I came across a series of interesting posts from Greg Friese, Steve Whitehead, and Chris Kaiser regarding the common practice of “CPR Theater” or “Going through the motions for the family” when it comes to pediatric arrests. These are blogs that I read often, and I find myself often agreeing with their observations and points of view.
This is not one of those times.
Just for a little background, I spent 2 years working in the Bronx. Out of the five boroughs, the Bronx has the highest infant mortality rate of the city (6.3 deaths per 1,000 births in 2005) that has seen a decline in both birth rates and infant mortality over recent years. Both my first and last calls in the Bronx were infant arrests (speculated to be SIDS victims) and there were more than two handfuls in between, so I have a bit of insight into pediatric cardiac arrests and resuscitation efforts.
On every single one of those resuscitation efforts, I did everything I possibly could, including transporting the pulseless child with their grief-stricken parents up front, even when I obviously knew that there was no hope of regaining a pulse short of a biblical style divine intervention. I made sure the parents understood that not only was I doing everything that I could but that the hospital would do everything they could when we got there. Say what you want about the hospitals in the Bronx, but they never failed me in doing exactly that even when they also knew there was no hope unless the new janitor was also able to turn water into wine amongst other things.
So why do it?
At their very core, every parent ultimately wants the best for their children. Now as Dan Carlin points out in Suffer the Children, this was not always the case in society and while we may revert back to it at some time, right now as a society we place a high value on the very essence of life itself.
In fact, we place such a high value on life that we employee people trained to preserve that life the best way we think we know how whenever we know that the essence of life is threatened. We call those people EMTs and Paramedics. We have also scientifically found ways to extend the essence of life by performing changes on our own bodies (such as open heart surgery) and through machine augmentation (such as ventilators and bypass machines) so much that we have doubled the life expectancy of a person in 100 years.
Every parent wants the best for their child, including healthcare and efforts taken to preserve their essence of life. They want to know that everything that could have been done for them was in fact done for them. So do it. Don’t “go through the motions” or perform “CPR Theater”… actually run the code, perform CPR, and transport as you would a viable patient.
EMS personnel are also not trained or equipped to assist grieving parents either at home or on the scene. Not transporting is denying the parents the knowledge that everything was done for their child, you deny them access to a neutral place they may associate their grief, and professional help on “what happens next”. No parent plans for this event unless there is an underlying condition with an inevitable conclusion. Even if they consider the “what if” scenarios, rarely are they in a state of mind to follow through on what they should do next. This sort of training is beyond just knowing what to say (because in the death of a child there truly are no words, but we should allow our actions to speak for us instead), but more importantly about how to guide them as they step into their new reality.
But aren’t there undue risks involved to both EMTs and the public in transporting a pulseless patient that science says we should leave at the scene?
This is an argument where I sit on both sides of the fence.
On one side, I agree that transporting a patient that qualifies for field termination lights and sirens does create an undue risk and hazard to both personnel and the public.
At the same time, society demands that we respond to these threats to the essence of life expediently even though the perception of that threat may be increased upon by the caller and scientifically the patient’s essence of life is not threatened in the least.
This also creates an undue risk and hazard to both personnel and the public.
Therefore I would submit the argument that as long as society views protecting the essence of life, therefore employing EMTs and Paramedics to protect that essence of life, then the undue risk is an acceptable one. Once society no longer values the essence of life, then we can have real health care reform by not extending lifetimes past their expiration with radical treatments such as chemotherapy and radiation, we will be fine with patients who choose euthanasia, and we will no longer place personnel or the public at undue risk because there will be no more ambulances.
The fact is that perception plays as big a role in all of this as protocols. A field termination of a pediatric will leave the grieving family going through the shock of the 5 Stages of Grief without support from trained personnel.
One of the thoughts among them may very well be, “Those Paramedics did nothing! Nothing!” We already have cases of that, and adding that perception from a grieving parent will be damning to not just the agency, but the industry as a whole. This is not the perception we need to maintain. We need to show that our industry is not only able but willing to go that extra mile in the quest to preserve the essence of life.
In most instances, patients, and their families do not know good patient care from bad patient care. They do know an effort from no effort and nice from not nice. Every now and then though we’ll come across people who know all three… and heaven helps you if that child you chose to field terminate because you didn’t think they were viable happens to be the son of a Chief or Director of a large EMS Agency.
There are a number of systems with field termination guidelines. While I am a proponent of field termination, specifically for the hospice enrolled patient, I am in opposition to any guideline allowing field termination of a patient under the age of 18 barring significant obvious trauma. Make “No Child Left Behind” more than a failed education initiative, make it your Pediatric Arrest Protocol.