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?
- How do you debrief this case with Melanie?
- How do you address her fears that she did something wrong?
- What is a general approach to debriefing a medical student after a bad outcome in a young patient?
- 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.