junior doctors. [blog]. Available at: https://onthewards.org/arrest-calls-wards-tips-junior-doctors/ [Accessed 31 October 2014].