Terrible Code

Welcome to season 3, episode 8 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, John Eicken, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss difficult medical education cases each month. As usual, the community discussion will be reviewed using qualitative research methods to produce a curated summary that will be combined with two expert responses to create a functional teaching resource.

In this month’s case a resident observes a code that is not going well. She should help, shouldn’t she? But she doesn’t want to offend the attending…

[su_spoiler title=”MEdIC Series: The Concept” style=”fancy” icon=”caret”] 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.[/su_spoiler]

MEdIC: The Case of the Terrible Code

by Dr. Tamara McColl

Malory, a seasoned senior emergency resident, had just signed out his cases for the evening to his colleague. He grabbed his jacket and empty coffee mug and was just about to pass through the doors of the Emergency Department when he heard the alert sounding overhead: “Trauma Code – Emergency”.

Having recently completed several trauma electives at various sites, Malory was always looking for opportunities to polish his trauma resuscitation skills and procedural dexterities. He looked at his watch, hesitated for a moment, and thought, “Well, maybe I will just peek in and see what it is. I’ll be out of here in 30 minutes, max!”

He walked briskly towards the trauma bay, setting down his belongings on the nurses’ desk, and then grabbing a trauma gown and mask off of a nearby shelf. Not surprisingly, a large crowd of various providers that had already gathered into the room. The trauma team, consisting of both emergency medicine and surgery providers, had already arrived and a veteran emergency medicine attending was leading the code.

Malory hung back beside the charting nurse and watched as the team worked together to revive an elderly man. The patient had been crossing the street when a car ran a red light and struck him before speeding away. As Malory observed the resuscitation, his gaze floated from the monitor to the patient, and onward to the nurse delivering chest compressions. His eyes finally rested on the emergency medicine attending calling out orders. He frowned as the entire picture came into focus.

The senior emergency medicine and surgery residents were frantically attempting to insert femoral and subclavian central lines as the junior surgery resident was struggling to successfully assemble the intraosseous drill. The patient had no vascular access! No fluids or medications had been administered. Malory also noticed that since the team was so focused on chest compressions and attaining venous access, no one had put in chest tubes or performed a bedside FAST ultrasound. The resuscitation leader, the emergency medicine attending, was calling out orders into the air, to no one in particular, and the nurses were scrambling around looking for blood and IV tubing. It was certainly a chaotic situation!

Malory grew increasingly upset as the code continued. He debated whether it was appropriate to get involved. On the one hand, he felt that he had the skills and knowledge necessary to take over leadership, or at least assist in some way. “This is so disorganized and nothing is getting done! Should I say something? Should I just step in and help?”

On the other hand, there were several other staff physicians and residents in the room watching the code. No one else was speaking up or offering to help. And the emergency medicine staff physician leading the code, Dr. Berkley, was well respected. Malory couldn’t just interrupt him! “Who am I to question a staff physician? I’m just a resident! If the other staff in this room are keeping quiet, I should just keep my mouth shut, right?”

And with that, he made the decision to stand back and simply watch. Fifteen minutes later, the resuscitation was terminated.

Discussion Questions

  1. Why was it so difficult for Malory to speak up? What are some potential barriers to speaking up during a resuscitation?
  2. There is a hierarchy of structure in resuscitation scenarios with the team leader making the management decisions. If those observing or indirectly involved have differing opinions, when is a good time to speak up? And how should they do so?
  3. How can we improve communication in code situations? Could simulation play a role?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This time the 3 experts (Lalena and Joshua are writing one of the responses together) are:

  • Lalena Yarris, MD is an EM Residency Director and Education Scholarship Fellowship Co-Director at Oregon Health and Science University. Her academic interests include education research methods, faculty development in education, feedback in medical education, and wellness in academic medicine.
  • Joshua Kornegay, MD is an emergency physician and Assistant Program Director at Oregon Health and Science University. His academic interests include resuscitation and simulation.
  • Chris Hicks, MD is an emergency physician and trauma team leader at St. Michael’s Hospital in Toronto as well as a Clinician Educator at the University of Toronto. His academic interests include simulation.

On June 17, 2016 we will post the expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. 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.

Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at CanadiEM.org
Brent Thoma, MD MA