Premature Neonate CPR

[Medic744]

For the paramedics out there this not only a treatment but ethics/moral question. I dont have all the exact details but try to go off what I have. Here goes.

Call for 3 month premie infant, mother gave birth at home and baby is not breathing and has no pulse. On arrival mother is in hallway with cord still attatched and mother is in no apparent distress but baby is confirmed no pulse no respirations, down time approx 10 min. It is you, your EMT partner, and at least 4 first responders (all are EMT or EMT-I). Additional help is requested and they have an unknown ETA, its at least 5-10min once they get moving to get there. How would you handle it?

I can give more info if you need it. Just wondering how you would handle it, not what needs to be done or how the book says to do it. That I know but on a personal approach to this situation.

 

[jrbigelow]

I know the down time is fairly long in this case and the chance of survival for this neonate is slim at best, however I would treat the PATIENTS the same way I would if I witnessed the delivery. Its a neonate with a low probability of survival or even a normal life but I'm still morally (my own morals) obligated to at least try. Clamp, clamp cut, place the mother in the care of another provider provided that she is in fact not experiencing an emergency and begin NRP on the new born.

 

[Jeffrey_169]

I agree with jrbigelow on every point. Clamp, cut and go to work on baby. Begin immediate CPR on baby, O2, ACLS, etc. admin. baby, and then have another provider go to work on mom. It is not my job to pronounce, and so into the heat of battle we go.

 

[Medic744]

If it helps, other than still needing to deliver the placenta mom was stable with no complaints but after additional unit arrived mother was complaining of abdominal and vaginal pain (Im going to have to just say Seriously?!). Mom is stable, no hemmorage or additional complaints.

 

[redcrossemt]

It is not my job to pronounce, and so into the heat of battle we go.

Do you not have termination of resuscitation protocols? We can't "pronounce" either, but we can declare death at a scene and terminate resuscitation.

How would you handle it?

Exactly how far along is this newborn? 6 months?

Start police and another transport vehicle for mom, cut the cord as usual, have 2 of your team move her to a different room and start working on her.

For the newborn, my criteria to not start resuscitation would not be met, so we would start resuscitative measures. I would not transport unless we achieved ROSC, or if we could not establish an airway or venous access quickly. Resuscitation would be provided as per protocols/NRP/PALS/whatever.

 

[VentMedic]

Begin immediate CPR on baby, O2, ACLS,

NRP and not ACLS algorithms apply to a neonate. Unfortunately some do try to treat infants and peds as small adults.

If one takes an NRP class there are guidelines about the terminination of resuscitation of a neonate. Your medical director should incorporate these guidelines into your protocols. Dead is dead. Leave your own personal emotions out of it. Of course, many EMS services will not allow their providers to pronounce death of a child so you would have no choice but to work through your protocol. But, if the baby is dead you are not doing the mother any good by doing a show code.

 

[Medic744]

We dont pronounce or terminate without DNR or obvious injuries incompatable with life. Neonate was at around 24 wks gestation. This really isnt a how would you treat question, they followed protocol on that. But what do you do ethically/morally? Do you cut and run leaving the mother in capable hands until another unit gets there? or Do you treat the infant and mother splitting attention and time on scene? ROSC was achieved en route to the hospital.

 

[VentMedic]

We dont pronounce or terminate without DNR or obvious injuries incompatable with life. Neonate was at around 24 wks gestation. This really isnt a how would you treat question, they followed protocol on that. But what do you do ethically/morally? Do you cut and run leaving the mother in capable hands until another unit gets there? or Do you treat the infant and mother splitting attention and time on scene? ROSC was achieved en route to the hospital.

The mother is also your patient. You technically can not abandon her unless there are other medical personnel at scene especially if the placenta has not delivered. A preterm birth is NOT normal and the mother must be cared for as well. If you are not a Paramedic, then an ALS truck should be called for at least an intercept for both patients.

Again, just like SIDS, many of our ALS systems can pronouce a baby at scene as that may be the ethical and moral decision to make. Most babies are not born with DNR instructions to follow and this should be an issue to be discussed with your medical director. The NRP guidelines can also be used by you medical director to assist with future protocols.

Have you checked back to see how the baby is doing?

 

[Jeffrey_169]

NRP and not ACLS algorithms apply to a neonate. Unfortunately some do try to treat infants and peds as small adults.

If one takes an NRP class there are guidelines about the terminination of resuscitation of a neonate. Your medical director should incorporate these guidelines into your protocols. Dead is dead. Leave your own personal emotions out of it. Of course, many EMS services will not allow their providers to pronounce death of a child so you would have no choice but to work through your protocol. But, if the baby is dead you are not doing the mother any good by doing a show code.

I may in the wrong here, but here we go. There seems to be several others here who have least implied for us to "leave our emotions behind", or something else to the same effect. Maybe I am overly emotional, and perhaps my motivations and expressions here are a direct reflection of this, however I have done things a certain way for many years, and they have always served me well at the end of the day. I am not saying I am not open to change, nor am I saying treatments cannot be altered for the betterment of patient care, but from an "emotional" standpoint, I see no problem with how I conduct business.

This situation here, and those like it, are without a doubt disturbing to any sane human being, and we are clinicians are no more immune then anyone else. To say performing advanced and aggressive resuscitation techniques on this child would be a waste of time, or not worth the effort is, at least in my opinion, close minded and pessimistic. Perhaps I am overly optimistic, and we all have our opinions, however it is not my place, regardless of my system, to say when someone is no longer salvageable. We do what we do to save lives, however we are not doctors and we are not qualified unless death is obvious. Decapitations, the onset of rigormortous (I think I spelled it right) etc are all causes to call it quits, but in this case I see no signs the patient is no longer salvageable. In this scenario we do not know what the cause of death was, or even the time it occurred. There is no way for us to make a sound judgment with the insufficient facts which are presented here, at least in my opinion.

No one understands more then I the fact that we lose patients; this is a fact of life, especially in our line of work. I have lost my fair share of people, including children, and no one despises it more the me. I do believe in miracles, and I have seen my fair share of patients recover from the depths of death. Numbers are all fine and dandy, but I do not believe statistics have a reputable role in our profession, at least in the cases where a survivability potential of a patient is i question. I can recall a child who fell into the Potomac River in VA years ago, was under the water for 40 minutes, and even with the technology of the day survived. There is no reason, in my estimation, this baby should not be worked on. I would not perform slow code on this child, it would be full speed. I do what I do because I believe in saving patients.

Wall have our opinions, and we all have our standards, but mine are personal to me. I am not saying someone who disagrees is wrong, merely that I disagree. I would much rather find a patient did not survive because it was their time then find I could have saved them but didn't do all I could for them. I sleep well at night, even after hte more horrific things I have seen over the years, because I know in my heart I did all I could. I have never had a person tell me I could have done more, and I have never had the nightmares that some of our brothers and sisters have had because I know in my heart I do all I can regardless of the outcome. I have a need to do everything in my power in order to maintain a certain level of sanity.

I had an instructor tell me once, after I told him the same thing, that I wouldn't last long in this profession unless I altered my attitude. That was 10 years ago, and I am still here practicing as I always have. I am not saying he was wrong, only that he misjudged me. I operate the way I do because this s the way God designed me. We are all different, and we all must do what we must do to feel secure in our judgments.

 

[redcrossemt]

Perhaps I am overly optimistic, and we all have our opinions, however it is not my place, regardless of my system, to say when someone is no longer salvageable. We do what we do to save lives, however we are not doctors and we are not qualified unless death is obvious.

You don't have to be a doctor to follow protocols in declaring death on-scene due to extended downtime or other circumstances. Cold water drownings are a different story altogether because of the pathophysiology of what happens.

Do you transport every CPR in progress emergently?

Numbers and research should play a larger role in our professional than the anecdotal and emotionally based care many provide.

 

[18G]

The human element cannot be lost. As health care providers we need to utilize our emotions in a manner consistent with our education and training. We would be doing every single one of our patients a great disservice if we abandoned our emotions while providing care to them. I've seen it way too many times how providers approach patients like inanimate objects.

Science, statistics, numbers, or whatever... need to be strongly considered, however, who are we to say, "they are gone", or "no chance in surviving"? This obviously is exempt from the obvious situations of death. But we need to give patients every fighting chance we can. Miracles do happen and patients defy the odds. Each clinician needs to make decisions that they are comfortable with and at the end of the night, they can sleep well with.

I don't think telling someone they are wrong is the right thing to be doing on a subject such as this. Give it your all and at the end of the day hope you made a difference. That's all you can do.

Jeffrey_169, another great post. Well articulated.

 

[Aidey]

In some places delivery at less than 22/23/24 weeks gestation is considered incompatible with life, and a justification to not start resuscitation if there are no signs of life after the birth.


Personally, I have a problem when people go with their personal emotions/morals/ethics/feelings/whatever over science. When it comes down to it people will die. People will be disabled. We will never be able to save 100% or have 0% deaths. Those are unobtainable numbers, and we have to accept that. Ignoring science and instead providing care based on on the idea that "miracles occur" does not sit well with me at all.

 

[Jeffrey_169]

In some places being less than 22/23/24 weeks gestation is considered incompatible with life, and a justification to not start resuscitation if there are no signs of life.


Personally, I have a problem when people go with their personal emotions/morals/ethics/feelings/whatever over science. When it comes down to it people will die. People will be disabled. We will never be able to save 100% or have 0% deaths. Those are unobtainable numbers, and we have to accept that. Ignoring science and instead providing care based on on the idea that "miracles occur" does not sit well with me at all.

I understand your point, and please don't think me sarcastic when I say this, but according to science as it pertains to the laws of physics, it is impossible for a bumble bee to fly. It is, according to science, not physically possible, yet everyone, even a 3 year old knows it happens, all the time.

Just something to think about, and again please don't think I am being a smart a**; its true.

 

[Aidey]

I hate to tell you but that is a myth that probably started by someone who applied the wrong formulas to describe how a bee flies. If you apply the formulas that explain how an airplane flies to a helicopter would they show that the helicopter could fly? Probably not. Same concept.


By doing everything on everyone all of the time, how much of a difference are we going to make? How many outcomes will change vs how many times will we increase the family's grief? If we ignore resuscitation guidelines, how many times will we actually resuscitate someone who would have been declared dead? Of those few times, how many of those will live any length of time in the hospital?

 

[Jeffrey_169]

Not my decision to make. By this logic, why do we still perform CPR; it has been shown by some studies to be only 4-6% effetive, the highest I have seen is 10%, and that is only when everything is text book. According to the studies is statistically a waste of time. The reason is because even 4% of 100,000 people is 4000 people. We do it because even if one life is saved, then it is worth the extra effort. It may nt seem like a lot, but it is, especially when its your loved one in the mix. Wouldn't you want to know, if it was your kid, that everything was being done to save him or her? I know I would. Besides, whats the harm in trying?

Besides, the reason they came to this conclusion is because of the relation of the bee's wings in proportion to it's body is not equal. The body is not aerodynamic, and the wings are too small.

 

[Jeffrey_169]

Another good example I can provide comes from an issue of Time Life Magazine. Several years ago there was a man who was parachuting. He jumper 10,000 feet and both his main and reserve shoot failed to open. He landed on the ground, bounced a few times, and walked away.

There have been numerous scientist come out and claim they know why and how this could happen, but its funny how none of them will try to recreate it. Maybe they are not too sure of what they preach.

Like I said, I believe in science, no question; but I also believe there are other forces we do not fully understand at work. Some people call it fate, God, Chi, carma, etc.; what ever you call it there can be no denying its there.

 

[Aidey]

That is exactly the point though. We don't do CPR on everyone. We have guidelines that indicate who is most likely to benefit from resuscitation attempts and who isn't. This allows us to withhold resuscitation on those who are not likely to benefit from it. In some cases that is going to include withholding resuscitation on newborns who are premature, or children, along with adults.

How many "saves" do you think will come out of doing CPR on everyone? 1 out of 100,000? 1 out of 500,000? Do you realize that rather than increasing the save rate that doing CPR on everyone will actually cause the CPR effectiveness rate to drop because the ratio of people "saved" to people who are declared dead will be astronomical? And those that are "saved" are not likely to make it out of the hospital alive. In those cases we are really just delaying legal death, not saving a life.


Please do not turn this into a "What if it was your loved one!" discussion. That undermines science, logic and education. It is an irrational argument that attempts to sway people against science by appealing to their emotions.

What is the harm in trying? I don't even know where to start. I'm going to let Vent handle that one because she will be able to say it better than I can.

 

[Smash]

It saddens me that there is still such a pervasive ignorance regarding science and satistics, and that subsequently magical thinking fills the void. If you rely solely on "experience" or emotions you are destined to make the same errors over and over again with an ever increasing degree of confidence.

Weis-Fogh in the 70s comprehensively put to bed the myth of bees "not being able to fly". You may as well argue that a 747 can't fly because it can't flap it's wings.

I'll leave the exercises in futility to those who aren't capable of acting rationally so I can provide appropriate, compassionate care to those who need it.

 

[Jeffrey_169]

It saddens me that there is still such a pervasive ignorance regarding science and satistics, and that subsequently magical thinking fills the void. If you rely solely on "experience" or emotions you are destined to make the same errors over and over again with an ever increasing degree of confidence.

Weis-Fogh in the 70s comprehensively put to bed the myth of bees "not being able to fly". You may as well argue that a 747 can't fly because it can't flap it's wings.

I'll leave the exercises in futility to those who aren't capable of acting rationally so I can provide appropriate, compassionate care to those who need it.

When did "experience" become an irrational way to practice? Furthermore a 747 does not need to flap its wings because it creates enough thrust without this ability.

You say you are going to perform "compassionate care to those who need it". yet you imply you agree with Aidey in that not everyone is entitled to it. So who are these chosen ones? Who decides who lives and who dies/ Who decide who is worth the effort and who is not? We are not gods, and we practice under the pretense that if they are salvageable then we have a duty to act. Again, if stats and logic is to be applied then no one is worth CPR because only an average of 5% will live anyway, so they are apparently not worth the energy...right?

I am not saying everyone we treat will live. I have lost more patients then I care to remember, but I gave each the benefit of the doubt. You tell me about science and logic, but when the flaws of the 100% science mentality is proven to be inaccurate and not all encompassing you provide mockery and sarcasm.

Statistics are of no use when it comes to human life. There is not now, nor will there ever be, room in my truck for it. I will give competent CARE to all my pts, and if I believe they are salvageable then I will do whatever is within my power to save them....that is why I practice medicine and not mathematics and statistics. If I wanted to study stats, I would get a degree in accounting; I practice medicine to save lives and leave the stats to the CPA's.

Anyone who fails to care about their patients, fails to give compassionate care; and the key word here is "care". There is nothing magical to it. I am not a Shaman, I am however a proud Medic. Medicine to me is not an occupation, but a state of mind. Its a passion.

 

[redcrossemt]

When did "experience" become an irrational way to practice? Furthermore a 747 does not need to flap its wings because it creates enough thrust without this ability.

Please stop arguing about the bee. That is a myth that has since been disproven (once we came up with better analytic models of what actually happened during a bee's flight). Regarding the 747, it's not really about thrust; it's about lift, which is created by velocity.

Again, if stats and logic is to be applied then no one is worth CPR because only an average of 5% will live anyway, so they are apparently not worth the energy...right?

I am not saying everyone we treat will live. I have lost more patients then I care to remember, but I gave each the benefit of the doubt. You tell me about science and logic, but when the flaws of the 100% science mentality is proven to be inaccurate and not all encompassing you provide mockery and sarcasm.

I'm not sure you're listening. Some people are worth CPR. We know that resuscitation is most effective when started quickly. Tell me a story of someone who survived after being in arrest for an hour or two, without some special circumstance (like cold water drowning)... I bet you can't.

Science isn't inaccurate. That's the whole point.

Statistics are of no use when it comes to human life. There is not now, nor will there ever be, room in my truck for it. I will give competent CARE to all my pts, and if I believe they are salvageable then I will do whatever is within my power to save them....that is why I practice medicine and not mathematics and statistics. If I wanted to study stats, I would get a degree in accounting; I practice medicine to save lives and leave the stats to the CPA's.

Well why don't you just throw out albuterol, onandestron, and all the other drugs that are based in evidence and statistics, then? EBM is all about statistics. Haven't you ever read a research study?? Did you ever wonder what the "confidence interval", "SE", and other numbers meant?? Well they have to do with statistics. That's how we get new protocols, and lose old ones. It's called scientific research, and therefore yes, statistics has a place on every ambulance.

Anyone who fails to care about their patients, fails to give compassionate care; and the key word here is "care". There is nothing magical to it. I am not a Shaman, I am however a proud Medic. Medicine to me is not an occupation, but a state of mind. Its a passion.

Compassionate care also includes NOT starting resuscitation when it is not going to fix the patient. Starting resuscitation can be much more detrimental to the family than not starting it.

Medicine is NOT a state of mind. I encourage you to go to your medical director and state, "Medicine to me is not an occupation, but a state of mind. Statistics have no place in my truck." I would be various curious to what he says.