What to Do in a Resuscitation as a Junior Learner

Background

If you’re a medical student interested in emergency medicine, it’s a pretty safe bet that you’re also interested in resuscitation medicine. It’s a defining aspect of the specialty — how to take a sick, undifferentiated patient and simultaneously investigate and treat a potentially very broad differential diagnosis. 

The challenge is that, as a junior learner, you’ve likely received limited teaching in resuscitation medicine, and what teaching you have received is probably more theoretical for your level of training (e.g. fluid choices, key ECG rhythms, etc.) than practical (what am I actually supposed to do when a cardiac arrest rolls into the ED at 3am?). It can be a bit of a catch-22: it’s difficult to learn the practical expectations in the classroom so you have to learn them on your feet during a resuscitation, but also you don’t know what you’re supposed to be learning on your feet in the first place.

Not only can this be anxiety-provoking in and of itself, but it’s also potentially detrimental to your learning. As much as resuscitations at the junior learner level are an exercise in learning through observation, it’s hard to do even that if you’re preoccupied with something as basic as figuring out where to stand in the room. The goal of this post is to help bridge that gap by providing a practical guide of what to do during a resuscitation as a junior learner. 

Make resuscitations part of your pre-shift plan

Hopefully you’re already starting each shift discussing your learning plan and expectations with your preceptor; add resuscitations to that discussion. If you know you’ll be covering the resus room, ask your preceptor if there’s anything in particular they want you to do during a resuscitation. Not only will different attendings have different preferences, but different hospitals will have different resuscitation and trauma procedures as well. If you’re on the ambulatory side of the department, ask if it’s okay for you to observe any resuscitations that come in during your shift. Finally, if there is a resuscitation-related skill or procedure that you’re genuinely interested in and that would be reasonable to practice (e.g. maybe you just finished your anesthesia rotation and want more practice intubating) letting them know ahead of time and showing initiative can improve your chances of actually getting to perform any procedures that do arise. 

Play an active role in CPR

One area where you will absolutely get hands-on experience in a resuscitation is performing CPR. Good quality CPR is critical in the event of a cardiac arrest, and research has shown that medical students lose both skills and confidence in their skills following training.^​1​ It’s a good idea to review your BLS-HCP skills prior to starting your first EM rotation, especially if you haven’t previously performed CPR in a real-world setting. Here is a quick reminder of some of the basics:

• Place both hands on the sternum between the nipple line.
• Perform 30 compressions to every two breaths, unless the patient has an advanced airway – don’t forget to count down for the person managing the airway and keep track of your cycles. If there is an advanced airway (e.g. the patient is intubated), perform continuous compressions. 
• Compressions should occur at a rate of 100-120 compressions per minute and a depth of 5-6 cm (approximately half the depth of the chest) with full recoil.

If possible, you should switch who is performing compressions every 2 minutes or 5 cycles during the pulse and rhythm check to avoid fatigue down the road (and switch earlier if you feel tired). Even better than simply performing compressions, help organize the compression line. Minimizing time off-chest is essential for high-quality CPR: make sure others are swapping out on time, help grab/remove the standing stool as necessary, and provide helpful and constructive feedback if someone’s form is off. Anything that helps the resuscitation leader focus on higher level management instead of micromanaging CPR is immensely helpful. 

Primary Survey

Another area you might get to practice some hands on skills is if you’re asked to perform a primary survey. The primary survey is a rapid physical exam to identify immediate, life-threatening concerns. It’s typically thought of as the ABCDE approach:

• Airway: Is the patient’s airway patent and protected? Is the trachea midline?
• Breathing: Is there equal air entry bilaterally? Are there any obvious chest wall deformities?
• Circulation: Is the patient perfusing all their extremities? Are there any signs of hemorrhage into a significant potential reservoir: Is the abdomen soft? Is the pelvis stable? Are there any long bone fractures?
• Disability: What is the patient’s GCS? Are their pupils equal and reactive? Are there any gross neurological deficits? On log roll, is there any focal spinal tenderness, step deformities, or loss of rectal tone?
• Exposure: Are there any other injuries, including everything from open fractures and amputations to simple abrasions?

A primary survey is then typically followed by (in a conscious patient) an AMPLE history:

• Allergies
• Medications
• Past Medical History
• Last meal (time of)
• Events leading up to presentation 

Though technically the primary survey is from the ATLS guidelines, it is often used as shorthand for a focused history and physical examination in medical resuscitations, and the same principles and general approach still apply. As a junior learner, make sure to get gloves and personal protective equipment (PPE) on – so that you can become involved with key parts of this primary survey (long as you’re allowed)! Your help is much appreciated to help with tasks such as transferring the patient from the Paramedic/EMS stretcher to a hospital stretcher, log roll, completing key parts of the initial assessment. Failing that, you can have a key role in the trauma resuscitation by acting as a runner to retrieve key objects (suture tray, ultrasound machine, video laryngoscope, and even warm blankets) or act as a safety officer to remind the team to don their necessary PPE. No job is too small when you’re resuscitating a sick patient.

The little things: keep your POISE

A helpful medical student is a genuine asset to the team during a resuscitation. As the only team member without specific, critical duties during a resuscitation, there are a number of seemingly minor actions you can take that will not only help your team and resuscitation leader, but also demonstrate initiative and interest in EM. A helpful mnemonic is to remember to your POISE:

• Protect yourself (e.g. don your PPE): At baseline, PPE is important for your own health and protection, and resuscitations put you at increased risk of coming into contact with bodily fluids. Additionally, if nothing else, you don’t want to miss your chance at learning a procedure because you have to sheepishly run to the back of the room to grab gloves and a mask. It’s always a good idea to have an extra pair of gloves in your back pocket throughout your shift, make sure you have eye protection during any resuscitation, and, as a general rule, try to match the level of PPE of the most protected person in the room. It’s better to be over-dressed than under-dressed!

• Offer to Help (e.g. Log Rolls, transfers, helping to hold limbs during splinting, etc.): This doesn’t require much explanation, but it will amaze you how much time gets wasted on that “Are you going to do it? Or should I do it? Or…?” eye contact between team members whenever someone mentions log-rolling the patient. Just get your gloves on and then get in there to help.
  
• Investigate past history: For obvious reasons, many resuscitations are going to involve undifferentiated patients with entirely unknown past medical histories. If you can find a computer and check the patient’s EMR it can significantly narrow down your team leader’s differential and allow them to target specific investigations/treatments. Along the same lines, in a prolonged resuscitation it’s extremely helpful if you follow up on bloodwork results.
  
• Show initiative: Spiking IV bags? Tracking down the ultrasound machine? Grabbing a chest tube kit? Letting someone borrow your stethoscope? It may not be glamorous but it certainly helps. Any time you hear the words “can someone help me with…” or “can someone grab me…” and it’s something you *can* do, just say yes and do it. 

• Environmental Control: You may find yourself using blankets for different reasons in the various cases. For instance, hypothermic coagulopathy is a major concern in trauma patients, with even mild hypothermia causing a significant reduction in clotting time^​2​. So as trivial as it might sound, grabbing a set of warm blankets is an incredibly important and time-sensitive task. Meanwhile, for a hypothermic patient, blankets may be a key resuscitative strategy for ensuring their core temperatures begin to rise. Finally, in the patient who has had a return of spontaneous circulation (ROSC), you may find that you need to remove the blankets and get ice packs to initiate targeted temperature management.^​3​

Pitfalls: Don’t forget your PPE

This is so important we’re going to say it twice. While it’s always been important to wear PPE, it is absolutely critical in a post-COVID world. PPE requirements for resuscitations, especially those involving Aerosol Generating Medical Procedures (AGMPs) are much more strict and intensive, and often involve significant restrictions on what junior learners are allowed to perform during a resuscitation. Make sure you’re familiar with your local health system’s requirements, equipment, donning and doffing procedures, and limitations on learner participation.

Don’t be Passive

There’s a definite balancing act to being a junior learner in a resuscitation. You’re going to be faced with some conflicting priorities — you want to be as helpful as possible, while also learning as much as possible, all while avoiding anything that’s detrimental to the patient or team. 

Hopefully it’s obvious that you shouldn’t distract the team leader with unnecessary questions and that you shouldn’t volunteer for procedures you’re not comfortable performing, but the other side of the coin is that it’s easy to become too passive of an observer. Remember your POISE as described above, and in the event that there really isn’t anything for you to do, try to put yourself in the team leader’s shoes. Come up with your own working differential diagnosis, think about how you would manage the patient, and keep track of where the leader makes a different choice than what you would have done. This is a great way to learn, and it’ll help you come up with high quality questions to ask your preceptor when you debrief later on.

Put your emotional wellbeing first

Resuscitations can have a major emotional effect on anyone, but especially junior learners who are not used to seeing poor outcomes. It’s impossible to predict how anyone will react to any given combination of patient and condition, and it’s particularly common to experience an unexpected emotional response during your first few resuscitations. Crying is okay, feeling fine when everyone else is crying is okay, and it’s not a test if your preceptor offers to let you take a break. If you don’t feel ready to get back to work tell your preceptor, talk with them about it, and take a coffee break to reset and recharge. 

Take Home Points

• Make resuscitations part of your pre-shift discussion with your preceptor
• Get involved with CPR, and take charge of making sure the compressions line runs smoothly.
• Know how to perform an efficient and effective Primary Survey
• Remember your POISE! 
• Put your well-being first, whether that means wearing adequate PPE or asking for some time to debrief and de-stress if you’re feeling emotionally overwhelmed following a resuscitation. 

Further Reading

• How to survive (and like) your emergency medicine clerkship core rotation
• Make sure to check out the latest Clerkcast episode on cardiac arrest!
• Post-resuscitation debriefing is an important and often overlooked part of the resuscitation process. Learn more here.
• While by no means necessary at the medical student level, taking an ACLS and/or ATLS course is a common way for medical students to become more comfortable with resuscitations and gain a better understanding of basic management principles

Reviewing with the Staff

Knowing how you can help during a resuscitation is half the battle. The other half is made up of two other things: 1) having the courage to get in there, and 2) having the wisdom to step out of the way. In acute resuscitations, things can turn on a dime - knowing when you can be useful may come down to making eye contact with the trauma team leader and making a small gesture to get their approving nod, but it also may be about maintaining some situational awareness about when the room has suddenly changed in feel. Some clues to this are that the room suddenly becomes quieter and/or louder. In the OR, surgeons are well-known to turn off the tunes when a difficult part of the surgery comes about… Similarly, trauma team leaders or resuscitation captains may ask for silence as they come to a critical juncture. Pay attention to these cues and try to step out of the way when you need to.

Otherwise, I fully agree with this post. Get your gloves on and get in there to help!

Teresa Chan

McMaster University | Associate Professor, Div of EM, Dept of Med; Assistant Dean, Program for Faculty Development, Faculty of Health Sciences

@TChanMD

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Steve Hale

Steve Hale is an emergency medicine resident at the University of Manitoba in Winnipeg. His interests include critical care, knowledge translation, and resuscitation medicine.

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• What to Do in a Resuscitation as a Junior Learner - November 17, 2020