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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.
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