On-table cardiac arrest – a CT1’s perspective | Association of Anaesthetists

On-table cardiac arrest – a CT1’s perspective

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