| I
have been certified in Cardiopulmonary Resuscitation
(CPR) for over 20 years. Since 1992, when I began
my internship, I was first certified in Advanced
Cardiac Life Support (ACLS). In 1998, due to job
requirements, I became certified in Pediatric
Advanced Life Support (PALS). The purpose of all
this advanced training? To have the skills needed
to participate or manage a CODE - an organized,
coordinated delivery of ACLS techniques. I served
on many CODE teams and run many codes, yet the
only training I received was that of the Advanced
Life Support courses. There was no additional
instruction in running a CODE Team, what resources
were available to us, or what types of responses
to expect from a CODE. This dichotomy and the
obvious oversight in this aspect of medical education
intrigued me. I began exploring the impact that
participating in CODES may have on the participants,
in particular the emotional impact on physicians
and those in training.
In reviewing course materials for ACLS (1) and
PALS (2), there is no mention of how participating
in or running codes may impact the team members.
Within recent years, the American Heart Association
has included new information in the training manual
on topics such as: Ethics, Advanced Directives,
Do-Not-Resuscitate Code Status, Organ and Tissue
Donation, Practicing Intubation skills on newly
deceased - especially infants and children, and
the role of the EMS. It would seem logical to
devote some time in the course, to discuss how
CODES may affect the providers, teach some basic
coping strategies, and provide resources for those
who are involved in CODES.
Critical Incident Stress Debriefing (CISD) and
traumatic stress defusing are techniques used
in the prevention of acute and posttraumatic stress
among high risk occupations (identified as fire
fighters, law enforcement, emergency medicine,
disaster response, emergency dispatch and public
safety personnel). Other occupations such as clergy,
military, high-risk business and industrial settings
may also utilize these techniques and train their
personal who might be exposed to traumatic events
or involved with the counseling of others. (3)
The usefulness of CISD and defusing techniques
are well known within the EMS and disaster agencies,
but perhaps overlooked as applicable in other
"non-emergency" areas of medicine. These
techniques could be beneficial for those in the
medical profession, not trained in emergency medicine,
but who occasionally encounter traumatic, life-impacting
events.
CODES
in Medical Training
In most training programs, the resident physicians,
also know as house staff, are expected to respond
to the CODES. Which residents respond usually
depends on the type of the code. There is a difference
between medical, surgical/trauma and pediatric
codes. Internal medicine residents run the cardiac
codes. Surgery residents or emergency department
residents run trauma codes. Pediatric residents
(if present in the hospital) run the pediatric
codes. The trauma codes often have more anticipated
blood and guts, whereas the medical codes may
have resultant non-anticipated blood. The pediatric
codes are often some of the longest, due to the
reluctance of the team to give up on the very
young. This is especially true if the participants
are not trained in PALS or are from non-pediatric
specialties.(4)
Of interest about the medical education process
is the assumption that all medical students and
residents can function well in a CODE situation,
regardless of their underlying personality type;
this is far from the case. There is nothing in
the screening process for medical education that
selects for those who will function well under
high stress environments. Rather it is assumed
that if an applicant can make it into medical
school, then he/she is capable of dealing with
life-threatening stress situations. In creating
CODE teams for cardiac arrests, everyone, regardless
of their personality type, is put into situations
where they must react, frequently quickly. CODES
may be difficult, traumatic experiences for those
who prefer the non-patient contact specialties
or the thinking specialties because they want
to analyze situations before responding. Those
who function well under high-stress situations,
who are reactors or "adrenaline junkies"
will do best in CODE situations. Some may freeze
when faced with a real-life situation and cannot
translate the learned book knowledge into active
practice. Freezing can become a pattern, a conditioned
response for subsequent CODE situations. One may
argue that medical training deconditions medical
students to deal with traumatic situations, just
by putting them into the environment. I believe
that with some people, no amount of training,
or attempts at deconditioning can make an "adrenaline
junkie" out of someone who fundamentally
is not.
Code
Blue Experience
I entered medical school having already been involved
in Emergency Medicine as an Emergency Medical
Technician (EMT) in the early 1980 s. I also had
been impacted by many of the CODES I was involved
with as an EMT, which gave me a different perspective
on CODES during my medical school training.
One of my first experiences in determining a CODE
was a call for a person "found down"
near a recreation lake. By the time we were notified,
easily more than 30 minutes after the accident,
there was little hope of initiating a successful
CODE. The chances became infinitesimal when we
reached the scene and discovered the victim with
a large boulder crushing her chest. This traumatic
experience haunted me for several years - primarily
the guilt at not being able to do more. The event
is chronicled in an article, "Fleeting Moments"
that I wrote later as a medical student (5). It
was my way of coming to grips with the reality
that there was nothing more we could have done.
I felt fortunate as a medical student that I had
my prior EMT training. For the most part, CODE
training occurred when the situation arose during
a particular rotation (e.g., pediatric codes during
pediatrics, surgical or trauma codes during surgery.)
While on a surgical rotation as a student we had
a patient CODE right in front of us as the intern
was presenting the case, a
post-op abdominal aortic aneurysm repair. The
team started the code. I jumped in to do chest
compressions. The patient was CODED for a few
minutes, declared dead and then the team moved
on to the next patient. The surgery intern was
obviously disturbed by the incident, but did not
want to discuss it when I tried asking him about
it later. Instead, he preferred adopting the "distancing"
mentality, the "get over it" and "put
it behind you" coping strategy so prevalent
within the surgical field.
As a resident, I experienced even more emotionally-laden
CODES and can still remember the feelings of helplessness
elicited in the CODE teams. One memorable CODE
occurred when I was a resident in Fresno. One
minute my 26-year-old male patient, recovering
from pneumonia was walking in the hall, the next
he was coughing up a sink full of blood. Moments
later he was dead. We discovered after the autopsy
that the cause was mucormycosis that had eroded
into a pulmonary vessel. I presented his case
at a chest conference - as an interesting teaching
case. Another CODE occurred when I was an intern
with the trauma service. I don t even remember
the details of the case, but I believe the person
arrived with terminal injuries. This CODE was
a pediatric trauma - the victim, a two-year-old
child. I watched as the senior surgery resident
tried and tried and tried to establish a line
in this child, but was unsuccessful. Even after
the code he kept berating himself, believing that
somehow if he had gotten the line, the child would
have lived. What was even more tragic was that
this resident had a child of his own the same
age. Another traumatic CODE, because it was unexpected,
occurred when I was a senior resident at Santa
Barbara. The 70-year-old female patient with terminal
cancer, known to the attending, was found coughing
up copious amounts of blood through her tracheotomy
opening. No one knew how to stop the bleeding,
so we watched helplessly as she bled to death.
What was worse for me as a supervising resident
was that this type of incident had been anticipated
by the attending, but not made clear to the nursing
staff, so several very new interns were exposed
to this traumatic event. The intern was going
into radiology because he didn t like dealing
with patients. Trying to talk to him about the
case, I discovered that he was choosing to "deal
with it later." Yet, months after the event,
comments he made indicated that he was still bothered
by the memories of the code.
Equally tragic was the aftermath of these codes.
Not only did I want to do more during the codes
for the patients, but I also wanted to do more
for the participants after these traumatic codes.
However, there were no mechanisms for providing
some structured help or education.
Are
Physicians Really Immune to the Effects of Stress?
Within the medical education system, beginning
as medical students, we are taught to "keep
on going," and there is no need to discuss
cases that might affect us. There is the pervasive
feeling that "I should not need any help,"
"I can cope with this," and frequently,
"I cannot ask for help, because this would
be viewed as a sign of weakness." There is
an overwhelming pressure to keep it together,
no matter what happens, no matter who dies, no
matter how it may impact you. We are taught to
distance ourselves from the situation, become
scientific and clinical. The physician cannot
allow any inner emotions to affect their duties
or performance at the moment. "You can deal
with it at a later time." Unfortunately,
too often that "later time" is suppressed,
or ignored, and the effects become cumulative,
until the response or coping strategy becomes
dysfunctional.
In looking at the impact of traumatic stress,
it has been observed that unexpected, uncontrollable
traumatic events can overwhelm a person s sense
of safety and security, leaving them feeling vulnerable
and insecure in their environment. (6) Depending
on the circumstances of the CODE and the experience
level of the person, it is conceivable that a
CODE or the effects of multiple CODES could potentially
precipitate Acute Stress Disorder or even Posttraumatic
Stress Disorder. The impact of the stress experienced
from participating in CODES, combined with the
stress of medical training was never addressed
within medical school or residency training. Research
on other professions - EMS, Fire and Law Enforcement
- has shown that chronic exposure to stress can
be a factor in developing Acute Stress Disorder,
and even Posttraumatic stress symptoms. (7) In
my experience, it appears that the profession
entrusted with the health of the nation, too often
neglects the health of the physicians. The physician
"role models" were always rushing off
to deal with another patient or another problem
- not taking time to process the events and encouraging
their students to do the same. The residents and
physicians modeled other dysfunctional coping
styles - yelling, screaming, blaming, ridiculing,
distancing, or drinking. Of interest is that the
behavior we were expected to model - the yelling,
screaming, blaming, or drinking are among the
early warning of possible PTSD. The warning signs
may also include self-medication with alcohol,
anger, irritability and hostility. (8)
The medical culture teaches us to view death as
a "failure," rather than being a part
of the life cycle. This type of attitude leads
to blaming and fault-finding which are pervasive
within the field. Often following the death of
a patient, the situation is converted from a failed
CODE into a "teaching case," and a chance
for participants to practice procedures. This
is a preferred method of coping for most medical
personnel, especially in the aftermath of a CODE.
It somehow makes the death less in vain if someone
can learn something from the death.
The public believes that physicians have been
"trained" to deal with the difficult
situations, that somehow we react differently,
and are immune from the impact of practicing medicine.
In my diverse training, I discovered that this
was not even close to reality. I always found
the assumption interesting and erroneous, that
if you have made it into medical school, you can
adequately cope with high-level, life-threatening
stress. Many physicians will attest that this
isn t always the case. Let their ACLS lapse once
in practice and they may not want to be part of
a CODE Team again.
For me the memories that remain are the emotional
ones, the "what ifs" and questions "could
we have done more?" (5). I felt fortunate
because I was an Emergency Medical Technician
prior to medical school and experienced death
in the field. One wonders what the impact of being
involved in CODES or of repeated exposures to
other stressful events has on the untrained responders.
Residents
Level of Confidence about CODE situations
During my medical education I saw the impact of
being involved in CODES on my fellow residents
and colleagues, in medicine, surgery and trauma.
The lack of preparation combined with the expectations
of being the team leader put a great deal of additional
pressure on resident physicians. They may be called
upon to perform procedures or run CODES, which
they may be uncomfortable doing. In many situations,
there are no other options. The senior resident
is on call, is the one in charge of running the
code, with an ACLS or PALS course as their sole
training. One has to wonder, "Is advanced
life support training enough to provide residents
with the background and the confidence needed
in a code situation?"
There appears to be a difference of opinion amongst
medical educators as to why residents may have
poor CODE skills. In one article examining the
performance of PALS skills by pediatric residents,
the authors found while retesting their house
staff previously trained in PALS, that they demonstrated
poor performance and prolonged response time in
mock CODE situations. The authors recognized that
"inpatient pediatric resuscitations occur
infrequently, providing fewer practical practice
opportunities for house staff." One author
felt that "...the results are disturbing,
but not surprising. Practice does not make perfect;
only perfect practice makes perfect." (8)
This article offered few insights as to reasons
for the "poor performance" other than
suggesting "the need for greater attention
to detail during training." Yet there may
be other reasons for poor CODE performance. Recent
studies have shown that stressful environments
are not conducive to learning, and that learning
under stress results in poor retention of new
material. (9,10) My own suspicions about the pervasive
unspoken feelings regarding CODES, of fear, anxiety
and inexperience, experienced by many in training
were confirmed by a survey conducted on Pediatric
Residents at the University of Louisville, Kentucky.
This survey of residents found 79 % of them scared
by CODES, 76 % felt that they needed more knowledge
and 82 % felt that they needed more experience
before running a CODE. Researchers of this article
concluded that residency programs were not meeting
the education and confidence needs of their residents.
(11) In other studies it is noted that those not
actively participating in CODES lose their basic
hands-on skills, with recommendations for testing
skills every 12 months and yearly recertification
in ACLS. (12, 13).
Implementing
Additional Information into ACLS Training
Within my medical education CODE experiences,
there was no instruction in what to expect during
CODES. There were no attempts to bring the students
or residents involved in the CODES together for
any sort of "debriefing" or "defusing."
After discovering this omission, as a medical
student at U.C. Davis, I obtained permission for
medical students to access the Critical Incident
Stress Debriefing Team. Prior to that no one thought
to include them. During residency training, if
there was talk about the CODE, in my experiences
the students, residents, nurses, and EMS personnel
discussed the case separately, rather than in
a formal, organized manner. Once in the position
of being "teacher" rather than just
"student," I made sure to discuss CODES
with my medical students and fellow residents
and educated them prior to CODES if possible.
There is a significant range of "normal responses
and symptoms" which may occur after experiencing
a traumatic event.(3) These symptoms may also
occur after repeated exposure to stressful events.
It is important for those in high-risk professions
to be aware of these normal responses. From discussion
with colleagues, I discovered that many of them
had experienced these many of responses at different
times.
- Nightmares
(more than once/week)
- Feeling
"numb" or detached
- Intrusive
memories (more than once/day)
- Depressed
mood
- Irritability
- Feeling
guilty
- Difficulty
concentrating
- Feeling
anxious
- Anger/Hostility
- Feeling
as though the world no longer "makes
sense"
- Fear
and/or avoidance of similar situations
- Avoidance
of people or things that remind you of the
critical incident
- Questioning
religious values
- Hypervigilance
- Stress-related
physical complaints
- Exaggerated
startle response
- Flashbacks
- Difficulty
Sleeping
- Withdrawal
from usual activities
- Difficulty
remembering the critical incident
One compelling reason for implementing additional
education into ACLS and PALS training, is that
unprocessed reactions to traumatic events can,
in time, progress to have significant negative
outcomes. A recent study of EMS personnel looked
at workers who were frequently exposed to multiple
traumatic stress events, including injury and
death, accidents, fire, murder, drug abusers,
and those with chronic illness and medical problems.
The EMS personnel, who were exposed to major traumatic,
stressful events and chronic stress, were typically
responding to multiple calls with little time
for a break. Of those surveyed, 9.3 % met full
DSM-III criteria for PTSD and an additional 10
% met full criteria, except for time criteria
(the symptoms had not been present for a month.)
(7) Those in the medical profession - students,
residents and physicians - are also exposed to
traumatic events, chronic stress and must often
respond to multiple "calls" without
time for a break. Unprocessed reactions to traumatic
events can potentially progress to become posttraumatic
stress disorder, leading to significant impairment.
This can impact job and relationships, both professional
and personal. Unprocessed cumulative traumatic
events can eventually lead to professional burnout,
another issue recognized within the high stress
professions - police, fire, and EMS - but practically
ignored in the medical profession.
Conclusion
The public often views doctors as being superhuman
and believes that tragic events do not truly impact
them. There is an assumption that physicians are
somehow "trained" to cope with CODE
situations. I discovered that this was not even
close to reality. Within the medical education
system there is the assumption that all medical
students are capable of adequately handling high-stress
CODE situations. The impact of the potential stress
experienced from participating in or running CODES,
combined with the stress of medical training was
not addressed within medical school or residency
training. Studies on other professions have shown
that chronic exposure to stress can be a factor
in the development of Acute Stress Disorder and
even posttraumatic stress symptoms. Traumatic
events can be detrimental to someone s personal
or professional life.
There is a need for medical students and residents
to be educated as to what to expect during CODE
situations and afterward. Furthermore, students
and residents need to have more positive role
models that can demonstrate functional coping
skills in order to develop healthier coping mechanisms.
This would help to prevent the dysfunctional,
maladaptive coping strategies so frequently adopted,
and too often accepted as "normal behavior"
by those in the medical community.
References
1. Cummins, RO Editor. Textbook of Advanced
Cardiac Life Support. American Heart Association:
Dallas, TX 1997.
2. Chameides. L. Pediatric Advanced Life Support.
American Heart Association: Dallas, TX 1997.
3. Mitchell JT, Everly GS. Critical Incident
Stress Management: The Basic Course Workbook,
2nd Ed. International Critical Incident Stress
Foundation, Inc. Ellicott City, MD: 1998.
4. 0 Marcaigh AS, Koenig WJ, et.al. Cessation
of unsuccessful pediatric resuscitation-how
long is too long? Mayo Clin Proc 1993 Apr; 68:332-6.
5. Dyer KA. Fleeting Moments. West J. Med. 1990;152:195.
6. Volpe J.S. Traumatic Stress: An Overview.
Trauma Response, 1996. http://www.aaets.ore/arts/artl.htm
7. Blumenfield M. Byrne DW. Development of Posttraumatic
Stress Disorder in Urban Emergency Medical Service
Workers. Medscape Mental Health 2(9), 1997.
www.medscape.com
8. White, J.R.M., Shugerman R, Brownlee C. Quan
L. Performance of Advanced Resuscitation Skills
by Pediatric Housestaff. Arch Pediatr Adolesc
Med. 1998;152:1232-1235.
9. van der Kolk BA, Fisler RE. The Biologic
Basis of Posttraumatic Stress. Primary Care.
1993;20(2):417-432.
10. Yehuda R, Keefe RS, et al. Learning and
Memory in Combat Veterans with Posttraumatic
Stress Disorder, Am J Psychiatry 1995; 152(1):137-139.
11. Cappelle C. Paul RI. Educating residents:
the effect of a mock code program. Resuscitation.1996;
31:107-11.
12. Mancim ME. Kaye W. The effect of time since
training on house officers retention of cardiopulmonary
resuscitation skills. Am J Emerg Med 1985;3:31-2.
13. Stross JK. Maintaining competency in advanced
cardiac life support skills. JAMA 1983;249:3339-41.
|
