(First of all, Portishead’s Only You is playing in the ex-pat bar from where I am currently blogging – awesome.)I asked Annie what today’s subject should be, and she said, “Code dynamics.”
By Code, she means the standardized sequence of events that is classically followed when a patient loses circulation (otherwise known as Advanced Cardiac Life Support, or ACLS). In the US, the success of ACLS is achieved in large part due to implentation of a highly systematic process in which everyone’s role is clearly delineated. A “code leader” stands at the foot of the bed and gives instructions, while nurses and other residents are performing chest compressions, performing bag-mask ventilation, drawing blood, achieving intravenous access, or securing an airway via endotracheal intubation.
So, things run a little differently in Bugando. First of all, the ICU is not consistently staffed by residents. The residents round once in the morning and once in the evening; the remainder of the day, the patients are monitored by the nursing staff. Based simply on who is usually present, the nursing staff classically initiates what they call “resuscitation” when a patient loses a pulse, including fluid administration, cardiac resuscitation, and intubation. But this becomes a problem when a code occurs while residents are present. The reason this is a problem is because (and there’s no other way to really say this) the nurses code patients in a manner that is largely incompatible with any positive outcomes. Resuscitation is often not even begun until the patient has been without a pulse for minutes, and the sequence of events occurs at a painfully slow pace.
So. Situations often occur like this morning, in which a lovely, middle aged woman who was transferred to the ICU in relatively stable condition yesterday was found this morning by a humble visiting medical student to be hypotensive and largely unresponsive, and after recruiting his resident/wife, the patient took 2 agonal breaths and abruptly lost her pulse. Our natural reaction was to begin chest compressions; yet, it was critical for us to successfully attract the attention of a nurse in order to get permission to begin participating in a code situation. Throughout the code, we struggled against the slow pace at which resuscitative efforts were happening (you should all be proud of the multiple ways in which Annie politely asked for a defibrillator without losing her cool), all the while realizing that at this pace, nothing we were doing would be of any benefit, yet we were limited by the culturally established hierarchy on whose totem pole we were woefully low.
Ultimately, our success in this situation, like in a recent situation, came when we were able to partner with the in-house resident when he arrived to prevent a lifeless body from being intubated. However, our attempt to gain permission for an autopsy (the only way that we would ever find out if and how the management of this patient had been misdirected) was unsuccessful, leaving us to wonder if we had made any positive impact at all. Today was the second consecutive day that a patient we hoped would pull through literally took her last breaths in front of us, as we struggled against 2 very different, but equally frustrating limitations: first by the hospital resources, second by our lack of authority.
Not all is depressing, however. In fact, I’m very proud of the fact that our current team, led in tandem by Annie and Meda (our brilliant Tanzanian resident) and supported by Judith (who is headed to MGH for medicine) and myself have been able to promote a systematic approach to daily rounds in the ICU. I think we’ve helped show one of the best senior residents here that a systematic, evidence-based approach can be effective even when optimal resources are unavailable. It’s the refrain that we all repeat to ourselves: that the benefit we are providing is (hopefully) systemic.
In other news, I played soccer over the weekend with a bunch of local Tanzanians and Indians. News flash: people who play soccer often are awesome at soccer. My big success was that I managed to play for a half hour without attempting to strike the ball and completely missing, or committing any abhorrent turnovers. Of course, once I left the field, I had to pretty much go into suspended animation for the next 12 hours to recover enough strength to even eat dinner. Still, it was awesome, and made me even more excited to go see a soccer match (featuring Simba FC, who stand atop the Tanzanian Premier League) this Saturday!
Till next time!
By Code, she means the standardized sequence of events that is classically followed when a patient loses circulation (otherwise known as Advanced Cardiac Life Support, or ACLS). In the US, the success of ACLS is achieved in large part due to implentation of a highly systematic process in which everyone’s role is clearly delineated. A “code leader” stands at the foot of the bed and gives instructions, while nurses and other residents are performing chest compressions, performing bag-mask ventilation, drawing blood, achieving intravenous access, or securing an airway via endotracheal intubation.
So, things run a little differently in Bugando. First of all, the ICU is not consistently staffed by residents. The residents round once in the morning and once in the evening; the remainder of the day, the patients are monitored by the nursing staff. Based simply on who is usually present, the nursing staff classically initiates what they call “resuscitation” when a patient loses a pulse, including fluid administration, cardiac resuscitation, and intubation. But this becomes a problem when a code occurs while residents are present. The reason this is a problem is because (and there’s no other way to really say this) the nurses code patients in a manner that is largely incompatible with any positive outcomes. Resuscitation is often not even begun until the patient has been without a pulse for minutes, and the sequence of events occurs at a painfully slow pace.
So. Situations often occur like this morning, in which a lovely, middle aged woman who was transferred to the ICU in relatively stable condition yesterday was found this morning by a humble visiting medical student to be hypotensive and largely unresponsive, and after recruiting his resident/wife, the patient took 2 agonal breaths and abruptly lost her pulse. Our natural reaction was to begin chest compressions; yet, it was critical for us to successfully attract the attention of a nurse in order to get permission to begin participating in a code situation. Throughout the code, we struggled against the slow pace at which resuscitative efforts were happening (you should all be proud of the multiple ways in which Annie politely asked for a defibrillator without losing her cool), all the while realizing that at this pace, nothing we were doing would be of any benefit, yet we were limited by the culturally established hierarchy on whose totem pole we were woefully low.
Ultimately, our success in this situation, like in a recent situation, came when we were able to partner with the in-house resident when he arrived to prevent a lifeless body from being intubated. However, our attempt to gain permission for an autopsy (the only way that we would ever find out if and how the management of this patient had been misdirected) was unsuccessful, leaving us to wonder if we had made any positive impact at all. Today was the second consecutive day that a patient we hoped would pull through literally took her last breaths in front of us, as we struggled against 2 very different, but equally frustrating limitations: first by the hospital resources, second by our lack of authority.
Not all is depressing, however. In fact, I’m very proud of the fact that our current team, led in tandem by Annie and Meda (our brilliant Tanzanian resident) and supported by Judith (who is headed to MGH for medicine) and myself have been able to promote a systematic approach to daily rounds in the ICU. I think we’ve helped show one of the best senior residents here that a systematic, evidence-based approach can be effective even when optimal resources are unavailable. It’s the refrain that we all repeat to ourselves: that the benefit we are providing is (hopefully) systemic.
In other news, I played soccer over the weekend with a bunch of local Tanzanians and Indians. News flash: people who play soccer often are awesome at soccer. My big success was that I managed to play for a half hour without attempting to strike the ball and completely missing, or committing any abhorrent turnovers. Of course, once I left the field, I had to pretty much go into suspended animation for the next 12 hours to recover enough strength to even eat dinner. Still, it was awesome, and made me even more excited to go see a soccer match (featuring Simba FC, who stand atop the Tanzanian Premier League) this Saturday!Till next time!
this is the greatest blog post in history
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