On-table cardiac arrest – a CT1’s perspective
It is a Friday afternoon in what has been
a busy week for a novice trainee who is
still climbing up the steep learning curve
of the job and every day, without fail, is
a learning day. In preparation for solo
on-call duties we have been carrying the
on-call bleep ‘in hours’ with more senior
support who can attend emergencies
with us if required. Earlier in the week
I asked the specialist registrar for help
in the Emergency Department with a
patient who had collapsed, and I was
taught about the principles of neuroprotective
anaesthesia. A few days later
I saw the patient’s organs donated. That
surreal moment of disconnection will
stay with me. Earlier that morning I had
assisted in an anaesthetic for a patient
with a severely stenosed heart valve who
nearly arrested in the anaesthetic room
and required adrenaline to stabilize them.
I spent the end of my morning zipping
back and forth to ITU with gas syringes.
Over lunch I talked to my educational supervisor about this and
we agreed my week has been surreal in places, with a multitude
of learning points to take from these experiences. My brain feels
fried and I haven't assembled my thoughts about the organ
donation. However, I have a straightforward general surgery
list to carry me through the afternoon and then I’m going
home for the weekend. Later that afternoon we are finishing
up a hernia repair without any hiccups. I can’t even remember
what procedure the next patient was due to undergo, all I can
remember is my brain being slow when the alarm goes off. It
was 'the alarm'. My theatre is between cases, so the consultant
and I are free to go, flashing lights guiding us to the theatre
with the emergency. It all happened very quickly. All the people
in surgical gowns backed away, trays are pulled out and the
drapes were ripped back. It felt unnatural. The patient was the
wrong colour and chest compressions were started. There
was a clear history of what happened: it was expected to be
a straightforward case; they were otherwise fit and well; and,
this sort of cardiovascular collapse was not on the cards. My
consultant did the compressions as I stuck the defibrillator
pads onto the patient around his hands. I can feel the femoral
pulse under my finger in time with the chest compressions. It
was an easy stab and I filled the bottles and as I headed across
to ITU a flurry of people run past me including my educational
supervisor. They said something to me, but I didn’t catch it.
Something encouraging? A question about the case? All I replied was: “I’m going to get the gas.”
The ITU trainee said “Another gas? You already needed three
this morning.” It was said in jest, but I must have looked anxious
because their expression is a look of sincere concern. They got
a one-sentence, garbled handover and those who were free
went to help. I returned to the arrest with the ITU trainee. As we
entered the theatre more adrenaline was given; everybody was
un-scrubbed, and the wounds were closed. People queued up
in an orderly fashion to do the compressions. Somebody at the
head end called instructions, somebody on the defibrillator
called timings and there was a frantic scribe. We thrombolysed;
the most likely ‘T’ of the situation was ‘thrombosis’. The ITU
trainee promptly turned back around and took me with them. I
was going to learn where the alteplase was kept along with the
dosing regimen. Yet another learning opportunity.
There is some irony in emergency drugs that we rarely use
being ever so slightly awkward to draw up. On our return the
adrenaline pile was bigger, and bicarbonate was being given;
the compressions were good quality and everybody was
encouraging each other. All elective theatres have stopped
and everybody was here. The scrub staff asked why we had to
continue CPR for so long. I explained that we needed to “give
the clot-busting drug a chance to bust a possible clot”. As I was going in and out of theatre so much I had only been getting
short clips of the situation as it evolved. Later on I would think
about how everything had happened as it should; there was
leadership, there was a plan and we were working as a team. The
more senior staff from every faction, though they looked a little
on edge, forced a calm atmosphere – a quiet confidence which
in turn spreads to the rest of us.
As I waited my turn for compressions and I had a feeling of
nearing my limit. The combination of cognitive demand, stress
and emotion was reaching maximum capacity. I didn’t suddenly
break down weeping or screaming, I just knew that I wouldn’t
be as good or potentially as safe at my job as I could be. As
time passes in medicine, you accrue experience and it takes
more and more stress to have that feeling of reaching maximum
cognitive capacity - but it will happen. Perhaps not as often as
in your junior years, but it does happen. After the week I had
experienced, I wanted to stop. As I approached the front of
the chest compression line my educational supervisor made
eye contact, and they saw it too. They told me to leave; I did
not protest. I left theatre and had a cup of tea. I spoke to the
specialist registrar coming on duty for the evening and tried to
get them up to speed. I felt bad for leaving my colleagues, but
I knew there were plenty of people there and the patient was
having the best care possible.
That evening I was heading home to visit my family. The
drive home gave me time to dissect my week. I have been
watching my seniors practice for the viva and follow suit:
classify and categorize, or die. I looked at objective learning
points: physiology, pharmacology, physics and non-technical
factors. As the cases become increasingly complex it gets
more complicated and subjective but ultimately I feel like all
the training we have for when things go wrong, works. A sense
of urgency rather than panic, hoping for the best possible
outcomes while making plans for the worst-case scenario, and
everything in between. On Monday night I came in for my shift.
So, I missed the debrief in the morning. The patient sadly died;
they had a ROSC for a time and the family were able to come
into theatre to say goodbye. The surgeon cried. Everything
that could have been done was done. There was no fault made
regarding the resuscitation attempt.
A mini-debrief just for me
The following morning as I finished my night shift, we had a
junior’s meeting for sharing learning experiences and drinking
tea. The consultant leading it got me to talk through what
happened. A mini-debrief just for me and I couldn’t be more
grateful. Somebody to confirm it really was as stressful as you
remember it - you are experiencing something like a normal
human being. It should feel strange to rip drapes off people and
feel disheartened when you have done everything you can and
nothing seems to change.
From a CT1’s perspective I was glad my seniors let me talk
as much as I needed and provided a balanced debrief.
Discussing treatment and management is just as important as
acknowledging the emotional side of an emergency scenario.
I don’t want to be sheltered or coddled: that won’t make me
a good doctor. And yes, it is helpful when seniors question
our clinical understanding, as much as we may protest. This was a tragic story at the end of a challenging week for me as a
junior. However, I want to feel capable about it when there is a
next time, so I know am doing right by the patient. As a CT1 I
don’t know how often to expect certain scenarios, should they
happen once a month, once a year or once in a career? After this
scenario, I don’t think this is an area where anaesthetists should
ever allow themselves to become desensitised.
Catriona Spiers
CT1 Anaesthetics
South Wales
Need some help?
This sounds like an incredibly challenging week for an
anaesthetist of any grade, let alone a novice. It seems your
department have done a great job in offering informal support
to you – this is essential. A well-structured de-brief with others
present during a specific incident can be reassuring but, due
to shift working, this may occur at times when not all staff can
attend. As trainees we should therefore have numerous people
we can turn to in times of need, which may vary depending on
the situation.
Educational Supervisors are often an excellent first port of call;
there should be an existing relationship here. College Tutors are
likely to have extensive experience of helping trainees and may
also offer assistance. Other trainees can provide great support in
difficult circumstances and may feel more approachable. In our
experience of challenging situations, we’ve turned to consultants
and colleagues with whom we’ve had a close relationship, and
despite not having a specific pastoral role, found them incredibly
supportive. It is unlikely consultants will have made it through
training without experiencing significant events in their work that
have had an effect on them and they can offer vital perspective.
Outside work, letting friends and family know that that you’re
having a challenging time can help them to help you.
Sometimes situations we are involved in can leave us
emotionally stressed, anxious or depressed. Informal chats with
colleagues may not be enough; friends and family may struggle,
and we may need professional support. Beyond the anaesthetic
department, the hospital occupational health team have a
responsibility for the health and wellbeing of staff and should be
able to arrange assessment and counselling sessions if needed.
Depending on the arrangement in your Deanery, this may also
be available through your Lead Employer Trust. We should all be
registered with a GP who can provide objective advice – don’t
forget them. There is also the BMA, who offer excellent 24/7
counselling services. They have a peer support network and can
put you in touch with other doctors experienced in supporting
the emotional needs of doctors and medical students. Peer
support is also available via the Doctors' Support Network.
DocHealth is a confidential, not-for-profit, psychotherapeutic
consultation service for all doctors and up to six sessions can
be booked, although there may be a fee. Trainees in England
can contact the Practitioner Health Programme, a free and
confidential NHS service for doctors and dentists with issues relating to a mental health concern or addiction problem.
A social media initiative worth noting is the ‘Tea and Empathy’
group on Facebook and Twitter, a national peer support
network for NHS staff. Many of these support options can be
found on the Association’s wellbeing page and are listed in
the box.
Life as an anaesthetist can be varied, hectic and incredibly
rewarding. It can also be stressful and heart-breaking. Our
patients and their families are often experiencing one of
the worst days of their lives and it is only natural that we
take some of that on ourselves. As clinicians we rarely talk
openly about the emotional toll of our work. The Association’s
#coffeeandagas initiative was launched to encourage
informal chats between staff. Another option could be a
hospital Schwartz Round. These are evidence-based forums
for hospital staff from all backgrounds to gather to talk about
the emotional and social challenges of caring for patients,
and offer a safe and neutral place to share experiences –
it’s worth looking into whether your Trust offers them, as
evidence suggests that those who attend regularly feel less
stressed and isolated at work. Ultimately, whatever your
week may throw at you, we’re all working in this environment
together and better relationships mean better support in
times of challenge. It is important we look out for ourselves
and each other, and remember that it’s ok to not be ok.
Karen Stacey, ST7 London
Lucy Powell, ST6 Newcastle
Trainee Committee, Association of Anaesthetists