The Personalities in Your Resuscitation Room

Issue: March/April 2023

Author: Andrew Mayer, MD FAAEM

Walking into your emergency department’s resuscitation area usually causes each of us to heighten our senses. We become hyper alert so we can determine what we will need to do in the next few minutes. Sometimes we know something about an incoming patient via an EMS report but often you simply hear that you are needed in “trauma.” Almost all emergency physicians start at least as adrenaline junkies. We walk towards the sickest patients with the anticipation of a procedure or an interesting diagnosis or intervention. We have learned to walk into the room and focus on the patient. We have that first glance assessment of the sights, sounds, and smells of our newest and sickest patient. This is what we do and most of us keep up an interest in seeing these patients. Besides for the patient, when you walk into this room with the newest and sickest patient is a diverse group of individuals who all have a unique role and perspective.

In this article, I ask you to look around your resuscitation room and try and put yourself into the other participants’ shoes and see the resuscitation from their perspective. I want you also to consider the many personalities, goals, and expectations of the other people in the room and consider each of their goals and objectives. I find that many of the issues which arise out of difficult resuscitations have little to do with the medicine but more to arise from each member of the teams’ expectations and perceptions of what did, or what they think, should, or could have happened.

Let’s look at a few of the people in the room and wonder what they are thinking. First, consider the EMS crew who brought the patient. They may have just spent the last 30 minutes dragging a very large patient down stairs in front of a screaming family knowing that what they were doing was hopeless. A seasoned paramedic usually knows what is going to happen and has an expected timeline and outcome. However, the brand-new crew member with little experience on the street may be surprised and disappointed when the emergency physician or resuscitation team is not excited and ends a code quickly. This young and enthusiastic EMS team member may have anticipated a heroic and lifesaving procedure on the asystole code and walks away upset. He or she may have expected a more noble effort with a TV ending.

Look at your charge nurses’ eyes when they follow EMS into the room. See his or her thoughts spinning as they consider how this patient’s arrival will impact the function of the department. They may be realizing that you just filled up their last trauma bay stretcher and another sick EMS patient is inbound. They may be wondering how long you are going to “play around” with this hopeless case or even worse regain ROSC when there are no ICU beds in the hospital. They need the room and the nurses to keep flow going. Their eyes may roll when they hear the “seventh epi is going in.” Remember we all have our own priorities and expectations with any given situation.

Think about the resuscitation room nurse. Typically, they are one of your best nurses who know how to get things done. However, in today’s world they could be an agency nurse you have never worked with before. You may have no rapport with the nurse and do not know their strengths and abilities. Can they juggle three drips? Remember that they are busy and will have to deal with the physical and emotional mess which you have help create from the bloody sheet to the crying widow. They have to complete all of the paperwork and sit with the family when you leave the room after the notification. They also realize that they have not given the lovenox, zosyn, or whatever to their other patient in the next bed. They may be thinking that their other patient actually has a reasonable chance of survival while they were helping you with the latest code from the local nursing home. Their thoughts could be focused on why EMS bothered to transport this patient or why you did not call the code on arrival. They may also be thinking that one of your colleagues may be disappointed at how long it took them to accomplish some task placed for them in the electronic record while they were focusing on your patient.

Consider the new ED tech who has never seen a code and is eager to perform CPR for the first time. In their mind, the ED saves lives and they want to be part of the team. Their mind is racing forward to years from now after they finish nursing or medical school to when they can really have a more important role and start “saving lives” for themselves. It truly is delightful when you see the wonder in their young and impressionable eyes the first time they see a patient go into ventricular fibrillation in front of them. They are amazed when the patient jerks and wakes up groaning when the defibrillator goes off just like on their favorite medical television series. However, also peek at them when that decubitus ridden contracted nursing home patient rolls in and see them trying to understand modern medicine and the futility and waste of some of the things which we are required to do. Their minds are trying to rationalize some of their new experiences with their expectations. The conflict in their eyes can be dramatic and can change their career goals and dreams.

The police officer who arrived with the latest shooting victim may be the battle-hardened homicide detective or a rookie cop. The role they play is different and unique. They want evidence and victim statements while still trying to figure out if the patient laying on the stretcher is really a victim or an assailant. They can show real sympathy or think this is a hardened criminal who has finally gotten his just rewards for his criminal life.

Your consultants are a mixed lot of perspectives. I work in a community hospital which has some residents. This is different from the team of consultants at a big urban trauma or tertiary referral hospital which has every type of resident in house. I can see a tired middle-aged surgeon walking in at 2:00am thinking he is too old to be on call. He or she is thinking about the five elective cases they have scheduled in the morning and what the case laying in front of them is going to do to their day. They may be grumpy and in “survival mode.” This consultant may just be considering if they still have the stamina to get it all done. Their surly attitude usually has little to do with you or your team and more about where their head is related to the case. In contrast, you can have some senior resident walk in and want to show off his superior clinical prowess and power. They may spout off ridiculous statements related to the resuscitation to boost their ego and stake their role as a leader. The perspectives and attitudes are as varied as can be. You have to navigate these turbulent waters to keep the room in balance.

The emergency medicine resident has their own perspective walking into the room. They want the procedure. Being able to practice at the top of their skill set while having a staff to watch over them can be wonderful to watch. You see the growing confidence and you know that they are ready to be on their own. They can be the one that the room looks to for calm and order. It can also can be disheartening to me when as the staff, I ask a resident what they want to do when faced with a critically ill patient and their answer is to do what I think is best. They are unable to commit. The fear of being in charge has to be overcome in that resuscitation room and faculty has to be willing to give them enough autonomy to start making the tough decisions. If a resident cannot make this transition then they will always struggle in emergency medicine and when I see one of these residents in the resuscitation room I feel for the resident as I know their road will be difficult.

Then there is you. How do you feel and more importantly, how do you act in this room? Who knows what you will see when you walk through those doors and pull back the curtain. Remember, it could be anything and you have to appear to be ready to take on the challenge no matter the situation. The whole tone of the resuscitation will be dictated by your composure and cadence. Everyone in the room can sense fear or uncertainty. All emergency physicians learn this early. The captain of the ship needs to act like they know what they are doing and exude confidence or the whole experience can sour for all of the participants. Your personal armor has to shine so you can personify confidence and skill even if you are thinking to yourself that you have no idea what to do next. I am not saying that you cannot ask for help but you need to establish the rhythm and tone of the resuscitation. If your team senses anxiety, then they too will be anxious. If you project ability and confidence, then your team will follow your lead even when it is a hopeless situation. You will also need to be able to process this stress for the sake of your own wellness.

In the end, remember the poor housekeeper. You simply walk away from an especially messy, smelly, or bloody resuscitation. You have to go speak to the family and complete your chart. Some housekeeper who had nothing to do with the resuscitation or any knowledge of health care has to walk into the shambles which you have created and clean it up. They have to watch for dropped needles and the various bodily fluids which are on the stretcher and floor. Remember that they are the ones to mop up your bloody footprints. These staff members need our thanks and respect as they keep us going. Often, the next deathly ill patient rolls into this area before the floor dries and the whole things starts again.

There are others in the room who I have not discussed. Think about all of them. Remember that as the leader of the team you need to help all of these individuals process the events in the room and the role that they played. Any one of them can grow and mature from being a participant in an especially difficult or emotionally charged resuscitation. However, try to notice anyone who is struggling or seems upset after the event is over. A kind word of reassurance or understanding can make all of the difference to this struggling team member. Witnessing a young nurse transform into a rock-solid trauma nurse or a junior resident who shows leadership ability and who has just realized that they can be a leader in the room is gratifying to watch.