Knowing Your Place Can Cost Lives
Medicine has a long history of hierarchy, which does not always serve the patient well
Early one Thursday evening, I headed over to my hospital’s medical simulation centre to take part in a two-hour code training session. In medical-speak, when a code is called it means that a patient has gone into cardiac arrest or may be about to do so.
At our hospital, when a code blue (signifying cardiac arrest) is called on the loudspeaker the code team – anaesthesia, medicine and surgery residents, as well as several nurses – rushes to the scene. Their job is to determine reversible causes of the arrest and, most importantly, initiate cardiopulmonary resuscitation (CPR). Successful resuscitation requires each step to be carried out flawlessly: CPR and defibrillation must be initiated immediately.
The patient’s life depends on good leadership, communication and teamwork. Although caregivers have the best intentions, these emergency situations can often dissolve into chaos. Last year, as an intern, my responsibilities during codes consisted mainly of performing chest compressions. Now, as a junior resident, I might be responsible for running a code.
That evening’s training session brought back one of the codes I had taken part in as an intern.
One night last autumn, Mr X, a 24-year-old man with a congenital heart defect, went into cardiac arrest. The words “code blue!” resounded overhead and I rushed with my resident to his room. I immediately went to the side of his bed and began compression.
A nurse stood by, waiting to relieve me. Before I could let her take over, a second resident pushed her out of the way, taking my place. I saw the look of hurt and anger on the nurse’s face, but this was no time for discussion. Despite our best efforts for over an hour, we could not restore a heartbeat. I lifted my hands from his chest. The room was quiet. My resident, the code leader, was devastated. I knew from her face that she was reliving every minute of her direction, wondering if she should have done something differently. Time of death: 2.54am.
As I entered the simulation room, I thought about Mr X. As the instructor programmed the expensive mannequin, our group of nurses, interns and residents waited anxiously; we were then told to go into the simulation room one by one.
Later, we watched the recording of our simulation. It had taken us four minutes and 32 seconds to initiate CPR and even longer to shock the mannequin patient. That is unacceptable. Every second without circulation decreases the patient’s chances of survival. One of the nurses had been first to enter the room. She immediately saw the “patient” needed shocking and placed defibrillator pads on the mannequin’s chest. Yet she never instructed the team to initiate CPR. It was several minutes later that our code leader grasped the situation and we began chest compressions and defibrillation.
The facilitator asked the nurse why she hadn’t told the team to start CPR. “I didn’t feel like it was my role. I’m just a nurse, not the code leader,” she replied. Yet for those four minutes and 32 seconds she was the only one who realised that we should be doing CPR. I thought back to how I saw a doctor push a nurse out of the way during Mr X’s code.
The nurse who held back in the simulation has been a critical care nurse for more than 30 years and has more experience with code situations than any resident I know. She should not have had to think twice about calling for CPR.
Medicine has a long history of hierarchy, which does not always serve the patient well. Training sessions like these are slowly breaking down barriers.
Financial Times Weekend Magazine | August 12, 2011