My First Time

“Push one milligram of epinephrine!”

The code leader didn't appear very comfortable. The terse speech and abrupt movements reflected his frustration in managing this unexpected event.

“You, get in here!”

“Who…me?”

“Yes you! You have hands, don't you?”

This wasn't a mock code. This was real. This was my first cardiac resuscitation. I suddenly found myself standing perpendicular to the patient, leaning over him, counting in my head as I thrust my weight into his lifeless chest wall. One…two…three…four…five. I pushed on Mr. W's chest as fast as I could.

Despite the noise, the flurry of individuals rushing into the room, and multiple voices yelling for one thing or another, time slowed down enough for me to realize that Mr. W's eyes were open. He seemed to be staring right at me. Did he recognize my fear?

Despite nearly 20 minutes of a coordinated effort to jump start his sick heart, our efforts were for naught. The atmosphere was deflated and the room quiet as Mr. W was declared dead. The code leader calmly said, “Okay folks, that's all. Time of death is ….”

And with that, the personnel dispersed back to their usual activities. Nurses began tending to other patients. The respiratory therapist removed the ventilator from the room, half-joking that it was still clean for the next patient in need. The interns, resident, and attending physician resumed morning rounds as if they had been interrupted by a trivial event.

I felt a rising panic. My curved eyebrows, clenched jaw, and motionless mouth were a disguise to an inner dismay, but my hands could not suppress my true feelings. They were clammy and tremulous, a clear window to my inner turmoil. I played the scenario in my head over and over again. Could I have done something different? Were my chest compressions hard enough?

My intern was a preliminary radiology resident—a stocky, taciturn man with thick eyebrows overlying droopy eyes, and a rough voice. In hindsight, he was the most unlikely source of sympathy. Yet he sensed my compunction and asked, “Are you okay?”

“Uh, yeah, I think so,” I replied.

“Okay, so let's talk about what just happened,” he said. And we did. We found ourselves in the middle of a ward exchanging thoughts for several minutes.

Perhaps others deemed participation in a cardiac arrest as perfunctory in their day-to-day hospital lives. I couldn't. My intern began to emphasize what others seemed to regard as trivial, first by recapping the sequence of events, then noting the potential for grief at the death of a patient, and lastly, empathizing with my feelings.

“Don't worry, you didn't do anything wrong and we did everything we could to help Mr. W. You'll be okay and this gets better.” At the time, I didn't know what “this” meant. But by the end of the conversation, my hands had stopped shaking.

Debriefing is a group-oriented intervention in which major elements of a trauma are reviewed by the participants. The intervention has historical roots in the military. U.S. Army historian Colonel Samuel Lyman Atwood (S.L.A.) Marshall was the chief U.S. Army historian in World War II, Korea, and Vietnam. While working as a reporter during the Korean and Vietnam wars, Marshall's intention was to study small unit performance in ground combat. According to Marshall, the modern battlefield presented the soldier with very little positive information, with multiple ambiguous cues as to where the sources of danger and threat are hidden. A soldier's capacity to overcome his fears, therefore, depends on the presence of others.

His debriefing sessions took place immediately after a traumatic event, conducting interviews with the surviving members of small units in the field. As a historian, he was concerned with facts, and this was the only way to find out what had truly happened. He found that these historical debriefings, when properly conducted, were also very beneficial to the units themselves. The process repaired and strengthened unit cohesion and readiness to return to battle. ²

Similarly, the medical resuscitation team is a unit that requires cohesion and postcrisis repair. In 2003, only 17% of all in-hospital cardiac arrests survived. Of the survivors, more than one-third had clinically significant neurological dysfunction. ¹ By 2009, survival after in-hospital discharge improved to 22%. Knowing this, the next cardiac arrest is still likely to result in a poor outcome. Perhaps debriefing after these emergencies is the key to ongoing repair and strengthening cohesion. Studies of debriefing after a life-threatening emergency in the intensive care unit have shown an improvement in patient-focused outcomes and processes. In particular, it has led to increased cardiopulmonary resuscitation processes and increased return of spontaneous circulation. ³ Debriefing has been well received by clinicians, with improvement in learning and improved technical and nontechnical performance. ³

But are improvements in team cohesion, patient outcomes and processes, and technical and nontechnical performance enough? What about the individual clinician/trainee and their subjective experience? In my case, the failed resuscitation left me with a mix of negative emotions: sorrow, anxiety, panic, and fear. I knew the immediate emotional wound wasn't physical and any attempts at a quick cure would not suffice. But like all wounds, this one needed time to heal, and debriefing was the tool to allow for the initial cleansing of the wound. From that point, I grew and began to reengage with my surroundings.

It has been nearly 10 years since my “first time” and I still recall my intern's action of debriefing, and his final words of that conversation: “This gets better.” Indeed, the nervous tremor has disappeared. Yet the fear of the unknown outcome still lurks. Perhaps it is our obligation to recognize the multiple emotions, conveyed through distressed eyes, tremulous fingers, or a clammy hand. And perhaps it is our duty to then debrief and begin to purify the wound, all in an effort to promote healing, both of the team and the individual.