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CASE PRESENTATION

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A respiratory arrest occurs in the intermediate care unit on the surgical ward. The patient is an elderly man in a cervical halo, 3 days after admission and following a motor vehicle crash. Soon after a “code-blue” is called overhead to which both the intensive care unit (ICU) resident and the anesthesia resident respond. Upon arrival, a large number of other health care providers are crowded into the room, including many medical students who were receiving a lecture nearby. The noise level is high, and it is impossible to hear anyone calling out instructions. It is also impossible to tell if someone is leading the resuscitation or preparing for intubation.

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Two nurses are taking turns performing chest compressions and a respiratory therapist is performing appropriately slow bag-mask-ventilation. The anesthesia resident goes to the head of the bed. He starts making suggestions: “perhaps we could intubate”; “maybe it's time for others to take over compressions”; and “I think someone needs to lead this resuscitation.” Unfortunately, nobody picks up on his initial polite hints. As such, he believes he has tried but there is no point trying again. He subsequently becomes silent, and stands at the head of the bed silently hoping somebody will hand him a laryngoscope and an endotracheal tube. The ICU resident goes to the patient's right groin to insert a central line and shouts for “someone,” “anyone” to get him “the damn equipment.” He is angry when nobody does and starts berating the others for being “lousy teammates.”

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A surgical resident arrives at this point and asks if the patient might have a postoperative pulmonary embolus and whether there are contraindications to thrombolysis. He announces that if the patient survives they ought to get “a 12-lead ECG and a bedside echo,” and then he walks away. Meanwhile the nurses performing chest compressions have become exhausted but do not know how to ask for relief. As such they cease compressions and it is 30 seconds before another person takes over.

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The anesthesia resident uses this pause in chest compressions to attempt tracheal intubation, but fails. He does not know if anyone has airway skills, so he tries four more times before causing airway bleeding and hence returns to bag-mask-ventilation. The patient has been without a pulse now for 45 minutes. A nurse suggests calling the ICU attending physician. She arrives and finds a Do-Not-Resuscitate order on the chart. At this point resuscitative efforts are ceased and the patient is declared dead. While several of the team members try to leave stating: “well, he was a DNR so it doesn’t matter,” the attending/consultant insists they remain for an immediate debrief. She states that the crisis management skills, and especially the communication skills need to be improved. They agree, but when they request specifics, the intensivist is unsure what to say.

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INTRODUCTION

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