What would you do?

[richmedic101]

Let's say your a supervisor for a big city EMS agency. One day your co-dispatched for a pediatric cardiac arrest. You minutes from the scene, when you hear the crew state; "we have the patient, we're going to the truck, send PD!" Your dispatch center calls you and repeats the traffic. your answer is, "I'm almost on scene, do they need me to continue in?" After a pause you are advised to continue in. Upon arrival you find a seasoned paramedic with two firefighters attempting to ventilate a five month old. The paramedic states to you, "we probably shouldn't have started resuscitation, but I didn't know what to do." You assess the patient and find that rigor mortis had set in. The rigor mortis is so bad that the jaw is not pliable enough to secure an airway. No other procedures had been begun at this time. As the supervisor, what do you do?

True story! Happened recently. I'll tell you the outcome later.

[Wingnut]

Wow, well coming from a total noob, if the CPR was worth doing for the parents sake, maybe..but if rigor is that bad, we all know there's nothing that can be done. Why did the parents/caretaker wait to call the ambulance or rather what were they doing that they didn't know the baby was dying or had already passed?

This is a nightmare of mine, my husband laughs that I still check the kids breathing every few hours at night when they're asleep.

[Ridryder911]

As a supervisor I would stop or cease the resucitation effortts, since there is obvious conclusive signs of death. If needed contact medical control, advise situation. Notify M.E. & LEO, treat the family and grief.

Then afterwards, I would have a personal session with the medics and hopefully medical director with them as well. They should be reprimanded for not recognizing conclussive signs of death & not performing their job accurately.

Good luck,
R/R 911

[TalkEMS]

Originally posted by Wingnut@Dec 9 2005, 12:01 AM
Wow, well coming from a total noob, if the CPR was worth doing for the parents sake, maybe..but if rigor is that bad, we all know there's nothing that can be done. Why did the parents/caretaker wait to call the ambulance or rather what were they doing that they didn't know the baby was dying or had already passed?

This is a nightmare of mine, my husband laughs that I still check the kids breathing every few hours at night when they're asleep.
Sounds like a SIDS case. Nothing the parents would've been able to detect or really prevent. If the crew had already removed the child from the home and the parents were not handling it well I would advise the crew to go ahead and transport for the parents ease of mind but they better be able to document why they moved the child and recall every detail concerning how they found the child. I'll deal with the coroner and if he doesn't like my call he can take it up with my bosses (most of who would do the same thing I did). Its not a black and white thing. I'm not a big one on jerking people around and come out and say someone is dead if they're dead but a SIDS case is that gray area in my book.

Interested in hearing how this played out ...
Matt

[rescuecpt]

Do CPR for the parents sake - if they're not in the rig, call medical control and get their approval to discontinue (here, even with obvious death, if you start, you have to get permission to stop) but continue to bring the baby to the hospital. At least that's what I would do, so the hospital staff (who are better trained and more experienced) can tell the parents and counsel them.

[Jon]

Depends on your protocols.

At the very least, get on the phone with OLMC and explain, get permision to cease efforts.

I really like the idea of sitting down with the crews and the Med. Director and "repremanding" the crew(s) involved, but CAREFULLY.

Jon

[CaptainPanic]

As long as parents are standing right there, at least continue with resuscitation efforts - for the parents sake.

Then when you load the child in the rig, call Med Control advise them that you are coming in with a pedi that has obvious signs of death (rigor mortis), but since resuscitation efforts had already begun before you arrived on scene, you need him to call it to stay within legal limits.

Then the crew needs to return to the station give them a good verbal lashing, suspend the crew for a week, and have them complete a refresher course before being eligible to return to their duties.

-CP

[TalkEMS]

Originally posted by CaptainPanic@Dec 9 2005, 10:05 AM
Then the crew needs to return to the station give them a good verbal lashing, suspend the crew for a week, and have them complete a refresher course before being eligible to return to their duties.

-CP
:blink: Where's the compassion?!

[MedicPrincess]

Originally posted by CaptainPanic@Dec 9 2005, 10:05 AM
Then the crew needs to return to the station give them a good verbal lashing, suspend the crew for a week, and have them complete a refresher course before being eligible to return to their duties.

-CP
WOW!! That seems really harsh. Perhaps it was thier first Pedi Code. Suspending them for working a code seems very harsh, even is rigor had set in.

'Round these parts, the medic and go ahead and call it, but before they do they almost always get on the phone with Med Control. Just for CYA purposes.

[CaptainPanic]

Upon arrival you find a seasoned paramedic with two firefighters attempting to ventilate a five month old. The paramedic states to you, "we probably shouldn't have started resuscitation, but I didn't know what to do."

When they arrived on scene it seems like they did not check for obvious signs of death and didnt they realize that the body was abnormally cold??

Youd think if they were Medics they would have come in contact with several codes as EMTBs and as Medic students, and had training over pediatric codes.

I can understand making a few mistakes on your VERY first code butit shouldnt be an obvious mistake such as completely missing obvious signs of death. Plus it clearly stated that the medic was seasoned and he knew he had fouled up big time. I think they forgot the common sense factor here.

-CP

[hfdff422]

Common sense and ped's are not as readily interchageable as common sense and geriatrics. I have over 40 hours of just SIDS and I am still woefully underprepared for the situation (that is for the B level).

[CaptainPanic]

Well if it was THAT difficult to pry the jaw open to get access to the airway, I think I would probably consider calling it on scene, before CPR was initiated. Took the parents into another room and had the coroner come and declare DOA. And have my crew attempt to keep the parents calm.

[richmedic101]

Great feedback! Thanks. Well here's what happened. I arrived on scene and found suspiscion of "foul play". Examples: The child was wrapped tightly in a blanket including occluding the mouth and nose. The parents had no emotional reaction to what was going on. Dispatch advised when pre-arrival was given the phone was just set down with no one coming back to it (not uncommon, but with everything else it raised some red flags). I "called the code", which ALS providers in my system can do without OLMC. The PD showed and obviously turned the ambulance into a crime scene. It tied up my unit and crew for five hours (upper management not too happy with that). All remaining evidence is preserved as best as possible with the detectives collecting it upon arrival. It turns out that the father (911 caller) was Nigerian and understood little english. The wrapping of the body was a religous custom for him. The mother was moderately retarded (Downs-I believe) and wasn't sure what was going on. The final piece was that the child had a terminal disease (wasn't told by detectives what). Obviously PD and ME were very upset with my crew. They stated that if it were a crime, that by taking the child out of the scene, PD had no right to enter the house now without a search warrant. This is bad, being that the parents then had the opportunity to destroy evidence. Long story short, CISM peer review was activated. The crew was not permitted to finish their shift. The call was QI'ed by me, my bosses, and the crew present. The crew was re-educated on dead is dead. They returned to work two days later.

[Strike3]

This is absolutely incredible some of the harsh responses I've read here. I thought we were all taught that you "work" a possible SIDS case, for the families sake. Put on the show, and at least take the kid out of the house. I was educated in CA, and this was taught in our BASIC class. Why a crew would be reprimanded for giving a mother and father a little piece of mind is unimaginable. Dead is dead. That's fine. I know there are signs and symptoms not compatible with life, that's fine too. But a SIDS case is a special issue, and we were taught differently.

[hfdff422]

Originally posted by Strike3@Dec 9 2005, 10:46 AM
This is absolutely incredible some of the harsh responses I've read here. I thought we were all taught that you "work" a possible SIDS case, for the families sake. Put on the show, and at least take the kid out of the house. I was educated in CA, and this was taught in our BASIC class. Why a crew would be reprimanded for giving a mother and father a little piece of mind is unimaginable. Dead is dead. That's fine. I know there are signs and symptoms not compatible with life, that's fine too. But a SIDS case is a special issue, and we were taught differently.
Not cold, necessary. Our system allows BLS providers to call it on scene with OLMC under the same criteria as for any other patient. If the parents are hysterical, then a FF or PD or other EMT will console them. We are taught to allow a little latitude on calling a possible SIDS case. It is recommended that a borderline viable patient be treated as a fully viable patient, and a patient is non-viable when there are at least two of the criteria met. These are not protocols, just recommended ot diffuse a horrible situation. This scenario was not one of those situations.

[rescuecpt]

No matter how seasoned you are, a lot of experienced ALS and BLS providers are deeply affected by infants, I can't say that I would be able to follow protocols perfectly either.

[Jon]

PoorMedic - Who initiated CPR? Did FD arrive first and start CPR, and your crew find CPR in progress? Or did your crew start with CPR.

Sounds like you handled everthing right. I'd love to work under a supervisor like you. Maybe I'll move ;) :lol:


Jon

[PhillyMedic]

I would take the child to the closest hospital, doing basic CPR, and inform the hospital enroute what is going on, and to have social workers, etc in the ER for the family.

[Strike3]

Originally posted by PhillyMedic@Dec 9 2005, 04:46 PM
I would take the child to the closest hospital, doing basic CPR, and inform the hospital enroute what is going on, and to have social workers, etc in the ER for the family.
I completely agree with you. That would be my course of action. I feel that in no way this crew should have been punished. Granted, none of us were there to see the actual child, but still.

[TTLWHKR]

Always do something, or the parents will have an emotional breakdown.

[Ridryder911]

So we are saying "give the parents false hopes & having an EMS bill and now a ER bill, an emotional lift ?" Not only that representing that we do not know what we are doing ?.... hmmm far as I recall obvious signs of death ( even AHA :BLS) CPR should not be performed. i.e rigor mortis. Dead is dead... declare it, take care of the family. Give empathetic care to the parents and help notify family, chaplain, counsleor, etc... for them.

Profesional and tactal empathetic discussion can occur. They will be told somewhere by someone that child is dead..pretending to perform a code ( knowing ther is NO chance of resucitation at all!) on a obvious non-viable patient could be percieved as unethical. Just because the patient is an infant, in an OBVIOUS non-viable patient should not matter.

The problem is rigor in jaw is very tale-tale sign... again, they crew screwed up and have learned their lesson. It appears it was handled diplomatically and well. I am sure they learned from it as well.

No matter by whom or when the parents are told, most parents have death and dying, grieving & emoitonal problems. It is a very sad situation.

Be safe,
R/R 911

[CaptainPanic]

Very well said Rid - thats why my response I was harsh because the crew did not take in consideration the obvious signs of death and had already initiated resuscitation efforts and if I am correct once you start you cant stop until the ER Doc or ER Nurse calls it upon arrival in the ER or unless Med Control tells you stop in the field. Again if it were my crew I would have suspended them for a week, verbal lashing, and required to take a refresher course.

And you hit the nail on the head when you said it was unethical - why put on a show for the family when you know the patient is not a viable one, only for the family to be completely let down in the end, and possibly the family later learns you put on a show which would upset them further. Dead is dead and grief is grief.

-CP

[hfdff422]

For once I agree wholly with Rid, this is a case where there is no chance of saving the child, so your job is now to prepare the parents for the reality of it all. Compassion starts with being honest, not giving false hope. If there was a slim chance of viability then that changes things, but any person who has been in fire or EMS for even a year would see that this is the wrong course of action with the presentation of rigormortis. These guys make us all look bad when they made that decision. I would not come down too hard on them though since, as I stated before, ped's and common sense tend to exclude each other. But it should be A+R'd into their heads.

[PhillyMedic]

I don't care about the bill, or the ER bill, I care about the safety of the scene, which could get ugly quick, I don't want to be at that scene any longer than I have to be.

[DFDEMS]

I have actually been part of that crew a couple times in recent years as bad as it sounds.

I have some questions first actually.

How many people responded and were on scene when EMS arrived.

Just how safe was the scene?

I understand rigor is rigor and most of us realize that the chances for survival are as good as you winning the lotto in all 50 states on the same day but does the family? Besides, realistically speaking almost every person in EMS/Police and Fire will go the extra mile for a ped. Without fail.

Here it is two dudes and a truck. If I have to do CPR on your dog to walk out of the house alive I will. If I think I’m going to get an a** kickin for telling you your kid is dead we scoop the kid, go to the truck and tell em we are going to x hospital and go.

Call the ER, advise them of what you are doing and why, i.e. I want go home at the end of the day and come on in. Let the ER with the big staff and armed security tell the family.

Some scenes we have been able to help the family along the grieving process with both young and old but in this city the mindset of “everyone goes” has been so ingrained that if you don’t take someone and start mentioning how they are as stiff as that nice new 42 inch plasma TV ( i.e. rigor, dependent lividity, etc, etc..)you are probably going to get hurt. It's unethical I guess for giving false hope but in certain cases reality or lack thereof makes the difference for you going home at night.

Every scene is different, every single one. 2nd guessing a crew when you weren’t there is crazy unless they are pushing D50 down the tube or something…

Either way, if I were a supervisor (I am not) I guess you have to look at the crew, their past performance, the scene, etc. At worst I could see counseling them on what could be considered poor judgment for a first offense.

[hfdff422]

In Indiana we have mandatory SIDS training- basically an hour of peds refresher and three hours of compassion training per session. They bring in parents who had children die of SIDS and do speeches, etc. The director of the organization that does this is who gives the talk to EMT classes and she is adament about being very frank and honest about what is going on. Her experience is almost text book of what to do. The cops and firefighters who responded first started rescue operations, the FD ambulance was next, they continued rescue operations while the cop went to get some information, then another volunteer FF from the neighborhood cam and found out all the info he could from the initial responders. The FF then went and started informing the parents what was going on, that the baby would not be resuscitated and they were going to have to start facing that fact- obviously with some more tact than that- and asked what he could do to help them. Keeping the rescue operation away from the parents (taking the parents to another room), telling them the truth about what is going on, offering what help you can, offering to contact support services, letting them see their child before the ME takes the child- with supervision if you or the cop thinks there are issues like that, using the terms he/she/the baby instead of it or the body, making sure they remember to involve other siblings in the situation are all important factors in an effective handling of the situation. If you handle it in a wishy-washy, indirect sort of manner you are being cruel. Offering false hope is just as bad as teasing- don't do it.

[FFEMT1764]

My protocols have very strict guidelines, and we are encouraged to NOT start resuscitative measures if we have a pt in asystole who is cool to the touch, and has an unknown down time...if the FD or PD arrives first and starts CPR, once we determine the above criteria, we can stop any further treatment...Like everyone else has said, to provide false hope, no matter how good the intentions are, is cruel...and could land you in the state EMS office for a very nasty QA session. However, if the absence of the aforementioned signs of death(rigor, levidity, asystole and cold, etc), by all means, work the code!

P.S. PEA/EMD is a workable rythmn.

[daemonicusxx]

No matter how seasoned you are, a lot of experienced ALS and BLS providers are deeply affected by infants, I can't say that I would be able to follow protocols perfectly either.



Amen to that. I'm not that seasoned, but i can tell you that my a***ole definatly puckers when i find out its a youngin. life's too short to sweat the small stuff. we are all gonna mess up. should we just get the rope out and tie the nuse now? or can we learn from our mistakes.

[FFEMT1764]

Yes we all mess up, but there is a difference between messing up and what a lawyer could consider malpractice, negligence, or theft by deception, or at the worst depraved indifference homicide...mind you I dont think anyone would take it that far, but in the litigiuos society we live in no one really knows who will sue who...

[Recruiting]

Do it for the parents...

[trauma1534]

I have to say, years ago, (I've been in for 11 years), we were taught to move in act like we were making an effort and then cease at the truck enroute in. Now, it is discouraged. As a mother, I can say that if i found my child not breathing, it would be hard for me to accept the fact and I would always wonder if EMS did all they could do for the child. As a provider, I feel that each situation is different. Go with the scene... what are the parents like? How for gone... morbidly speaking... is the child?

As far as what to do with the providers who started cpr, listen to the situation. What factors were involved in their reasons for what they did. Everyone... well anyone with a heart... has a soft spot for peds. offer support to the providers who were involved. If no harm was done, do make harm! It is not a problem, until it is a problem!!! Have a heart!!!

[Recruiting]

I have to say, years ago, (I've been in for 11 years), we were taught to move in act like we were making an effort and then cease at the truck enroute in. Now, it is discouraged. As a mother, I can say that if i found my child not breathing, it would be hard for me to accept the fact and I would always wonder if EMS did all they could do for the child. As a provider, I feel that each situation is different. Go with the scene... what are the parents like? How for gone... morbidly speaking... is the child?

As far as what to do with the providers who started cpr, listen to the situation. What factors were involved in their reasons for what they did. Everyone... well anyone with a heart... has a soft spot for peds. offer support to the providers who were involved. If no harm was done, do make harm! It is not a problem, until it is a problem!!! Have a heart!!!

Well said....

[Ridryder911]

Do wat for the parents...?.. Give false hope, watching their obviously dead child being coded... in which is not a pretty site. Do things the right way, as like any other obviously death. Deal withthe situation, treat the family with empathy, preserve the scene.. age should and does not make the difference.

Be safe,
R/R 911

[Recruiting]

This SIDS subject has been going on for years it seems.....

I would, I would not and so on.... I have seen some pretty heated discussions on this subject..

R.N.,CCRN,CEN,CCEMT/P,NREMT/P &amp; all the other vowels <-Damnnnnnnnnnnnnnnnn!!

[dhpd9807]

DFDEMS, I think you got it cracked for the most part. Not all scenes are unstable but you are right, I am going home and will do what I have to to insure that.

Captainpanic....hmmm. Have you ever worked the street? Going by your age, if you have, I think maybe not enough to be a Monday morning quarterback. I'd be willing to bet there are alot of natures/scenes and so on that would cause you to vapor lock. Hardly a soul deals well with sick kids and your harsh response indicates a gross lack of experience if not compassion.

As for the crew and the sup that handled the call? I was not there so I will try to keep my mouth resonably well shut. Just my 2 cents.

[TTLWHKR]

Captainpanic....hmmm. Have you ever worked the street? Going by your age, if you have, I think maybe not enough to be a Monday morning quarterback. I'd be willing to bet there are alot of natures/scenes and so on that would cause you to vapor lock. Hardly a soul deals well with sick kids and your harsh response indicates a gross lack of experience if not compassion.


:rolleyes: How long have you been working, dhp?

[Ridryder911]

Just wondering if your doing for the parents or for yourself ?..... Will you also pay for the expenses as well?...hmm EMS bill about $800.00 .. ER Bill (dependent) at least $400.00 .. if you are going to do it for the family when there was no need, think and look at the whole picture. Don't involve YOUR emotions...

Be safe,
R/R 911

[Wingnut]

This will probably show how green I am, but don't you leave and call the coroner if the pt (whatever age) has passed? Or does your service(s) require you to take care of the body? I don't know what mine are I really should find out.

[Ridryder911]

In my area, LEO (police) is automatically notified. After, I declare death.. my job is done for the infant, I will assist the parents and assist anyway I can. The State M.E. field investigator is notified and handles the remainder of the case.

Be safe,
R/R 911

[dhpd9807]

TTWHKR
been around 13yrs now. You?

[Jon]

I like the point raised by some of the "city" medics (DFD, Philly) - there are many, many things that can go wrong on a scene with VERY upset grieving parties.... What are the 5 steps of coping with death?

[Ridryder911]

Eliaseth Kubler Ross who researched death and dying categorized death and dying into 5 stages, in which many has also encompasses into grieving as well.
They are
Denial
Bargaining
Anger
Depression
Acceptance

Each person may go thorugh each or skip a phase.. here is a link for more information.
http://www.counselingforloss.com/article8.htm

Be safe,
R/R 911

[FFEMT1764]

This will probably show how green I am, but don't you leave and call the coroner if the pt (whatever age) has passed? Or does your service(s) require you to take care of the body? I don't know what mine are I really should find out.

Our local protocol for DOA's include comfirming that the pt is DOA, we then request the SO to come out if there are suspicious circumstances, otherwise we just have dispatch notify the coroner, and we stick around until he shows, anywhere from 20 minutes to and hour and a half later. Once the coroner does his investigation he decides if we are going to transport to the local hospital morgue, if the funeral home is going to come get the pt, or if he is going take the doa in the coroner's van for autopsy in the next county over...and after he is finished with EMS we are required to leave a copy of the run report with him, and of course collect his signature as the receiving agency and the report.