I think it is time to stop

Mia, the resident, now had tears in her eyes. She was sweating under the warmer, on top of the resuscitation table. Her hands were shaking. She re-intubated the mannequin a third time. She thought she might be “out.” Mia's technique was now sluggish and she was fighting with the plastic larynx. The tongue fell off. I let out a sigh. We would need another tongue replacement for “Annie,” and it was starting to get expensive. These new computerized high-fidelity fancy mannequins were great for teaching, but they broke easily. The residents used to have mannequins with huge vocal cords that were easy to intubate. “Annie” was more realistic, but now it was easier to injure the plastic larynx and to detach the tongue. Then, a serious leak would be created, which made the mock codes less realistic. We had previously tried suturing the tongue back, but it had not worked. We had tried stapling it with different devices: a generic stapler, a surgical stapler, and even a carpet stapler. A replacement tongue was almost $1000, and it had proved impossible to order over the internet from the hospital because the word “tongue” blocked access to the internet site. After three tongue replacements, “Annie” had needed a new head because the jaw was loose, which was even more expensive. Her head had been replaced a month ago. Mia looked at me in despair. She was an excellent and confident senior resident. She was looking at the flat line and the nonexistent saturations on the blank screen I was programming. She was listening to the silent plastic chest. I told her many times she had bilateral normal breath sounds. The mock code involved a term baby born by urgent cesarean section after the mother had come to the hospital because of decreased fetal movements. The fetal heart rate was 40 beats per minute before the cesarean section, but there had been no pulse since the baby was born. The cord pH was described as being 6.8. Mia had now intubated three times and had a “mock” chest radiograph described as normal. She had needled both sides of the chest. “Annie,” the mannequin, had received cardiac massage for 31 mins now; she had an umbilical venous line and had received four doses of epinephrine, a bolus of saline, a bolus of O negative blood, and 1 mEq/k of bicarb. Mia was in a state of shock. She seemed to think there was a trick, a weird diagnosis she had never heard of. Usually, in a mock code when the right interventions were performed, the baby recovered. It was like the game of Snakes and Ladders. Maybe she felt she only had snakes today. She restarted checking her equipment again. She asked all the good questions again. Mia asked for a fourth dose of epinephrine, another bolus of saline, another bolus of O negative blood, and more bicarb. She asked if the medication “really” had to be prepared, because the nurses wanted to stop the mock code and resume their shifts. I nodded. She knew they had to, to make the mock codes more valuable as a teaching aid for the whole team. We no longer prepared fake medications. The heating lamp was on, and Mia's surgical hat was plastered to her forehead. Mia explained once again to the new confused nurse how to prepare the epinephrine. No, the weird yellow plastic with the needle inside should not be used. Yes, a needle just had to be stuck in the blue plastic hub. The junior resident performing the cardiac massage for now more than half an hour was looking at her in disbelief with round eyes and sweat trickling in his eyes. “I think it is time to stop.” It was starting to be painful to watch. I was renowned for my spicy codes: hyperkalemia, tamponade with total parenteral nutrition, supraventricular tachycardia needing cardioversion, etc. Usually, the mannequin improved. This was the point. If the resident provided excellent care, then “Annie” would be fixed. I had to admit to myself this was an unusual mock. For the first time, I had decided that nothing could be fixed. Severe asphyxia with Apgar scores of 0-0-0. According to the neonatal resuscitation program, the resident should have stopped after 10 mins of effective resuscitation. I was determined to wait until the resident would stop the maneuvers, but I could not stand it anymore. How long would she resuscitate? The resuscitation Mia had provided was exemplary. “What happened?” asked Mia. The simulation was not all over yet. I had arranged for her to meet the mock father, who was a new unit coordinator in obstetrics. He loved the idea of mock codes and had experience with improvisational drama. “The father wants to speak to you.” When the mock father started crying and asking about funeral arrangements, I thought Mia would pass out. The outcomes of infants with no heart rate and with Apgar scores of 0 after more than 20 mins of resuscitation are dismal. They usually die, and if they do not, they are generally neurologically devastated. The neonatal resuscitation program covers what to do when resuscitation is started, but it also covers extensively and sensitively when to stop resuscitation and what to do in these cases. On paper, for the written examination, neonatal resuscitation program providers and trainees usually have the right answer. In practice, however, they do not. We have now repeated this mock code many times. Generally, trainees continue as Mia did. It is not rare for babies with no heart rate at birth to be resuscitated for more than 20 mins. Sometimes, after a long while, the heart of a baby starts and we are asked to transport the baby to our tertiary care center. Generally, these babies are stuporous, have profound encephalopathy, have fixed nonreactive pupils, and are extremely hypotonic. They usually eventually get comfort care. We generally accept these babies when we can often, with confidence, recommend comfort care in the primary setting with the family support around. Why do physicians in the community continue resuscitation efforts after 15 mins for babies born without a heart rate? They might feel less confident because these cases are rare. They might also think they are missing something. Maybe they feel mothers should not have a general anesthesia and a cesarean-section for nothing, for a dead baby. They might want the baby transferred to a tertiary care NICU so that the family feels “everything” was done for their baby, or that the tertiary care centers are better equipped to deal with end-of-life care in these situations. They might also have practiced many mock codes during their training, all of which included a mannequin that improved when they provided adequate resuscitation. As physicians, we are often critical of the media because they depict patients who cannot die without a round of cardiopulmonary resuscitation. In films and television, cardiopulmonary resuscitation usually works. This gives families the false impression that cardiopulmonary resuscitation really works most of the time, that it brings back their loved ones from the dead. We have to remember we are also guilty, with our “real-life” mock codes, in perpetuating this myth. In neonatology, it seems mannequins always improve if trainees do the right thing during extensive resuscitation, even when the mannequin loses its tongue. In real life, patients generally do not. If we want simulation to reproduce real life, then mannequins requiring cardiopulmonary resuscitation and epinephrine would die most of the time. They do not. Mia is an excellent general pediatrician in the community. She is also a neonatal resuscitation program instructor. She resented her mock dead baby for a while; however, the last time I saw her at a conference, she confessed doing this same mock for her trainees and neonatal resuscitation program courses. She told me I should write this article. We rarely teach trainees when and how to tell a primary care physician who has provided prolonged resuscitation that it is time to stop. We may even neglect to teach trainees when to stop resuscitation. Is it because we have so much difficulty in stopping ourselves?

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