#I got to do this in a simulation with a defib and it was so cool

[whumpy-daydreams]

CPR in hospitals

I did a post on doing cpr as a 'civilian' (i.e. in public with no equipment). But most people who follow me are writers! So here's how it goes down in hospital.

It varies on where someone is in hospital having a cardiac arrest, so this is just for if a patient is in a hospital bed with monitoring on.

The first sign is going to the monitor going crazy and the patient unconscious.

Step 1 - pull the emergency button and start chest compressions (they are still the most important thing!)

Step 2 - someone else will give rescue 'breaths' using an oxygen mask and bag (technically called a bag valve mask or BVM). Two breaths after every 30 compressions

Step 3 - someone else is cutting clothes off and putting defibrillator pads on. An anaesthetist may also intubate the patient and put them on a ventilator (this means you can do compressions continuously)

Step 4 - the defibrillator will scan the heart rhythm. If it's shockable (ventricular tachycardia or fibrillation) then everyone steps away while it shocks. As soon as it's safe, CPR continues (most defibrillators determine the rhythm and calculate voltage automatically)

Step 5 - if it's a non-shockable rhythm, give IV adrenaline ASAP

Step 6 - if it's a shockable rhythm, wait 2 minutes after first shock, check and shock again. Repeat a third time.

Step 7 - if the patient is still in cardiac arrest after 3 shocks, give IV adrenaline and amiodarone

Step 8 - continue CPR and give adrenaline every 5 minutes.

The person giving compressions should switch every 60 compressions (two cycles of 30) - the next person is counted in so there's no time without compressions

There are 10 main causes of cardiac arrest - while all of this is happening a team of doctors will be trying to work out the cause so they can treat it. I won't go into the causes because it's boring and technical.

CPR, defibrillation, and drugs will continue until the cardiac arrest stops or the patient is declared deceased.

If someone is in hospital because of hypothermia, remember! They're not dead until they're warm! (there have been cases of hypothermia patients being successfully resuscitated after over 5 hours of CPR!)

[dxmedstudent]

Hi dx. I'm the med student on a&e. Been getting really anxious when very sick patients come into resus, esp cardiac arrest patients. Heart starts pounding and I can't think, cant even remember bls. I dont even know why it bothers me so much, I don't think about arrests a lot or anything, my body just reacts. Generally like a&e otherwise. Any tips on dealing with this so I can actually help with the sicker pts, not just get in the way? I need to get over this so as an actual dr i'm ok!

Hello! First things first, you’re actually having a normal reaction to a very stressful situation. Sick patients are scary; it’s natural for all of us to be scared when confronted with such a situation. This is why we all train to work past our natural reactions :)  I don’t think there’s anything wrong with you at all for reacting that way, and I agree with you that it doesn’t have to have anything at all with finding them unpleasant; we can’t control how we instinctively react to unusual situations. But we can learn to build tolerance. The good thing is, you won’t be expected to lead the situation yet. So it’s OK if you can’t remember everything that has to be done in that moment. The person leading it is usually the med reg or a senior nurse, and in a well-led crash call it will always be clear who this person is. If there’s time (i.e. someone has already started compressions) It’s often a good idea to introduce yourself quickly to them as a student and ask what you can do; in this way rather than you stressing, someone who’s more experienced can dole out things you can actually do. If you don’t know how to do something, or feel uncomfortable doing it, you can just say. If it makes you feel better, I too used to feel in the way a lot as a student; because frequently I wasn’t doing anything much to contribute to patient care (apart from chat with patients). That’s part of why I loved A&E like I mentioned to you before; it was one of the busiest A&Es in the country, and they always had jobs for me to do and people for me to clerk, I felt almost like a doc! Exciting! But when calls happened, I still felt like I didn’t quite know what I was allowed to do. So I used to ask them ‘I’m a student, how can I help”; docs and nurses love when students try to help, and we know you won’t be able to do everything yet! I find it helps to give yourself a task, so you have something constructive to do and focus on. That always makes me feel better if I’m feeling nervous and my heart is pounding; focus on something and do it well. You’re the student, so you’re in a position where you can observe because you’re not running the scenario.  There are actually loads of roles you could take on:

Perhaps you could offer to scribe; someone needs to take down the times and just remind people when there have been cycles of CPR, when the adrenaline was given, etc. I used to love scribing as a student, because you learn so much about how a well run call works when you’re observing from the outside. Most people are dipping in to do stuff and involved in the chaos but the scribe has to stay above it, like the leader.

That may be slightly advanced for you, in which case you could focus on something more specific; I love being the bloods/cannula monkey; all you have to focus on is getting a line in and taking the sample, if you can. Just watch out for needlesticks and make sure sharps are accounted for.

Sometimes they just need someone to hand over new swabs, new saline flushes or new cannulas/abg needles; being the odd-jobs person can be really useful to the medical team who are concentrating on treating the patient, because it’s one less thing for your seniors to worry about.

 If you like CPR, you’re lucky because most people don’t, so you pretty much don’t have to think about anything if you don’t mind doing chest compressions; just remember to swap with people so you don’t get fatigued.

Until the anaesthetist comes, someone needs to bag the patient, if you’ve been trained to do it then its not very hard, doesn’t require lots of muscle, and as long as their chest is going up and down, you are probably doing OK?

They always need someone to run the ABG or send off the bloods. It’s not a glamorous or medical job, but it needs to get done so that they can try to figure out what’s going on. As a bonus, if you’re stressed out, it allows you to leave the area for a short while then come back and continue.

Someone always needs to find the crash trolley. OK, so youre not yet trained to use the defib so you’d leave that to someone else, but getting equipment like the trolley is an insanely useful thing to do. Waiting for stuff I need to materialise is my least favourite part of emergency situations, and I instantly love someone who appears with the right equipment just when you need it.

Don’t worry about necessarily doing the most medical jobs; at a call there will probably be a reg, a couple of SHOs and FY1s, a lot of nurses; so there will already be a lot of people to be doing some of the more medical tasks. Even as a doc when there are lots of us I just try do whatever needs to be done next, even if it’s the most unglamorous task on the list, if there’s no urgent medical task that needs my attention. Sometimes there are too many doctors! It might be useful to practise some BLS/ILS by yourself or with friends, again and again until it feels mroe automatic. Kind of like how we keep practising osce stations so that when you’re in the exam, and your heart is pounding, you don’t forget the entire thing through nerves. On my paeds job, we had weekly simulated paediatric rescuscitation, and it made simulation training (and real calls) much less scary. Mostly. I probably find simulation a little scarier than actual calls (because we’re being watched, eek!) but practice helps to desensitise us to the worst of it. I certainly got better with experience, and you learn to disregard your physiological reaction and get better at focusing past it. We’re deliberately put through simulations so we can get over some of our nerves and practice in a mock situation and I think it really helps. Because it’s well known that stress makes us panic or shut down or our minds go blank.  Whenever I do it with colleagues, people are still a bit nervous, but that’s part of the learning process. I don’t know if your uni offers sim training, but if it does, take it. Some hospitals offer it for junior docs and might let you come along, if you write to their educational department and ask nicely. If you can’t do that, you could try running your own mini simulation with friends. Our paeds ones were fairly minimal; a plastic baby doll and ECG etc printouts in resus. It doesn’t have to be high tech to feel scary! So even just taking yourselves through some common scenarios might feel pretty real, at least whilst you are in the scenario. The point is that the best way for us to remember our ABCDE and thought process is to keep practising in some way or other. Whether through real crash calls or by yourself with a pillow, or simulating scenarios with friends (or proper sim training). I think any and all would be a good start. I’m sure it’s something you can work through; in my experience we don’t all enjoy acutely sick patients (I’m no adrenaline junkie personally, so I don’t seek out jobs with lots of acutely sick patients, but I do what I have to when I have to) but we all get better at dealing with it through experience.  I have a feeling this is pretty common, so I’d love it if other medblrs shared any tips they have :)