Child/Adult Codes

[Sasha]

So, the code thread has got me thinking. I've been noticing that a lot of people feel children deserve more effort into their resucitation.

At the station today I was browsing OCFD's termination of resucitation protocol.

Their protocol is very simple, all guidelines must be met.

• Downtime greater than 20 minutes
• Intial and end rhythm must be asystole
• Worked for 20 minutes
• Two rounds of epi
• Two rounds of atropine
• Asystole must be confirmed in two leads
• ETCO2 read must be 10mmHg or less after 20 minutes of effective CPR

However, it also states that due to age or bystander input a paramedic can decide not to terminate resucitation efforts.

Why do people feel the elderly do not deserve your 100% effort and children do? Is their life any less valuable? That 60 year old woman is someone's mother, sister, etc.

 

[daedalus]

So, the code thread has got me thinking. I've been noticing that a lot of people feel children deserve more effort into their resucitation.

At the station today I was browsing OCFD's termination of resucitation protocol.

Their protocol is very simple, all guidelines must be met.

• Downtime greater than 20 minutes
• Intial and end rhythm must be asystole
• Worked for 20 minutes
• Two rounds of epi
• Two rounds of atropine
• Asystole must be confirmed in two leads
• ETCO2 read must be 10mmHg or less after 20 minutes of effective CPR

However, it also states that due to age or bystander input a paramedic can decide not to terminate resucitation efforts.

Why do people feel the elderly do not deserve your 100% effort and children do? Is their life any less valuable? That 60 year old woman is someone's mother, sister, etc.

Because, the elderly have had their time on the planet and are likely going to end up in a nursing home after thousands of dollars in ICU expenses, and never live a productive life again. They also may have many co-morbities like COPD, cancer, diabetes, neuropathy, degenerative neurological diseases, etc that will prevent them from becoming healthy again.

A child, well, if there is even a minute chance of giving it the gift of allowing him/her the gist of life, the chance to become somebody and live, it is worth the risks and expense.

 

[Sasha]

Why do you decide who should be allowed the gift of life? Who gives you that right? Elderly are still human, and they are someone's mother, sister, aunt, father, brother, husband, cousin, uncle.

I'm a firm believer that your patients should always be getting 100% of your effort, regardless of age, race, sex, religion, etc.. If you don't feel compelled to give patients of a certain age group the same kind of care and effort you would of another age group, perhaps you shouldn't be in health care.

It's not like we are making room for one life to "have their chance" by not giving the other that same "chance" at life.

 

[daedalus]

Why do you decide who should be allowed the gift of life? Who gives you that right? Elderly are still human, and they are someone's mother, sister, aunt, father, brother, husband, cousin, uncle.

I'm a firm believer that your patients should always be getting 100% of your effort, regardless of age, race, sex, religion, etc.. If you don't feel compelled to give patients of a certain age group the same kind of care and effort you would of another age group, perhaps you shouldn't be in health care.

It's not like we are making room for one life to "have their chance" by not giving the other that same "chance" at life.

I never said I actually chose who gets my 100% effort. I give it everyone regardless of my belief on who deserves it.

I was providing a point of view.

 

[el Murpharino]

I think we should deem this topic (among other topics) Sasha's soapbox

I think every patient gets 100% of a providers' effort...just in the case of children most will work it longer than an elderly patient.

 

[Sasha]

I think we should deem this topic (among other topics) Sasha's soapbox

I think every patient gets 100% of a providers' effort...just in the case of children most will work it longer than an elderly patient.

Hmph.

10chars

 

[Ridryder911]

We all can acclaim that we treat everyone the same.. yeah sure. However; in the real world, we all have the humanistic compassion for kids.

Which one do you treat first, the 90 year old with scrambled eggs & a 4 day old beard or a 10 month cute toddler that are having the same identical problems?

One has to be careful though, age discrimination (unless they have prior factors) can be used and has been. Children in cardiac arrest non-related to respiratory problems are very hard to get back. Most kids AMI are not r/t to ASCHD.

R/ r911

 

[enjoynz]

Not sure why it would state to give more enough due to an age group.
At least not in any books I've read....definitely nothing in our clinical proceduces that says that!

Children tend to hit home harder for many reasons, one.... being that they have not had a chance to experience life,
two... if the EMS personal are parents themselves, it can tend to hit a cord.
Every code is different and I guess you read it at the time!

You can set yourself up for all sorts of trouble in the public eye... with statements that say EMS do not put the time into the elderly!

Cheers Enjoynz

 

[Jon]

Why do you decide who should be allowed the gift of life? Who gives you that right? Elderly are still human, and they are someone's mother, sister, aunt, father, brother, husband, cousin, uncle.

I'm a firm believer that your patients should always be getting 100% of your effort, regardless of age, race, sex, religion, etc.. If you don't feel compelled to give patients of a certain age group the same kind of care and effort you would of another age group, perhaps you shouldn't be in health care.

It's not like we are making room for one life to "have their chance" by not giving the other that same "chance" at life.

Look at the statistics... a patient that meets ALL of those criteria has no chance. Even if you do get a pulse back with enough epi (I recall an instructor once saying you could get a heartbeat from a rock with enough epi)... the patient WILL be a vegetable with no quality of life, and would probably kick around for a few days in the ICU until the finially kicked the bucket, prolonging everyone's agony and the death.

I'm suprised your protocol doesn't include hypothermic patients found in arrest - is that covered under a different protocol?

 

[Ridryder911]

Why do you decide who should be allowed the gift of life? Who gives you that right? Elderly are still human, and they are someone's mother, sister, aunt, father, brother, husband, cousin, uncle.

I'm a firm believer that your patients should always be getting 100% of your effort, regardless of age, race, sex, religion, etc.. If you don't feel compelled to give patients of a certain age group the same kind of care and effort you would of another age group, perhaps you shouldn't be in health care.

It's not like we are making room for one life to "have their chance" by not giving the other that same "chance" at life.

That's nice to say... but come back after 5 years in the field. See how much effort you place in that 101 year old patient to compare with that 42 year old mother of three or that 650 pound trach patient will probably not get worked as long. Why not? There are many factors.

Real medicine real issues. The world is not always fair, it can't be. If you expect to see something different, you’re going to be heartbroken and very discouraged. Again, it is nothing alike on t.v. and one will see very fast that when patients are that severe or have any other contributing factors excuses are looked for to stop resuscitation; not vice versa.

R/r 911

 

[emtfarva]

I am only a Basic. every code gets worked the same with me, and every code gets transported when I work a double basic truck. I work a child or and elderly Pt the same way.

 

[emtfarva]

These are MA protocols:

I. EXCEPTIONS TO INITIATION OF RESUSCITATION
Other than in overriding circumstances such as a large mass-casualty incident or a hazardous scene, the following are the only exceptions to initiating and maintaining resuscitative measures in the field:
1. Current, valid DNR, verified per the Comfort Care Protocol.
2. Trauma inconsistent with survival
a. Decapitation: severing of the vital structures of the head from the remainder of
the patient’s body
b. Transection of the torso: body is completely cut across below the shoulders and
above the hips
c. Evident complete destruction of brain or heart
d. Incineration of the body
e. Cardiac arrest (i.e. pulselessness) documented at first EMS evaluation when
such condition is the result of significant blunt or penetrating trauma and the
arrest is obviously and unequivocally due to such trauma, EXCEPT in the
specific case of arrest due to penetrating chest trauma and short transport time
to definitive care
(in which circumstance, resuscitate and transport)​

3. Body condition clearly indicating biological death.

a. Complete decomposition or putrefaction: the skin surface (not only in isolated
areas) is bloated or ruptured, with sloughing of soft tissue, and the odor of
decaying flesh.
b. Dependent lividity and/or rigor: when the patient’s body is appropriately
examined, there is a clear demarcation of pooled blood within the body, and/or
major joints (jaw, shoulders, elbows, hips, or knees) are immovable.
Procedure for lividity and/or rigor: All of the criteria below must be established
and documented in addition to lividity and/or rigor in order to withhold
resuscitation:
i. Respirations are absent for at least 30 seconds; and​

ii. Carotid pulse is absent for at least 30 seconds; and

iii. Lung sounds auscultated by stethoscope bilaterally are absent for at least 30 seconds; and
iv. Both pupils, if assessable, are non-reactive to light.
II. Cessation of Resuscitation by EMTs
Emergency Medical Technicians must continue resuscitative measures for all patients in cardiac
arrest unless contraindicated by one of the exceptions below.
1. EMTs, certified at the Basic, Intermediate and Paramedic levels, may cease resuscitative efforts at any time when any “Exception to Initiation of Resuscitation” as defined in I., above, is determined to be present.
2. EMTs certified at the Paramedic level only may cease resuscitative efforts in an adult patient 18 years of age or older, regardless of who initiated the resuscitative efforts, without finding “obvious death” criteria only by the following procedure, and only if the EMS system’s Affiliate Hospital Medical Director has approved of use of this procedure, as follows:
a. There is no evidence of or suspicion of hypothermia; AND
b. Indicated standard Advanced Life Support measures have been successfully undertaken (including for example effective airway support, intravenous access, medications, transcutaneous pacing, and rhythm monitoring); AND
c. The patient is in asystole or pulseless electrical activity (PEA), and REMAINS SO persistently, unresponsive to resuscitative efforts, for at least twenty (20) minutes while resuscitative efforts continue; AND
d. No reversible cause of arrest is evident; AND​

e. The patient is not visibly pregnant; AND​

f. An on-line medical control physician gives an order to terminate resuscitative efforts.​

III. Special Considerations and Procedures:

1. In all cases where a decedent is left in the field, procedures must include notification of appropriate medical or medico-legal authorities.
2. EMS documentation must reflect the criteria used to determine obvious death or allow cessation of resuscitative efforts.​

​

 

[Meursault]

Think of it in terms of effort per year of life (or QALY, for anyone who's read effectiveness reviews).
If you get a legitimate save with no additional neuro damage on a 98 y/o demented SNF pt., you've expended effort and ACLS drugs to give her a chance to die from exactly the same causes in a few months.
If you get the same quality of save from the same amount of effort on a 2 y/o kid who fell in the pool, they might go on to be a 98 y/o demented SNF pt.
This doesn't absolve providers of the need to work all codes as well as is reasonably possible, but it gives us an incentive to work harder on the ones we can make a difference for.

EDIT: Obviously, there are a lot of peds disorders that don't count as "ones we can make a difference for", along with exceptions on the other end of the spectrum. Still, age is sort of an intuitive standard.

 

[AJ Hidell]

Okay, you guys are taking this off onto a tangent that was obviously not intended by Sasha. This isn't about the science of resuscitation probabilities. This is about the psychological component of resuscitation efforts.

The question is why providers "feel" like they must give some extra effort to children that they would not give to a 40 year old. The most common response we hear is this nonsense about children not yet experiencing life. Give me a break. That wasn't in your paramedic textbook. And I suggest that many providers don't even believe it. They're just parroting what they heard others say because they think they are supposed to feel that way. It's just like those people who say they volunteer because they want to "help people". It's giving the answer you think people want to hear instead of thinking critically and answering honestly.

I've have often heard brand new EMTs, who have never even worked a critical pediatric patient, talking about how pedi patients get to them. This attitude is bogus, and is likely to become a self-fulfilling prophesy. If you come into the field believing that kids are going to somehow bother you more than other patients, well then you can pretty much count on it happening.

 

[enjoynz]

They're just parroting what they heard others say because they think they are supposed to feel that way. It's just like those people who say they volunteer because they want to "help people". It's giving the answer you think people want to hear instead of thinking critically and answering honestly.

AJ answer me this! Are you a parent? Have you ever been a Volunteer EMT?
If the answer is 'No' to either of these, I don't know how you can possible know what either these people think, or say, to be anything other than the truth.
I take exception to your generalization of such people, being one of them myself.
Would be like me generalizing that all paramedic's are suck up, not that I think that at all, as most of my Paramedics friends (in NZ and US) would tell you!

As far as running of any code goes, know matter what level we are working at...we can only do our best for all of them, regardless of age the patient is!

Cheers Enjoynz

 

[UrbanEmt]

I can see some providers having issue with the death of a child. I have seen children with some pretty horrific injuries. I have also seen good providers wash right out of EMS because they couldnt get by that one call. They couldnt put it away for whatever the reason may be.

Not every provider can just forget it and move on. Other say they can and end up in some downward out of control spiral because they didnt get the help they needed.

I agree if your in EMS long enough eventually you will see children injured and dying its part of the job. The easy part sometimes is tending to the pts injuries, the hard part can be leaving it at work when you go home.

 

[AJ Hidell]

I take exception to your generalization of such people, being one of them myself.

You're taking it awful personal for someone who thinks that they are an exception, aren't you? What exactly makes you believe that anyone was speaking of you personally? Do you assume that every statement that anyone makes applies to every person in the world? Would you assume that, if I said that Poodles suck, that I was bashing all dogs? Get a grip.

 

[enjoynz]

You're taking it awful personal for someone who thinks that they are an exception, aren't you? What exactly makes you believe that anyone was speaking of you personally? Do you assume that every statement that anyone makes applies to every person in the world? Would you assume that, if I said that Poodles suck, that I was bashing all dogs? Get a grip.

Firstly, sorry Sasha I'm not trying to steal your thread!

And as far as getting a grip, my feet are firmly on the ground, thank you very much!.
Not for a minute did I think you were referring to me personally.
I do take it personally when I see volunteers and those new to the field, been dogged all the time.
I see you didn't bother to answer my question, so I would assume you are neither a parent or never been a volunteer,
therefore you really don't know that when a volunteer says they want to be an EMT because they want to 'help people',
that maybe exactly why they are looking at becoming a EMT.

Something else happened to me today that made me think about this thread.
My mother was take into hospital today and is now in the Coronary Care unit....the Cardiologist has said that it looks like LQTS,
which took my 2 teenage niece's and a nephew, all from the same family.
(This is unconfirmed though, the doctor's are still unsure what genetic cardiac condition killed them).
It was enough of a worry for them to place automatic defibrillators in my remaining two niece's.
If my mother is a genetic carrier, my girls may well be at risk also...we are going to sort some tests for them.

My point to this is...as I drove home from the hospital and thought about it, I would want the EMS to spend as much time on a code
with my 87 year old mother as my 14 or 12 year daughter's.
The reason being ....I love all of them the same!

Enjoynz

 

[Veneficus]

I think many providers treat kids differently is a combination of super imposing their own child’s identity and their insecurity with pediatric medicine. Most providers obviously not peds specialists and the like) see a lot more adult patients. They are comfortable with the process of treating them.

Peds on the other hand may cause the provider to recall pieces of information not regularly used from the depths of the mind. There is anxiety over whether the information is correct, complete, whether clinical response matches what is expected. The lack of measurable findings, you can ask an adult how they feel, an infant will just cry. Obviously not in a code, but I think everyone gets the point.

I agree with AJ, this idea that kids are somehow different, more valuable, etc, is purely psychological. Have a look at the epidemic and major disaster recommendations, they specifically state that resources may not be used on children under a certain age.

I wouldn’t say providers look for reasons to call a code, prognosis and resource allocation is just as much part of working a code as delivering a drug or a shock. It doesn’t take large amounts of medical knowledge to figure out somebody is dead. If nobody mentioned, you have a better chance of resuscitating a 98 year old SNF patient than you do a kid that codes.

Not trying to be mean or anything, but if you cannot handle patients of all ages dying or being grievously injured, maybe Emergency fields are not for you? Our purpose in society is to try and intercede when things go wrong, not to decide who or why one person deserves more than another. I am really starting to think PTSD is a disease of modern Westerners completely detached from the realities of life. If you can’t take the heat, get out of the kitchen. If you are worried you will be not be able to handle certain things, rest assured, you will be tested.

I suggest that rather than worry about what you might do, you spend some time now doing what it takes to give both you and your future patients a better chance to succeed.

 

[Ridryder911]

That's nice thoughts but it not real. Sorry to burst the bubble but I can assure you in the U.S. if you are over the age of 75 and have any history of coronary problems the best you will get is two rounds of med.'s and maybe, just maybe of 30 minutes of CPR.

Life sucks but statistics don't lie. Cardiac arrest means death. No matter how much you care, no matter how gallons of med,'s or high the voltage you can shock.

Unless, you are there within the first few minutes or the body just so happen to respond to therapy; as they say in the South .."it ain't go to happen".

That is why Emergency Cardiac Care Committee is attempting to educate & promote field termination and promotion of "short codes". If the patient is to going to respond to therapy; they will by the second round of medicines (about within 10 minutes).

Most codes I work usually last <15 -20 minutes. The physician will call it faster if they are over 75 or past medical history an no immediate signs of ROSC.

One has to realize real hard cold facts. Patients die. It's their time. There are times we can perform and be able to resuscitate them, and there are times we can't. We did not cause this rather this is part of life. Death is life's final stage of living.

Now, in regards to volunteerism. Let me ask you? Did you spend over four years to obtain an education level to be proficient to enter a calling to become a professional to perform medical care? Did you volunteer over a year or more of your life for clinical time to become proficient in skills? Have you spent over thirty years working within an industry serving countless hours that could be totally measured in years on committees? Researching, developing and arguing to ensure better quality medical care? How many nights in libraries have you spent researching? Exactly how many days did you review statistics? Did you ever have to stand in front of a medical examiner review board because you by-passed the local hospital and went to the most appropriate not nearest one ..... Since it was the first time it was ever done they wanted to prosecute? Well someone had to.

EMS is medicine and medicine is an industry. It did not develop overnight, those protocols and procedures did not "so happen". Reviews of what worked and not worked did not "magically" change by themselves. It took hard work and I gurantee it might have been through volunteerism but not the way most see it.

Now, all of this to be told...no, we will not need you and definitely not even pay you minimum wage; because we can get someone for free! You see, we have several that like to do this for a hobby or "you don't understand; it makes me them feel good about themselves; you know...giving back to the community".


Now I ask; have you ever attended a National Curriculum Committee to be told "we have to reduce our current curriculum" to be told "You guys (educators) don't seem to understand; the course is too long and we are loosing them (volunteers); so we need to make it easier and as short as possible"; well have you? That most of the reading material is still covered in just one text book with nice brightly colored pictures; when there are more diseases and treatment than ever? Not is it a shame but a tragedy.

Have you seen the industry you spent over three decades not to progress in comparrison to other health care professionals? That we are still the ONLY health care professionals that does NOT require an degree for license? Hell... license most still only certify. Now, you want to still know why?

No, technically I have not volunteered but I will challenge any volunteer on the number of hours I was not paid for developing and hopefully improving EMS. I have spent more free time at the Capitol attempting to change laws to benefit EMS than the majority have ever spent volunteering in EMS.

So now, you know what I find offensive. Groups of people attempting to destroy or water down a profession that needs; no.. has to be well educated and truly dedicated. Composed of not of those that cannot make this a past time nor does want to improve the system because all in the name of tradition or self ego's. Yes; I honor those that volunteer because there is no one else; nor will be anyone else to help but as my old saying goes; If your not part of the solution, your part of the problem.

Sorry, about the rant but there are always two sides.. just remember there are some of us that take this profession, pretty damned serious. Long night attempting to get a bill passed only to be told; we need to consider the volunteers it would make it too hard on them.

R/r 911