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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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