The Potential Impact of CODES on Team Members: Examining Medical Education Training

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.