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A respiratory arrest occurs in the surgical ward. The patient is an elderly man in a cervical halo, 3 days after admission 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/anesthesiology resident respond. Upon arrival, 15 other people are crowded into the room, including many students who were receiving a lecture nearby. The noise level is so high that 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.

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 if nobody will listen. Rather than escalating his concerns he becomes silent and stands at the head of the bed silently hoping somebody will hand him a laryngoscope and endotracheal tube. The ICU resident goes to the patient’s right groin to insert a central line and shouts for “someone,” or “anyone” to get him “the damn equipment.” He is angry when nobody does and starts berating the others for being “lousy team mates.”

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 replacements. As such they cease compressions and it is 30 seconds before another person takes over.

The anesthesia/anesthesiology resident uses this pause in chest compressions to attempt intubation, but fails. He does not know (or ask) if anyone has airway skills so tries four more times before causing an airway bleed and hence returning to bag-mask ventilation. The patient has been pulseless for 45 minutes. A nurse suggests calling the ICU attending physician. She arrives and finds a clear Do-Not-Resuscitate order on the chart. At this point, resuscitative efforts are ceased and the patient is declared dead. Several of the team members try to leave and one states dismissively: “well, he was a DNR so it doesn’t matter.” Instead, the attending/consultant insists they remain for an immediate debrief. She states that crisis management skills, and especially the communication skills, need to be improved. All nod their heads sagely, but when they try to be more specific the intensivist and other team members are unsure what to say.


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