The First Code: How Cardiac Resuscitation Shapes the Physician

The first code is one of the formation events medical training does not theorize. Every physician has one. Almost no curriculum names what it does.

Issue 013 of this publication argued that the board examination is a formation ritual as much as it is a knowledge assessment. This essay makes the same argument about a different formation event. The first code — the first time a trainee stands in the room while a patient's heart stops and a resuscitation team assembles around the bed — is a rite of passage that produces specific dispositions in the trainee who has stood in the room. The dispositions are part of what makes a physician. They are not on the curriculum.

The Scene

I remember mine in fragments. The overhead page. The run to the room, which was on a different floor from where I was standing. The nurse who had called the code already at the bedside doing chest compressions. The crash cart in the doorway. The senior resident arriving thirty seconds after me and stepping into the room in a way that made clear the room now had someone running it. My hands, which did not know where to go. The task I was given — bag-mask ventilation — because it was the task that could be done by someone whose hands did not yet know where to go.

The compressions continued. The rhythm on the monitor was one I had studied. I had not seen it in a body. Medications went in through the IV that the anesthesia team had established. Someone read out the time elapsed at intervals. Someone else called out roles that I was not yet in a position to fill. A team formed around the patient in a way I had not seen a team form before.

At some point the code ended. The particulars of that ending are not the essay's subject. The essay's subject is what standing in the room did to the person standing in the room.

The Ritual Structure

The code has the same three-phase structure that Issue 013 identified in the board examination. Separation: the trainee is pulled out of ordinary clinical work by an overhead page that has priority over whatever else was happening. Liminality: the trainee occupies a room whose rules are different from the rules of the ordinary hospital — hierarchy compresses, roles are assigned by function rather than by rank, the ordinary boundaries of professional deference are suspended in favor of whoever knows what to do next. Reincorporation: the trainee walks out of the room, back into the corridor, back into the ordinary rhythm of clinical work, changed.

Victor Turner's concept of communitas — the intense fellow-feeling generated among candidates undergoing shared liminal ordeal — applies here in a form he did not anticipate. The team that ran the code developed a shared intensity across the twenty or thirty minutes the code lasted. That intensity outlasts the code. Trainees remember who was in the room. Nurses remember which residents behaved how. The bond of the shared code, like the bond of the shared board examination, is real professional currency that operates in the years after.

The formation the code produces is specific. The trainee who stood in the room now knows what a code feels like to be in — the shape of the time, the choreography of the team, the noise level, the smell, the particular way certain drugs are handed across the bed. The trainee has moved from the category of person who has only read about codes to the category of person who has been in one. The category change is the ritual's central work.

What the Code Forms That the Curriculum Does Not

The code teaches things the ACLS course does not.

It teaches the compression of hierarchy under emergency. In ordinary clinical work, the attending is above the resident is above the intern. In the code, whoever knows the airway does the airway. Whoever runs codes best runs the code. A senior nurse with fifteen years of code experience often has more functional authority in the room than the second-year resident who is technically leading. The compression is not disrespectful of hierarchy; it is functional accommodation to the fact that the ordinary hierarchy was not designed for the room the code is in.

It teaches that competent hands do work that competent brains do not do fast enough. The bag-mask technique the intern learned in simulation runs on procedural memory in a way the diagnostic reasoning the intern learned in preclinical years does not. The intern who has bag-masked a hundred simulations can bag-mask under stress. The intern who has read about bag-masking cannot. This is the same lesson Benner named at the level of skill acquisition — that expertise is embodied, not just cognitive — arriving under conditions in which the lesson cannot be missed.

It teaches that the team is the unit of care, not the individual clinician. The code cannot be run by one person. The choreography requires simultaneous action by multiple clinicians whose actions have to be coordinated in real time. Every trainee who has stood in a code room has had the experience of watching a team form and function in a way that no individual member of the team could have accomplished. The team as the operative unit is a lesson that other clinical experiences teach more slowly.

It teaches that some patients die despite everything the team can do. The intern who has stood in a code that ended in death has learned something the intern who has only read about mortality has not learned. The learning is not about death itself — the trainee already understood that people die. The learning is about the specific experience of having done everything that could be done and having it not be enough. This is a formation event of a particular kind. It shapes the clinician's relationship to therapeutic humility for the rest of a career.

What Naming the Formation Would Change

Residency training treats the first code as an incidental clinical experience. It could treat it as a named formation event.

A residency program that named the first code as formation would build structured debriefing into the days after. Not just the incident-review debrief that focuses on team performance, but the formation debrief that names what standing in the room did to the trainee. The debrief would be led by someone whose role was to attend to formation, not just to clinical technique. This role does not exist in most programs.

A program that named the formation would attend to the difference between the trainee whose first code ended in survival and the trainee whose first code ended in death. The formation work is different in the two cases. Both are worth structured attention.

A program that named the formation would recognize that the code is a shared formation event across professions. The nurse who called the code has done formation work too. The respiratory therapist who managed the airway has done formation work. The pharmacy resident who arrived with the crash cart. A structured cross-professional debrief after significant codes would honor the shared work and address the shared formation the discipline has not been organized to see.

A program that named the formation would not pretend the code was a technical event with a technical debrief and nothing more. The code is a rite of passage that produces specific dispositions in the clinician who stood in the room. Naming the ritual is the precondition for tending to what the ritual forms.

The compressions continue. The team assembles. The trainee stands in the room. The formation is happening whether the curriculum names it or not.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.