Peadiatric Death

[Manicmedic]

Ok so here's one for you to ponder.

You are called to a "5 yr old cardiac arrest" no other info apart from address
Upon pulling up at scene you and your partner see the mother in the road flagging you down and on entering the premises find dad at the top of the stairs outside the child bedroom.
You enter and find a small male child supine on the floor with no visible signs of life.
ABC take fractions of a second on this call and you move staright into BLS protcols using the BVM and AED.
Initial findings are Resps Nil, Pulse Nil with assytole on AED. Palour is mottled and cyanotic and skin is warm and dry.
You now notice as you move to try to get some venous acess that there is a ligature mark in the crease of the neck under the chin which was not visible on first examination. What the hell has happened here?
Whilst your partner continues with BLS you gain from the mother that the child who is actually 2yrs old went up into his room over 20 minutes prior to the emergency call being placed and when the mother noticed his absence she went up and found him dangleing from the cord of the blind in the bedroom.
The child has had in the last 15 minutes 2.4 rounds of CPR from the father.
On secondary survey Hypostasis is found in the lower legs, the vitals remain unchanged and both pupils are fixed and dilated.


So heres the question: in your service you have the power to ROLE (Recognition of Life Extinct) One of the signs are Hypostasis.


Do you run to the ED with the child attempting IO in the back of the unit possibly giving the parents a false hope and utilising resources on a non revivable patient.

Or

Do you call it at scene and allow the parents to spend a little time to say goodbye in the home enviroment. also allowing coronors officers an uncontaminated scene to carry out their investigation.


I will say at this point that after 20 years on this job i chose the second option as being a father of 3 myself i realised the parents had already realised that their child was dead, unfortunatly my service had put out an e-mail (popular way to train staff here ,it saves money as they dont have to take us 'off the run' for training) that me and my partner were'nt aware of stating that all kids have to be resused no matter wether they have rigor mortice. hypostasis or what .
Upshot of this all i get busted from Paramedic down to Emergency Care Assistant.
Now dont get me wrong i am NOT saying i was unfairly treated what i am saying is that there is very little here in the way of training and support for frontline staff that are daily asked to make decisions that would make most physicians tremble.
I look forwards to a lively debate.

 

[8jimi8]

who took away your rights to ride as a medic? Your employer, or your state

 

[SeeNoMore]

Sounds like unfair treatment to me. I applaud the mindset in EMS that we have to be as responcible as possible, and to try and prevent any mistakes before they occur. But the flip side of this, which I think companies exploit out of greed and sloth, is to assign complete blame to providors for situations that are partially their fault, or do not require blame but education.

In this case, you chose not to give false hope or take time and resources for a patient you felt could not be saved. Your agency should have addressed this earlier with something more personal than an email. But now the fault is totally yours?

I don't buy it.

 

[emt_irl]

in ireland no matter what the age resus is not indicated if rigor mortis, hypostatis and injuries imcompatible with life are present.

so i wouldnt of either. can you appeal the demotion to eca? or will you?

 

[LucidResq]

All patients found pulseless and apneic are to be resuscitated, except patients found in any of the following conditions:
1. Decapitation or
2. Decomposition or
3. Third degree burns over more than 90% of the total body surface area or
4. Dependent lividity or rigor mortis or
5. A valid CPR directive present with the patient or
6. Evidence of massive blunt head, chest, or abdominal trauma

 

[Epi-do]

First I had to look up hypostatsis to be sure that I understood what it was. Once I was sure it was the same thing we refer to as dependent lividity, I can now answer the question.

I would opt to not work/transport this child. One of my least favorite things about this job is having to transport a corpse, and perform an exercise of futility in the process. There comes a point when dead is dead, and once that threshold is reached, there is no coming back from it.

Unfortunately, I work with people that think that if it is a peds run, you should do everything, regardless of the circumstance. There is a large chance that I would be ordered to transport anyway. (From an officer who is a basic, not a medic, but thinks he has the authority to over rule higher trained medical personnel anyway.) Since I have already gotten into trouble for "refusing to follow orders" while trying to make appropriate decisions based upon my skill set, knowledge, and protocols and/or medical direction, I would most likely go ahead and transport and then get into a little bit less trouble once returning to station and calling said individual out for not allowing me to properly do my job. But I digress...he's just one of those people that makes a decision and no amount of valid evidence will get him to admit he was wrong. And now, back to the program...

 

[MGary]

I'd put on a 4 lead or defib pads and hit up med direction on the cell phone. Pt would probably be asystolic by that point. If I told the doc "20+ minute downtime, asystolic in 2+ leads, lividity present", I'd bet that 90% would tell you to call it, regardless of age. If I have anything other than asystole on the monitor and/or the doc wants to see it, he sees it. Either way, my *** is covered.

 

[lsetzer]

The lone fact that the child apparently died from an unnatural circumstance prevents personnel in the service I run with to call for termination of resussitation...unless of course, the pt has been known to be deseased for some time.

I will say, that both pediatric arrests that I have been involved with, both were obviously dead, and both were transported emergency traffic to the ED.

 

[usafmedic45]

unless of course, the pt has been known to be deseased for some time.

Lividity (hypostasis) is a pretty good indicator of that.

 

[lsetzer]

Lividity (hypostasis) is a pretty good indicator of that.

Understood - that's exactly what I'm saying.

*edit* misspoke

 

[Manicmedic]

Glad its caused some thought

In answer to some of the posts, my service busted me.
We in the UK have the responsibility to ROLE patients so that it saves DRs coming out to every sudden death in the comunity to certify. the e-mails we receive are sent to every station but staff due to the workload ( 17 STATIONS WITH APPROX 2 RIGS PER STATION AND APPROX 800-900 CALLS PER 24 PERIOD) does not allow down time to catch up on these. we dont get inset /staff training days.
As has been mentioned it came down to a comon sense call over a paperwork tick the box call and at the end of the day you cant argue with managers.
I have the HPC investigating it (our version of the NREMT) so hopefully will resolve soon, just wanted to share this as i have been finding that there are more and more areas where we the frontline staff are being left hanging for making clinical decisions that our employers have given us the powers to do partly to save cost and possible litigation on their part.
As far as being an ECA for a while , hey i get to sit back and not have to use the old brain box....lol
Manicmedic

 

[Seaglass]

I'd put on a 4 lead or defib pads and hit up med direction on the cell phone. Pt would probably be asystolic by that point. If I told the doc "20+ minute downtime, asystolic in 2+ leads, lividity present", I'd bet that 90% would tell you to call it, regardless of age. If I have anything other than asystole on the monitor and/or the doc wants to see it, he sees it. Either way, my *** is covered.

+1. I can't declare unless I see some pretty strict criteria (same as Lucid's) no matter how long the downtime's been, but I can call control.

 

[Smash]

Sounds like a system problem to me. If you aren't given opportunities for continuing education, or even the chance to read up on the latest bulletins put out by your service, then it seems to me to be a failing of the system.

It also seems to me that you made an appropriate decision in not commencing resus, both from a medical point of view and also in being humane to the parents.

Do you know the rationale behind insisting on resus in dead patients? Seems rather odd, like a step backwards to me.

Good luck with the review, I hope it doesn't drag on too long.

 

[firetender]

Manic, Thanks for this one!

Medics, typically, are out there flying without a net. They are trained, but the part about "judgment calls" nobody teaches. And to make matters worse, there's usually a legion of people on the sidelines who, if they witnessed any call could find fault with how the medic or medics handle it.
To make matters even worse, if the sponsoring company or system or whoever gives you the keys to the ambulance sniffs that a choice you make could cost them money (yes, that IS what it boils down to!) then at the very first opportunity, you're GONE because, let's face it, medics are expendable because there's ten more wanting to take the job vacated (usually).

But that's not what annoys me. You, my friend stepped into the Twilight Zone between being a Human and being a Technician. In my opinion, you did NOT let your human considerations (Father of 3) influence your Technical decision based on evaluation of the scene. Regardless of your relationship with the kid's situation, he was dead.

In your narrative you said you were not aware of the recent Company directives. Had you been, is there any doubt you would have done what you were directed to do?

Even if you say you would have done exactly what you did do, I'd back you up because your judgment as a professional still amounted to "Dead is dead" First, and as a secondary consideration, now, your patients are the parents. As a professional, you have a duty to them as well. How more clear could that be? Is it any different with SIDS?

But now, you are put in the position of having to defend yourself against written directives that do not include the consideration of circumstances. You have been convicted and busted before a hearing was held.

There's no reason for it. If you're going to be put under a microscope, then that should include acknowledging the fact that as a Father yourself, you may have been in the best position to minimize the parent's trauma.

What I don't hear is anyone in your service standing up and offering you an ear to talk to or any other support, which, bottom line is what this is all about. You are the one being asked to both make the decisions and live with their natural consequences. Nothing you did or could have done affected the outcome for the child; the consequences on your service's part are manufactured.

It ain't about the kid, it ain't about the parents, it's about you, and you're the one in need of support for doing what they're asking you to do.

 

[medix99]

At the end of the day, you made a call not to resus. This is in line with JRCALC (2006) guidelines which recognises dependent lividity as unequivicable with death.

However, it must be recognised that a deceased adult and a deceased child need to be treated in very different ways:

JRCALC (2006) states that you should:

'Always take the infant [and parents] to the nearest appropriate emergency department, not directly to the mortuary. This should apply even when the child has dead for some time and a doctor has certified death at home'

This approach is country wide for ambulance personel and was recommended by the Kenedy report (2004).

[I]'This approach is to allow an immediate examination of the deceased child by a paediatrician and the taking of tissue/blood samples (which will degrade fast), it also allows the parents to be in a place where access to support services is faster' (JRCALC, 2006)[/I] (also removes parents from potential crime scene and the emotional upset of having forensics in)

You have stepped outside of established guidelines on this occasion and although they are guidelines and not protocols, I fail to see why on this occasion you chose to ignore parts of them, especially those 'Guidelines' that have been instituted following recomendations from both the Royal college of Pathologists and the Royal College of Paediatrics (Kenedy Report, 2004).

your out on a limb there fella.

 

[Manicmedic]

Reply

Medix you made good valid points, and on this subject due to the fact that we were suspicious about the circumstances of the death (due to no mention of hanging)and wanted the coronors officer present, when he arrived we transported the child direct to Peads ED, time from initial 999 call to hitting ED was 1hr 10mins and this was in Jan with 4" snow and ice on untreated roads over a distance of 5 miles.

 

[tazman7]

Dead is dead. No sense in transporting corpses to the hospital. Thats part of the job is having to "call it." It stinks but I think you did the right thing. Id tell your employer to get bent.