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MEdIC Series | The Case of the Debriefing Debacle

2017-01-20T12:30:39+00:00

Welcome back again this week to the Medical Education in Cases series.  Last month we had a record breaking number of people join us for the case discussion, and we hope you will come back and share your thoughts with this one.

This month’s case centers upon Dr. Berner and his student Melanie as they both go through a Cardiac Arrest case. Consider their story and think about how you might approach this case.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Debriefing Debacle

by Dr. Joanna Bostwick

“Excuse me Dr. Berner. One of the nurses came to ask me if we were aware that there is a 20 year old guy in the Resuscitation Room with a heart rate of 200,” said Melanie nervously, a third year medical student who had just started her Emergency Medicine (EM) rotation.

“What? I didn’t hear about that. Let’s go over right away.”

Dr. Berner sprinted ahead as Melanie grabbed her stethoscope. As Dr. Berner entered the Resus Bay he saw a young slender male who did not appear well with vomitus running down his cheek. He looked sonorous and diaphoretic and the monitor showed a heart rate now of 220 bpm. Two nurses were hard at work attempting to establish an IV and draw bloodwork.

“Can anyone tell me about this patient?” Dr. Berner demanded.

“He was found slumped over at a house party tonight. The paramedics think he took a cocktail of drugs and alcohol,” said one of the senior nurses while she primed an IV with normal saline.

Dr. Berner turned to Melanie, “Have you ever intubated before?”

“Ummmm… A few times?” Melanie stuttered, she had intubated a couple of times in the OR but never in the ER. “But I’m not even sure what’s going on here.”

“We can talk more about what’s going on in a moment, first we need to secure the patient’s airway.”

“The O2 sats are starting to drop and I can’t wake him up,” said a nurse anxiously.

“Ok team, let’s give the naloxone and get set up to intubate.”

“The naloxone was given per protocol by EMS with no effect earlier,” stated the charge nurse.

“Alright then, I’m going to intubate right now.” Let’s get the crash cart at the bedside and page RT stat.” Dr. Berner turned to Melanie, “I will have you watch this one and you can attempt the next intubation.”

The patient was intubated successfully and Dr. Berner sighed with relief. With the patient’s airway secure, his oxygenation improved. He now turned to Melanie to ask about toxins that could cause tachycardia when suddenly the monitor started to beep as Dr. Berner looked in horror to see VFib.

“Melanie start chest compressions,” ordered Dr. Berner, “Betty, can you give 1 mg of epi? Also, Sarah can you go get Dr. Takeda and his residents over in the Quick Care area?”

Melanie had never done CPR before in real life and shuddered in horror as she felt ribs breaking beneath her hands.

Her head was spinning. What had just happened? She was beginning to feel her arms fatiguing and didn’t know how she could keep this up.

There was a fury of people who suddenly appeared to help at the bedside.

“Ok stop CPR let’s check the rhythm and pulse,” said Dr.Berner.

“Asystole,” said several in unison.

“Resume CPR,” Dr Berner said and then turned to Melanie, “you can switch off with Joe. He’s right behind you, ready to take over CPR.”

“Dr. Berner the family has arrived they would like to find out what’s happening and want to see their son,” said the social worker quietly from the doorway. I have tried to prepare them for what they are about to see.” Dr. Berner nodded his assent, and the social worker disappeared momentarily. A few minutes later, she returned with a middle-aged couple, both clinging to her for support.

“Another round of epi please, Betty?”

“How long has the code been going on?” asked Dr. Takeda as he arrived. He and Dr. Berner turned to each other to discuss the proceedings on the code, just out of Melanie’s earshot. Dr. Takeda then went over to talk to the parents of the patient, talking to them somberly for several moments.

A few moments later, the couple looked to him and said: “Please stop.”

Dr. Takeda then nodded at Joe, who had the bedside ultrasound set up, and ready to use at the next rhythm check.

“Rhythm and pulse check please,” ordered Dr. Takeda.

“No pulse… Asystole…”

“Bedside echo shows no cardiac activity.”

“Let’s call the code,” sighed Dr. Berner. “Time of death…”

There was a large wail as the patient’s mother fell to the ground. Melanie tried to hold back her own tears.

For the next few minutes, Melanie felt like she was walking through a daze. Had that really just happened? She felt like it had just been a few minutes since she had seen him arrive with the paramedics! He had groaned when she tried to do a sternal rub… He had been alive. What had happened? Maybe her compressions weren’t forceful enough? What if it was her fault?

 

Key Questions

  1. How do you debrief this case with Melanie?
  1. How do you address her fears that she did something wrong?
  1. What is a general approach to debriefing a medical student after a bad outcome in a young patient?
  1. What is the role of the family’s presence during a resuscitation?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Hans Rosenberg (@hrosenberg33) who is an emergency physician at The Ottawa Hospital and Assistant Professor at the University of Ottawa. IT Director and Social Media keener.
  • Tessa Davis (@TessaRDavis) is a pediatric emergency physician from Sydney, Australia. She is also the co-creator of the Don’t Forget the Bubbles blog.

On October 31, 2014, we posted the Expert Responses and Curated Community Commentary for the Case of the Debriefing Debacle. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on October 31, 2014. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • S Luckett G

    I’ll start off the discussion by addressing the issue of debriefing.

    In my experience, learners are often not debriefed and instead must approach preceptors and teachers. This is tough for those of us who are not confident in approaching our superiors, and even harder when we feel we may have done something to cause or contribute to a bad outcome. If preceptors don’t facilitate debriefing, we begin to feel that we are needy or otherwise inadequate because we feel a need to debrief and discuss. In reality, even staff debrief with other staff, and I see that more often as a resident, but that’s relatively well-hidden from medical students, who then miss out on important role-modelling.

    In terms of addressing Melanie’s fears that she did something wrong, I think it’s important to explain to a learner in no uncertain terms that she had no role in producing a poor outcome (as long as that’s true). To do that, teachers and preceptors must anticipate these feelings of guilt regarding bad outcomes. I suspect that experienced clinicians know when they are and are not to blame, but learners nearly always feel that they have had something to do with the outcome, especially since we often do not understand the intricate details of the situation. We may have done something too slowly because we weren’t familiar with a procedure, or we may have done something inadequately because we had never done it before.

    I recall recently feeling that I had been responsible for a patient’s aggressive and challenging response to bad news; I worried that I had broken the news in a way that had made the patient react particularly badly. My only solace (and the only thing that let me sleep that night) was my attending’s reassurance that she would have broken the news in the same way and that the response of the patient was unexpected to her as well. Though this is not the same as a patient death, it does reflect the importance of attending physicians directly anticipating the feelings of fear and doubt that their junior learners experience and addressing them in a straightforward and direct manner.

    • Thank you Luckett for your insightful comments. I think your statement about the role of the staff person in guiding you through a difficult situation is amazing!

      My insight:
      Come back to this comment in a few years … And let it remind you of a junior resident’s perspective….

    • Eve Purdy

      Hi Sarah, I totally agree. There have been times when I have been craving a debrief but haven’t known how, who or when to ask for it. Often it ends up being with a close friend, who wasn’t a part of the situation. I know that those moments, while important, aren’t quite good enough.

      • S Luckett G

        Eve, I agree. Friends are often my source of debriefing as well. The situation is often complicated by the friends I choose to talk to being outside of medicine (don’t worry; privacy is never compromised!). I also find that writing can be an excellent outlet, but it’s not for everyone.

        I note that in our curriculum (knowing that we had a very similar curriculum), we are taught many things, but not how to approach staff for a much-needed debrief. Do you think this would be useful to students if explicitly taught?

  • Rob Woods

    I think for question 3, the key is to try and remember experiencing death for the first time in training. When the case might seem more obviously futile (elderly patient with significant co-morbid disease), we can easily overlook how stressful that can be for a trainee. Offering a debrief opportunity at the end of the shift is a good way to never forget. Given that trainees might not feel comfortable offering it up, preface things with, ‘that was a tough shift, is there anything you want to discuss?’

  • Nadim Lalani

    good case. First have to understand that no matter how resilient we think we are – situations like this can (and do) lead to post traumatic stress disorder. If melanie feels this way, chances are good that the rest of the code team does too. This requires critical incident stress debriefing and close follow up:

    Goals of CISB are to 1) lessen the impact by 2) allowing for venting and sharing of emotions 3) promote resilience and wellness. 4) promote human-ness

    I am sure you’ll hear more from Hans and Tessa, but I would:

    1) Have a Moment of Silence for the young man – we still don’t know his name. Dying naked, alone surrounded by strangers in the ER was probably the last thing he’d have wanted. He [like many of us] had a story we don’t know about. This needs to be acknowledged.

    2) Debrief with the entire resusc team. (Offer yourself up for follow up and
    check in with your team down the road)

    3) Take a break with Melanie …go for coffee and allow her to vent/talk:
    – let her lead
    – focus on the positives (this is why it’s crucial DURING the resusc to praise and acknowledge things like “great CPR Melanie – there’s a good wave-form on the monitor and we have decent end-tidal CO2”]

    4) Talk to Melanie about PTSD and keep a close eye on her over the next few weeks

    As for family presence – Literature supports having them there for closure. They need to see what great and heroic things we do. They also keep things human and real [we often run these codes with a lack of human-ness that we have discussed at length last MEDIC case].

    that’s my 0.02c
    thanks
    Nadim

    • Rob was telling me IRL about your moment of silence. That is amazing!
      I am just usually torn because I fully believe in the process of bringing in the family – and that is important to me because I think it helps them heal.

      I have seen first hand people work (rapidly) through the stages of grief into acceptance during the end of a resuscitation….

      If you bring the family in… how would you alter your above algorithm?

    • Eve Purdy

      Dr. Lalani, the moment of silence seems entirely appropriate and like something other institutions and teams might think about. It seems like more of the norm in some eastern medical cultures.

      Some places I’ve been move from code to the next patient without much in between. There seem to be pressures (real or conceived) that prevent people from taking the break you describe. How do you reconcile?

      • Loice Swisher

        Eve,
        I wonder if some of this is an individual thing. Perhaps it seems that I move from the code to the next thing without much thought. I had done what I could do for this patient and now I have to care for those who loved him. The moment I take is before going into the family room.

        I had a good friend whose mother and brother were killed in a motor vehicle accident after leaving his house for Thanksgiving dinner. I wasn’t even in medical school at the time when he told me how “the ER doctor came in and quietly tore his life apart”. I think of my friend and that phrase every time that I notify a family of a death. That is my private moment of silence and reflection.

        On particularly difficult situations, I may spend some time in the hospital’s chapel on the way out to my car at the end of the shift… even write in the prayer book.

        It may be people just have different ways that work for them to give meaning to the events.

        Loice

        • Eve Purdy

          Very good points and perspective.

  • Jeffery Hill

    There have been many great points already.

    I will add one brief comment in response to q1 q2.

    I think it is important for the attending to start off his debriefing with some expression of his own feelings. Something along the lines of “No matter how long I’ll work in this job, I’ll never get used to the death of a young patient.” Since Melanie is quite junior to the attending a good debriefing is going to require breaking down any hierarchical barriers to communication. I agree with Nadim and his suggestion to use silence and allowing Melanie to lead the conversation.

    I agree that ideally in the course of the code you would have used some positive reinforcement (i.e. great technique with the CPR Melanie). If you didn’t have the opportunity to do so (and even if you did) it’s important to reinforce those points in the debriefing. I would praise her HIGHLY for coming to get me right away when she saw that the patient was sick. (a. – she recognized sick vs not sick and b. she realized that the resources presenting in the room wasn’t sufficient to care for the patient – These are high level behaviors for a 3rd year medical student and show an understanding of system factors as well as an understanding of the emergent care of patients). I would also let her know that she shouldn’t expect to be able to “deal with” or “get over” the death of this patient immediately. In many ways, we carry the patients who have died on us with us for the rest of our career. The memory of some are more vivid than others. But, these experiences make us better physicians (as long as we choose learn and grow from them).

    • S Luckett G

      Thanks for your thoughtful comment! I really like your recognition that Melanie displayed skill exceeding training level during the course of this case, and also that you suggest validating that this experience is not something to be quickly ‘gotten over’.

      I’m curious about your suggestion that the attending initiate debriefing with an expression of his own feelings. I like this idea a lot. Do you think there are ever times when this would be inappropriate?

      • Loice Swisher

        Inappropriate? Harsh Reality?

        My first feeling: If you do this long enough you will make decisions that cause a patient pain, suffering and death- probably more than once. It is even more problematic in emergency medicine where we have to make rapid decisions with inadequate and incomplete data often having no established prior rapport with the patient or family.

        Yes, to err is human. Medical mistakes are now thought to be the 3rd leading cause of death in the US. http://www.forbes.com/sites/leahbinder/2013/09/23/stunning-news-on-preventable-deaths-in-hospitals/

        However, Melanie, for you this is not one of them. You acted admirably at the level of your training. The outcome is not your fault. At this stage you need to recognize the difference of sick and not sick and when you are in over your head needing help. You did that.

        I think we as a medical community need to talk about the impact of making medical mistakes (actual or perceived) and the coping-strategies different physicians use.

      • In my practice, although it is still evolving, I tend to start a debrief with systems improvements (CQI type questions – What went well? What could we improve for next resuscitation?) and then let people talk about what they are feeling…. I usually start each round… unless someone looks like they’re really interested in starting.

      • Jeffery Hill

        Thanks for the reply! I believe that the attending should make their feelings known clearly at some point in time in the “debriefing.” Whether or not to start off with it would depend on the medical student/resident and how they are responding to the situation. I got the sense from the write up that the medical student was drawing in upon themselves and “clamming up.” In that situation, there needs to be some gesture, recognition, or plain statement by the supervising attending that having strong emotional reactions to these situations is common and appropriate, and that talking about it makes us better clinicians.

        • S Luckett G

          As I mentioned before, I really like this idea. It seems to me that it normalises a lot of the feelings the learner might have after a difficult situation like this. I think that the fear of seeming needy or overwhelmed might otherwise prevent learners from stepping outside the machismo culture of medicine and admit to difficult to handle emotions.

          Do attending physicians get any training on how to debrief? Based on this discussion, it seems that a lot of the learning is done on one’s own time and motivated by interest and a desire to provide a better educational experience for learners.

          • Loice Swisher

            For me- zero training. I think it much here has been see how others do it and develop your own style. And no feedback on what might have made it better for others. In fact, for the experienced nurses debriefing of codes might be a “burden”. I will say that “new and different” changes things alot. With the ebola thing- every scare which is called seems to need quite a bit reflection.

            I’ve tried to learn what I can on my own. Being able to hear a wide range of thoughts is broadening (which is why I like the Medic Series).

            It may be that you will have to be the change you want to see in the world so that when you are an attending you are more prepared to give the debrief that you would have wanted.

  • Loice Swisher

    One of the most difficult situations is when a patient comes in alive to the ED and leaves dead. It is more angst-filled if the patient is young, mistakes are made and the cause unknown. In a 25 year career I think I can remember every case where I was “the one in charge” standing between a living ED patient and death and lost in the ED. Everyone struck my heart. After the world felt unsteady with questions and doubt flooding my mind while all the time knowing that someone would be “Monday Morning Quarterbacking”… certainly this case will be kicked out for review as a death in the ED. When I read this case I thought the questions would be about how doctors deal with uncertainty, making decisions with inadequate information and committing errors.

    There are management questions. Did this patient have V-tach which degenerated to V-fib? What the patient extremely acidotic and the intubation killed him with poor vent settings? Why wasn’t he shocked when he was found to be in Vfib and epi given instead?

    It seems unreasonable to expect a good debriefing by Dr Berner (at a time when he has to talk with the family and manage other patients in the ED and have his head in the game). Dr Berner may need a good debriefing himself. Unfortunately medicine does not have a great track record of dealing with potential medical mistakes. House staff have reported feeling judged and unsupported and that the tough issues are not dealt with (reported in http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743709/pdf/v012p00221.pdf)

    Over time I believe practitioners find what works best for them- maybe talking to a trusted friend or developing a plan for future similar situations. Perhaps it would be helpful to develop specific resources where medical students could go individually or in small groups to discuss dealing with uncertainty and errors so that each can develop a healthy professional style to deal with difficulty clinical scenarios rather than hoping whoever is around had the time, inclination and experience to help their junior colleagues on their professional journey.

    • S Luckett G

      Thanks for your insight, Dr. Swisher. I like your idea of having resources for medical students to discuss uncertainty and errors. At my medical school (Queen’s University in Kingston, ON), we had a medicine and literature elective that a small group organised and took. It was facilitated by faculty and alum. We analysed literature written by and about patients and physicians, and often this was a catalyst for discussing our own feelings, concerns, errors, and uncertainty. Though this wasn’t conceived as debriefing, strictly speaking, it often evolved into a discussion that was deeply therapeutic.

      What do you conceive these resources as looking like were they to be integrated into medical schools?

      • Eve Purdy

        I have found it very interesting to go back to Med Lit sessions as a clerk. Having worked clinically and been a part of some debrief-worthy scenarios, I bring with me a different perspective. Med Lit has a funny way of letting people talk about things, without really talking about them.

        • S Luckett G

          I agree! I was thrilled to drop in as a clerk. I also found that Med Lit was somehow freeing for many of us. You don’t have to specifically acknowledge anything in that group; somehow talking around it just works!

        • Loice Swisher

          Eve,
          I haven’t had experience with Med Lit sessions. Is it talking about literature or a case so that it isn’t personal? I have been part of workshops where 4 cases have been presented for small group discussion and then there has been a wrap up of some ways others have dealt with making mistakes. It did seem a way for people to open up.

          I recently listened to Brian Goldman’ Ted talk on medical mistakes.
          http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that

          I thought that might be a good way to start to talk about the personal feelings with medical mistakes. I’d be interested in what you think?
          Loice

          • S Luckett G

            Hi Dr. Swisher, I think I can answer that as Eve and I actually took the same course at various times. The Medicine and Literature elective is based on critically analysing literature written for and about patients and physicians. Usually we tackled short stories and essays, but sometimes we discussed longer pieces (e.g., one year we analyses ‘My Own Country’ by Abraham Verghese). Whether intentionally or unintentionally, these analyses often served as the jumping off point for discussing challenging situations we had faced or emotional events we had encountered in our early training.

          • S Luckett G

            I should note as well that these sessions were often well attended by guest attending physicians and residents, and so provided some near- and farther-peer mentorship.

    • Stella Yiu

      This point about the ‘angst’ filled young patient with bad outcome and also how “Dr Berner need a good debriefing’ really resonate with me. I agree that Dr. Berner might not be able to debrief since he might still be thinking about whether it was his management that leads to the outcomes (not that different from Melanie’s thinking) but much closer to reality.

      My thoughts now become: how do staff physicians debrief themselves?
      Personally, my outlets for debriefing would depend on what I need: a more experienced colleague (for medical opinion), a similarly level of training staff (for ‘would you have done differently or is it just me’), a mentor (for hearing out the angst), or the chief (for dealing with how to move on re: M and M for review).

      That leads me to: is Dr. Berner the right person for Melanie’s debriefing needs? Time (and his own angst) aside, I think it depends on what Melanie needs. Dr. Berner might only be able to fulfill the role of the ‘more experienced colleague’. Perhaps we should teach learners that debriefing can happen with multiple people each debriefing a different facet.

      One of the advice I give leaners (mostly residents) is to cultivate a ‘work spouse’ – someone with your similar level of training whom you bounce cases of, a bit of a mirror for you, who challenge you but in a gentle and non-competitive way. I now realize that ‘work spouse’ role really fulfill the role of ‘would you have done differently or is it just me’ during debriefing.

      Thank you for this case. It was a really helpful dive to tease out the elements.
      Stella Yiu

      • S Luckett G

        Dr Yiu, an insightful comment, as always!

        Eve Purdy and I discussed below that often medical student debriefing happens with peers and close friend who were not directly involved in the situation. I find this very, very helpful, but I also find that an element is often missing. Sometimes I think junior learners need a combination of at least two or maybe all three of the types of debriefing that you mentioned above.

        I love the ‘work spouse’ term! I do think, however, that sometimes (perhaps often) we need someone with more clinical experience than we have to conclusively tell us that, no, we did not do anything wrong. I imagine that’s more salient for junior learners than it is for our more senior counterparts. What do you think?

        • Loice Swisher

          Sarah,
          I think it is important for many senior physicians to talk with others on the way that they would manage difficult or poor-outcome cases. Sometimes the opinion will be that it was the patient’s disease and there wasn’t much you could have done to alter the course. The more important ones to me are those cases were there was more that one could have done. Someone else might have a more detailed framework or some real pearls to remember.

          It is much easier to do once one is in a permanent job than as a rotating medical student as one can cultivate long term relationships with trust and mutual respect. it shouldn’t be “did I screw up” but rather “how can I become even better/more competent/more confident”.
          Loice

          • S Luckett G

            I like the way you’ve framed this as ‘how can I become better and more competent’ rather than a matter of ‘did I screw up’. As a junior learner, I find that the latter is quicker to roll off my tongue than the former, and good modelling of these sorts of discussions can be helpful in developing a mindset more in tune with the former.

        • Stella Yiu

          Sarah,
          I am not so sure if it is insightful, but it was from Loice’s (and others’) comments that got me thinking!

          I agree junior learners often need more experienced clinicians to listen and normalize their feelings since there has not been that big N of individual patient population to draw from (as in if Melanie had a code earlier that she did CPR that had a better outcome maybe she wouldn’t find the case as difficult). I see the need for the debrief completely. I am just not sure if Dr. Berner could fulfill that role at the time (maybe next shift?). It is tricky since they were both there at the case.

          I wonder if there are other resources who would be helpful for the ‘clinical/cognitive debrief’ rather than the ’emotional debrief’ or ‘supportive debrief’. If Dr Berner couldn’t do it, who else would be helpful? Or should it be him (but at a time that he is able to?)

          Stella

          • S Luckett G

            Interesting question! I’d like to know what others think about this as well…

          • Loice Swisher

            Stella,
            Looking at the case, I don’t think that Dr Berner could do a great clinical/cognitive debrief anytime in the near future. I think it will take some time to work this through himself and then decide how to incorporate what is learned into a their own clinical framework. In the way clerkships work in the US the rotating medical student likely would be gone by the time Dr Berner he is able.

            Perhaps Dr Takeda (who seems to be more senior) could take a few minutes to explain ways one can know that they are doing great CPR. I know that some docs have a metronome on their phone to play for the speed of compressions and I find end-tidal CO2 to be very helpful.
            I am not sure who else- the clerkship director or the director of the ED might be able to give added perspective to a student. It would be best to have it be someone that is trusted and the student doesn’t feel would negatively impact their evaluation.
            Loice

      • Loice Swisher

        Stella,
        Your post really got me to thinking of how I developed my approach to cognitively and emotionally dealing with “bad cases”.

        I remember a case more than 2 decades ago as a very junior attending where I admitted an early 20’s patient who had a “typical sickle cell crisis”. His vital signs, labs and x-ray were normal but he died several hours later on a regular unmonitored medicine bed.

        I was a wreck. I went to several other attendings (maybe a dozen) one on one to see what they would do. There is no way I could have debriefed anyone. The fact I couldn’t answer the question “what happened” was paralyzing. Since there was going to be an autopsy, Bob McNamara told me to stop beating myself up until we had better answers as to what happened.

        Now I have one maybe two “work spouses” that I go to. I personally read and reflect on cases on what I am going to do different next time. I no longer need to go through dozens of “confessions” to see if I am going to be absolved of sins. Looking back, it has been a “cultivated” process.

        Love your thoughts on this.

        Loice

        BTW- My patient an undiagnosed and unsuspected and undiagnosed congenital heart defect which was thought to have caused a lethal arrhythmia.

        • Stella Yiu

          Loice,

          Thanks for sharing. I understand the angst of that super tricky case. I empathize with the ‘not knowing what happened was paralyzing’ and the ‘confessions’ part – I was there in my earlier years. As I became more senior (and collected more N) I had that pool of N to base my batting averages on, it somehow got a bit better thankfully.

          I think my multi-facet debriefing network developed as I realize what I need from certain people, and who is better at certain parts (clinical versus emotional vs supportive). I think it is a bit like knowing what friend to talk to for a problem and knowing if you just want them to agree, solve, reason or listen.

          Thanks again for sharing. What a wonderful space to dive into this.
          Stella

  • Robert R Cooney

    Wow, great case and many great points already. My 0.02:

    I agree with several of Jeff and Nadim’s comments on this one. As Jeff mentioned, some deaths are more vivid than others in our memories. Likewise, some deaths are easier to accept than others based on our own life circumstances. As a father of 3 very young children, dealing with a pediatric code is about the hardest thing for me to handle. Afterwards, I need to compose myself before even thinking of the learner. For me, this is very private and I’ll step away asking for a few minutes but with the promise that we will get back together. Having the learner see this vulnerability helps them to accept that their feelings are not isolated. For other deaths, it’s much easier to accept and we can move into “debrief” mode.

    While I love the idea of team CISB, our center doesn’t have it in place. We will ask the team for inputs at the end of the code: Is there anything we missed? Is there anything we could have done better? Most times there isn’t, but in this case, perhaps it would have been an avenue for Melanie. If she didn’t speak up with that, I think taking “the walk” is always beneficial and I would use similar techniques to those already mentioned. I would also try to help her think more “systematically” once she was able or ready. This particular case illustrates several high level “system” problems and would be a beneficial M&M using the Vanderbilt matrix. Working through it with her as the attending partner could help her accept that even death can be an impetus for learning and improving the systems we work within.

    As to her fears, lots and LOTS of reassurance that she did everything right. I still remember my first code where I broke all of the ribs on the first compression. It was an awful feeling and to this day, I still question why we do CPR on very elderly patients. I would comment on the fact that she quickly assessed the patient and ran to get help, admitted to her inexperience with the intubation, and performed the CPR well. It doesn’t sound as if there were any points that needed negative feedback, but if there were, it is not the time for that type of feedback. While we want “temporally related” feedback, sometimes it should wait.

    Finally, as for family presence, I really, really like having them present. It just isn’t always possible at my shop. When it is, the families always seem much more accepting of the death and appreciative that “everything” was done. I wish I could do this more.

    • S Luckett G

      Thanks for the thoughtful commentary, Dr. Cooney. I like your idea of reinforcing what Melanie did right in this situation. In my experience as a junior learner, explicit praise can often be the only way that we are reassured that we did a good job when there is a bad outcome, and can often make the difference between leaving the shift feeling destroyed and leaving with a sense of having done the best I could in a difficult situation.

      With regard to family presence, do you always have social work support available? I’m curious about the pragmatics of having the family in the room and how this is done at different shops.

      • Robert R Cooney

        Hi Luckett, first, please call me Rob:-) To answer your question, we have no social work presence in our department. We’re hoping to add this support soon. Where I trained, we had 24-7 social work and they were a wonderful resource. I miss having them on the team. In my current setting, it is up to the charge nurse to approach the family and determine whether they would like to be present or not and then support them in viewing the code, explaining the process, etc. Varying levels of comfort with this task explains why sometimes we offer the opportunity and sometimes we don’t.

        • Recently I was involved with a very very emotional case that involved the police and the coroner… And aware of a number of police officer suicides in Canada lately, I did pull them aside to debrief with them too… And the coroner.

          The coroner was touched because in 30 years he’d never seen that happen… And the police officers also told me their official channels were already on it… Which is reassuring.

          That said… At the end for all the debriefs… With the learners, the nurses , the RT, the police, the coroner… I was pretty emotionally tapped and needed some time to reset too.

        • S Luckett G

          Wow! It’s hard for me to imagine an ED without a social work presence, perhaps because I have trained in departments that have SWs in-house; I’ve felt their absence keenly on the occasions when they were not available.

          It seems almost unfair to ask a charge nurse without specific training to support the family through a resuscitation. It sounds extremely emotionally taxing.

          • Robert R Cooney

            It can be. I would love to have social work again. They make such a difference. Since we don’t though, we make do with what we have. We do have wonderful nurses, several of whom I have seen offer an enormous amount of comfort to families. Their compassion is amazing.

    • What’s the Vanderbilt matrix? Can you share a bit more about that?

  • Michael

    On point 4 – I always offer family the chance to be present, supported by a nominated person (usually an experienced nurse). They are guided to a point where they can see what is happening, and touch the patient if they want, without interrupting resuscitation.

    It is important (to me at least) that they are not asked to make decisions. When to stop is a medical decision – but they are given warning when it is going to happen, and the reasons are explained. No references to hand, but I believe the emotional recovery is generally better in family members who have been given the chance to witness the resuscitation effort.

    The team may find it more difficult though, and this needs to be recognised during the attempt and at the debrief.

    • S Luckett G

      Thanks for your comment, Michael. I’m relatively inexperienced at this, so I hope yo’ll forgive my ignorance. You mention that the team might find it more difficult to have the family involved; have you ever had to deal with a team member asking a family to leave? What did that look like?

      • Michael

        Good question. I have to say I’ve never been in that position. I’m generally the team leader these days, so if the situation arose I would probably let the concerned person leave and manage with the others.

        I think there are often concerns about any mistakes being made being directly witnessed, about the family member interfering with the resuscitation, and a general apprehension about being ‘on show’. There is also the loss of the black humour that some people use to cope (which was discussed recently in the MEdIC series.

        If anyone has run into a direct conflict with a team member over this, I’d also be interested to hear about it.

        • Thank you Michael for raising your amazing points of view! I have a procedure that when I’m running a code and I would like to bring the family in, I allow people to leave if they disagree. Some other MDs and RNs have told me they appreciate this since they are no comfortable with my chosen plan. The NEJM article from 2013 and the pediatric literature seem to suggest that it is the best thing for the family to bring them in with ongoing resuscitation.

          I always debrief with these folks after (and everyone else too)… And they seem to like they I gave them an out…

  • Chris Merritt

    This is something that, for better or worse, never seems to get easier – I agree with Dr. Swisher that it seems unlikely that a high quality debriefing in the moment seems unlikely unless there is some mechanism to allow for this. After the shift, or in a quiet moment (I think I remember one of those once) taking a few minutes to address Melanie’s concerns, praise her performance, and express one’s own feelings may allow Melanie to begin to open up about her own worries of inadequacy or failure. We should remember, though, that she may not express them without prompting (especially to a supervisor or superior). Trying to create – whether in the moment or sometime later – a safe opportunity for her to voice her worries and fears is so important.

    I’m curious as to how other institutions or individuals approach post-critical incident debriefing. Does it occur as a matter of routine? When does it happen in relation to the incident (i.e. during the same shift or 2-3 days later or on some regular basis as in monthly meetings or debriefings)? Who should lead or facilitate? We have some fantastic social workers and even a psychiatrist who have interest in this process, though it’s far more common to occur in the inpatient setting (on the oncology service or the ICU) than in the ED. In our ED it’s unfortunately an ad hoc thing that may or may not happen with regularity.

    I worry that we often downplay (or forget altogether) the second victims in these situations – junior colleagues like Melanie, but also the rest of our nursing and other clinical staff, and even our non-clinical staff.

    Personally, I think I’d do my best to reassure Melanie in the hours that follow the event that (a) I’m as distraught as she is, and acknowledge the difficult position of having to move on and care for other patients, without forgetting entirely to care for myself and my colleagues on an emotional level, and (b) that she was in no way responsible for the outcome. I might revisit things some days later – on a future shift, or over coffee – to be sure she’d had time to reflect and debrief further.

    As to family presence, I almost always ask that families be allowed to remain with their loved ones during these events. We have social workers available 24/7 to help address their concerns, and if there’s an additional resident or a senior medical student who can help translate from jargon to English, that’s also helpful. When families are present, its so important to provide them with a few moments of my own time throughout the event – especially when it comes near time to end things. They need a “warning shot” that despite all of our efforts, things are looking poorly. I usually insist that this comes from me (or whoever is in charge).

    • I am fascinated by the PCID team like Rob Cooney… How does it work at your shot? How is it arranged? I find it hard to operationalize since all the staff are dysynchronous?

      • Chris Merritt

        It’s haphazard at best, and only seems to occur when there’s a particularly worrisome event – I work in peds EM so deaths in our ED are thankfully uncommon, but obviously emotionally difficult when they do occur. I’ve had experience with “in-shift” debriefing, which if it’s feasible is great – most recently I was involved with a tragic trauma case in a toddler. After returning from the OR, the trauma surgeon and I gathered the staff involved and debriefed in the ED, which was really important for my own emotional debriefing as well as the med/surg management. Less ideally, we’ve also had organized sessions several days or even weeks later – these are typically run by a social worker and are advertised by email or word of mouth. While helpful, they tend to be so temporally distant from the events that it seems (to me anyway) to lose some of its impact. Not to mention the sleep lost in the interim.

  • Eve Purdy

    Great case! As an early learner I have been involved with debrief-worthy cases where a 1) a seemingly productive debrief has happened 2) a seemingly non-productive debrief has happened and 3) no debrief has happened. I assure you that the non-productive debriefs are substantially better than the no debriefs and the seemingly non-productive debriefs are in fact useful. However, on the no debrief occasions I have been left (and still am left) with questions of self doubt, concern for the patient and family, and regret.

    Interestingly, I have found that Emergency Medicine lends itself most naturally to these conversations. There is always a scheduled and predictable time for learners to touch base with seniors/attendings at the end of the shift, ideally it would have happened already but that doesn’t always happen. This is a natural time for the subject to be broached in either direction. The culture in most centres and people that I have worked with would mean that these are perfectly reasonable conversations to be having. Unfortunately I have found that while on services where I do not have scheduled feedback every day that it is in fact hard to touch base or catch somebody that I should or could be talking to about the situation. When our paths do cross there might be a big audience of people who were not involved with the incident or we are scheduled to be performing other tasks.

    Having predictable and regular times for learners to touch base with you in a non-threatening, non-assessment-based way is key to facilitate these types of conversations. This is especially important when the incidents that are concerning to us may not seem in any way de-brief worthy to you. Setting up a culture of safety around these discussions will make us more likely to request a debrief when we feel it might be helpful.

    • S Luckett G

      As a learner just barely ahead of where you are, I have found debriefing to be very dependent on the individual. While some staff are easy to debrief with, others are not as comfortable, and thus are more difficult to broach the topic with, even in the emergency department where I am regularly touching base with my staff or seniors.

      I’m curious about your ‘non-productive’ debriefs – what has made them less productive? How do they contrast with more productive debriefs?

      • Loice Swisher

        I’ve had one more thought about this case in looking at productive vs non-productive debriefings. I have wondered if thee best “debriefers” likely are ones that have an understanding of what the learner needs as well as the a level of experience to feel comfortable themselves- not only with the clinical material but also with their feeling and their errors.

        An article on how medical errors affect physicians lists that physician want-
        -an opportunity to talk
        -reaffirmation of their competence
        -validation of their decision making
        -reassurance of self-worth
        ….and that to promote healing that they need to disclose the case and study the case for lesson to be learned.

        http://www.aaos.org/news/aaosnow/nov11/managing8.asp

        Maybe those points would aid a willing but less productive debriefer in becoming better.

  • Ali Mulla

    As a current medical student, this case hits close to home. Eve, I would definitely agree with your previous comment where a “non-productive” debrief is still better than no debrief. However, I would argue that all debriefing sessions are actually ‘productive’ as they are likely to have a positive impact on the student-supervisor relationship, as well as allow for the student to self-reflect and learn from the just completed situation and possible poor-outcome.

    In terms of debriefing with Melanie, I feel that this would be best completed in a private setting where she is comfortable. I think a simple open ended question inviting Melanie to talk about the previous situation is all that is necessary. Afterwards, I think some positive reinforcement supporting her clinical judgement (as mentioned previously) and the reassurance that she acted appropriately.

    I will say that as a medical student, many times in these situations we feel isolated and inadequate. We are of the belief that no one else is affected by these situations and that we only feel this way because we are early in our training and haven’t learned how to separate our emotions from our work. Having a supervisor who is approachable and willing to debrief as colleagues creates a more positive working relationship and allows for a more constructive debrief.

    • S Luckett G

      Ali, thanks for bringing another medical student voice to this case.

      I want to share with you an anecdote about a recent debrief I had with a staff physician who was supervising me as a junior resident. Following the incident, she asked me if I was okay, and I said that I was, but also excused myself for a few minutes. I felt (self-imposed) pressure to come back as quickly as possible, so I’m sure that on my return I was still red-eyed and puffy-faced. She suggested we go somewhere quiet to talk. Immediately on closing the door, I began to cry. I expressed embarrassment about crying and she said something along the lines of, ‘We all cry about these situations. You just get better at pushing it down.’ This is not a staff with whom I had a strong or warm working relationship, but just that little bit of understanding about what I was experiencing was hugely helpful because I felt that a) I had done something wrong and b) that I was alone in experiencing such intense emotions. I think this speaks to your point about learning to separate emotions from work, and how this hasn’t happened at that early juncture.

      I posed this question to Eve above, but I’d like to pose it to you as well: We integrate discussions about goals of care and navigating hierarchies into medical school curricula, but we don’t talk about initiating a debrief. Do you think this would be a useful skill for medical students to learn?

      • Ali Mulla

        Absolutely Dr. Luckett. I think educating medical students on the importance of debriefing and affording them the opportunity to practice this skill in a safe and controlled setting would be extremely valuable. By teaching students through practical scenarios early on in their medical career, we as students would be more comfortable with supervisors when attempting to engage them in a debriefing discussion, and would begin to understand what is necessary for an effective debrief.

        • S Luckett G

          Please, just Luckett! I wonder if cases like this one could form the foundation of the type of curriculum you describe. I’d like to see that happen!