why give false hope

[hippocratical]

I was taught to start CPR unless there are major obvious signs of death (DRIED), and if in any doubt, then start CPR.

I believe the idea is:
1) CYA
2) To make the parents think that we at least tried.

I've never been in that situation (hope not too) but I can see that unless it was overwhelmingly obviously a very long dead child, then I'd probably start too. Not an easy one...

 

[JPINFV]

This is why:

http://www.boston.com/news/local/breaking_news/2009/06/two_new_bedford_1.html

Providers (ALS and BLS) are taught that you work the hopeless pediatric code for the parents. Take a moment to think for a second: You're a parent, and your entire world has just come crashing to a screeching halt when you find your child lifeless. You call 911 because, like it or not, we're the people that are supposed to know what to do. How would you feel if a couple of paramedics walked in, looked down at your (dead) child, and said "Sorry, there's nothing we can do. By the way, get ready for a whole bunch of police and the medical examiner to come in to your house, ask you to re-hash the most terrible event that will ever happen to you again and again, and not even leave you with one physical location that feels safe (since that's going to be where their "baby died")."

If you say "sorry, he's dead" that's it. They didn't get to say goodbye, the room where their child lived is (probably) also the room where their child died, and nothing is ever going to expunge their guilt and anger. Worse, you (and our entire profession) may become the target of all of that anger - "Why didn't you help our baby? Why did you let him die?". Regardless of the fact that the child was dead before you got there you're going to be looked at as the monster who "wouldn't save our baby". (Not "couldn't"; "wouldn't").

No parent wants to see their child stuffed full with tubes and wired like a Christmas tree, but no parent wants to see their child sick or dead, either. If you work the child it a) gets the child out of the house ("The child later died at Rampart General hospital..."), b) it looks like you tried everything you could, and c) it gets the parents into a physical location (the hospital) that's got the kind of support help they'll need. It won't help every parent but it's a start.

So, rushing them to the hospital with lights and sirens (an act which puts everyone else on the road at risk, but especially puts the ambulance crews at risk), wasting the time of many members of the ED staff (who could be treating patients instead of a corpse), and forcing the parents to move to a highly active and unfamiliar place is better? Furthermore, who says that the family is going to have the ability to "say goodbye" in the ED? The staff isn't going to keep running a code because the family is 5 minutes away from even parking so that they have a chance to say "good bye."

 

[JPINFV]

I was taught to start CPR unless there are major obvious signs of death (DRIED), and if in any doubt, then start CPR.

I believe the idea is:
1) CYA
2) To make the parents think that we at least tried.

I've never been in that situation (hope not too) but I can see that unless it was overwhelmingly obviously a very long dead child, then I'd probably start too. Not an easy one...

CPR can always be stopped by trained professionals. So i guess the question is, are paramedics trained professionals or just protocol monkeys?

 

[JPINFV]

Sasha, I agree with you on this, but I really believe that the majority of people in this field do not have the skills needed to let this happen in the peaceful way you describe. It is not something that is taught, and does not come naturally to everyone.

Well, of course it's not taught. We have to be able to package the foundation level (EMT) into a 2 week accelerated course. ...but hey, remember that 2 week accelerated course meets the national standard, so it must be ok!

 

[Shishkabob]

Before you get pissed look at their protocols. Some agencies don't allow field pronouncements, and even some that do don't allow pedi pronouncements...

 

[JPINFV]

Before you get pissed look at their protocols. Some agencies don't allow field pronouncements, and even some that do don't allow pedi pronouncements...

Can I still get pissed at both who ever wrote the protocols?

/hates the 'superior orders' argument.
//Protocols that prevent field pronouncements means either the crews are too stupid to make sure dead people are dead, the local system is too lazy to actually train their providers in appropriate after death care, or both.

 

[Shishkabob]

I agree it's stupid to not have them, and I've done my fair share of pronouncements and "No, there is nothing else that can be done" in my short career...


But depending on the agency's culture, variation from protocol via med control might not be allowed.



Not a fan of it, but you can't fault people for their agency's issues.

 

[Flightorbust]

This is why:

http://www.boston.com/news/local/breaking_news/2009/06/two_new_bedford_1.html

Providers (ALS and BLS) are taught that you work the hopeless pediatric code for the parents. Take a moment to think for a second: You're a parent, and your entire world has just come crashing to a screeching halt when you find your child lifeless. You call 911 because, like it or not, we're the people that are supposed to know what to do. How would you feel if a couple of paramedics walked in, looked down at your (dead) child, and said "Sorry, there's nothing we can do. By the way, get ready for a whole bunch of police and the medical examiner to come in to your house, ask you to re-hash the most terrible event that will ever happen to you again and again, and not even leave you with one physical location that feels safe (since that's going to be where their "baby died")."

If you say "sorry, he's dead" that's it. They didn't get to say goodbye, the room where their child lived is (probably) also the room where their child died, and nothing is ever going to expunge their guilt and anger. Worse, you (and our entire profession) may become the target of all of that anger - "Why didn't you help our baby? Why did you let him die?". Regardless of the fact that the child was dead before you got there you're going to be looked at as the monster who "wouldn't save our baby". (Not "couldn't"; "wouldn't").

No parent wants to see their child stuffed full with tubes and wired like a Christmas tree, but no parent wants to see their child sick or dead, either. If you work the child it a) gets the child out of the house ("The child later died at Rampart General hospital..."), b) it looks like you tried everything you could, and c) it gets the parents into a physical location (the hospital) that's got the kind of support help they'll need. It won't help every parent but it's a start.

The article says they didnt do what a good analysis to make sure the child was dead. Obvious signs of death here are enough for a basic to call death.

Or, you could allow them to spend a few quiet moments with the child, saying their goodbyes, instead of ripping their child from them in a fruitless attempt to revive them and stuffing them full of tubes and wires and playing with the mother's emotions by giving her a sense of hope and sticking them with a ridiculous bill.

This is my point here.

You said this so well.

Working the arrest "for the parents" is not always the right thing to do, but I just do not believe that the majority of medics or crews out there have the skills necessary to get the parents through this event without saying something exceptionally hurtful and stupid.

Speaking now as a parent who has experienced loss, I will say that the insensitive thing you say in this situation is magnified and NEVER FORGOTTEN. I am a forgiving person, and I try to forget, but it just doesn't go away. When I think of that time, I remember what that doctor said.

I think that this knowlede should lead you into being cautious, but still comforting. Do not EVER think that you can fix it, or make it better for the parents by what you say. In the heat of the moment, anything other than appropriate sympathy and practical help is running the risk of trying to "fix it" with words.

In my experience, guys especially are oblivious to this "fixing" that happens. It's really important that you (general you) think these things through beforehand to know what not to say to the family.

I agree that alot of people cant do it. I believe its something that should be taught. I know the person that was my instructor last time had always told us not to give the false hope. If some one asks if some one is going to be ok the normal responce is "were doing everything we can". Why would this be different. You dont give false hope and lie to make things look better then they are Also I want to point out that while "guys" may be oblivious it may have been a female medic that ran it.

 

[systemet]

This is why:

http://www.boston.com/news/local/breaking_news/2009/06/two_new_bedford_1.html

No it's not.

* This is why you don't decide not to start resuscitation without assessing the patient properly

* This is why you don't decide not to start resuscitation, then piss off PD by removing a corpse from a potential crime scene, and piss off the hospital by bringing them a corpse like they're some sort of funeral home.

This situation does present an argument against not initiating futile resucitations when signs of obvious death are present, nor does it argue against calling a resuscitation after 15 minutes of asystole. It argues against not doing your job properly.

Providers (ALS and BLS) are taught that you work the hopeless pediatric code for the parents.

This is not universal. In some areas providers are taught that it's in the parent's best interest not to start a futile resuscitation, and to call it in the home.

Which is the best approach seems to be a matter for debate. Perhaps someone here has a psychology/counselling background and can tell us what the relevant literature states?

Take a moment to think for a second: You're a parent, and your entire world has just come crashing to a screeching halt when you find your child lifeless. You call 911 because, like it or not, we're the people that are supposed to know what to do. How would you feel if a couple of paramedics walked in, looked down at your (dead) child, and said "Sorry, there's nothing we can do.

Pretty much exactly the same as how I would feel if they came in, rushed my kid to the hospital, and I got there to find their lifeless body on a stretcher with a bunch of doctors and nurses around, and some jackass in a white coat told me "Sorry, there just wasn't anything we could do".

I think I'd feel numb, then hungry, then want to get drunk, and probably spend a day or two considering suicide, then I'd remember that my wife is currently pregnant and that I have responsibility to my future unborn second child. I'd probably keep drinking too much for a little while, but then I'd tone it down before the baby was born. I'd also probably pick up my gloves, go down to the gym, hit people and get hit for a little bit, too.

And it would be the worst thing that ever happened to me, and I'd remember it for the rest of my life.

By the way, get ready for a whole bunch of police and the medical examiner to come in to your house, ask you to re-hash the most terrible event that will ever happen to you again and again,

Which is going to happen anyway.

and not even leave you with one physical location that feels safe (since that's going to be where their "baby died")."

Like I would ever walk into that room again, and not be reminded of my dead child.

If you say "sorry, he's dead" that's it. They didn't get to say goodbye,

Calling the code in the home doesn't preclude the parents getting to say goodbye. It just means it's done in a different place. Unless there are clear signs of a violent act, they're going to get to hold the child and have some time if I call it in the house.

the room where their child lived is (probably) also the room where their child died, and nothing is ever going to expunge their guilt and anger.

It's still going to be -- and possibly nothing is. Do you really think they're going to feel less guilty or less angry because you've moved the baby to the hospital, done some CPR and given some drugs? I think you're overestimating the potential impact we have on this situation.

Worse, you (and our entire profession) may become the target of all of that anger - "Why didn't you help our baby? Why did you let him die?".

That's not worse. It's utterly trivial. The parents are going to be angry. They're going to find somewhere to place blame. If they choose to place it on me, that's fine. Nothing is going to make their child come back, and as hard as it might be for you or me to endure, sometimes we get paid to have people dump on us for things we don't deserve.

Regardless of the fact that the child was dead before you got there you're going to be looked at as the monster who "wouldn't save our baby". (Not "couldn't"; "wouldn't").

If that happens, and they actually think I "wouldn't save their baby", not that I was the one who told them "their baby was dead", then I've failed somewhere in explaining to them what's happened, and what's going on, which is a vital part of doing this.

The majority of the time it's not going to happen like this. And when it does, you just have to fall back on the fact that you followed your training and your medical control guidelines.

No parent wants to see their child stuffed full with tubes and wired like a Christmas tree, but no parent wants to see their child sick or dead, either.

Agreed.

If you work the child it a) gets the child out of the house ("The child later died at Rampart General hospital...")

Which saves you and me from having to deal with the parents, but passes that responsibility on to someone else. It draws out the process, and changes where the parents are when they're told the kid's dead, which they probably already suspect.

, b) it looks like you tried everything you could, and

It does. But so does doing a proper examination of the child, finding obvious signs of death, and explaining to the parents that there's nothing you can do.

Running the asystolic arrest for 15' in the child's bedroom then calling OLMC, or d/c'ing based on protocol achieves the same. But we should only do this in the absence of criteria for obvious death.

c) it gets the parents into a physical location (the hospital) that's got the kind of support help they'll need. It won't help every parent but it's a start.

But those resources can be brought to the patient outside of the hospital, just as they are in other out-of-hospital arrest.

By this logic, when I treated a 48 year old man who had a witnessed SCA in front of his wife and 3 kids, I should have run him to the hospital, instead of running the asystole protocol for 20 minutes and calling it. Are we back to transporting all cardiac arrests, or just kids? [I recognise that this borders on a "slippery slope" fallacy, but consider the reasoning]

The reality here, is that some parents are going to be ok with the resuscitation either not being started or being called in the house. If you ask them afterwards, they won't mind. Some are going to wish you'd taken the child to the hospital, even if it was futile. The opposite is true as well -- some parents will be glad you took the child to the hospital, even if futile. Others would wish that you hadn't.

Ultimately what you do in this situation is going to be decided by your regional medical control guidelines, and the reaction of the parents is going to depend on individual circumstances and the personalities involved.

 

[Seaglass]

There's only one circumstance where I'd consider working an obvious death. If someone pulls a gun on us and demands we try to save the patient, I might work it for the sake of getting us into the ambulance and out of that situation. (PD comes to all of our codes, but we often arrive first, and bad stuff happens quickly.)

So far, I've never had to do that. I'm good at talking people down, but if anything ever gets a family member so upset that I can't reach them, it may well be a dead baby.

 

[systemet]

I just want to add to what I wrote above ---- this is my opinion. It was what I was taught, and it was how we practiced in the area I worked in. We were told that there was evidence to support this, and that this was in the best interests of the surviving family. I have never looked for the primary research. I'm not sure I would even know how to evaluate it, as it's so far out of my area of expertise.

If other people have been taught differently, I can respect that. I don't think we're necessarily going to agree, but as long as all of us are doing what we perceive to be in the best interests of the family whoever's getting it wrong can rest in the comfort that at least they did what they did for the best reasons.

All the best.

 

[medicnick83]

I also just want to add, that besides obvious DOA's - if a person is being resus'd or such and the patient has passed away while on route to hospital, it's best to let the doctors deal with giving the bad news or (and I've seen this) we get involved in the emotional side of things and it's not a good thing.

 

[systemet]

I also just want to add, that besides obvious DOA's - if a person is being resus'd or such and the patient has passed away while on route to hospital, it's best to let the doctors deal with giving the bad news or (and I've seen this) we get involved in the emotional side of things and it's not a good thing.

To add to this, in some places you may have difficulty finding somewhere to take your patient if you stop resuscitation in the ambulance. If you're on scene at a crime, once resuscitation stops there's a good chance the police will want the ambulance and body to stay, and consider it part of their scene. If you roll up to the hospital and say, "We'd like you to put this guy on the bed in the trauma room, then throw them in the morgue when you've got a bit of time", they may not be too accomodating!

 

[bigdogems]

Funny. Im probably one of the most straight forward, non emotional, and often look at as one of the "least caring" at my work. Now this is mostly because I have an acceptance of death and there are plenty of times that there is nothing we can do. However, Im going to have to go against almost everyone here.... First of all. You weren't on scene so be careful to judge. Now if there were obvious signs of death yes it could have been called and nobody would have questioned the crew. I'm guessing one of two things happened. Either it was a pedi code and they got tunnel vision. Or hopefully in the other possibility. They were actually thinking of the family. Transporting wont make things worse for the family. It will give them comfort. In your opinion the parents will put more blame on themselves because they will think they let their baby die and didnt even know it. Now as far as Im concerned you could even stop CPR during transport and let the ER know whats going on. This at least gives the parents and bystanders the impression that everything possible was done to save their baby.

 

[Shishkabob]

Except for the fact that taking a CPR to a hospital means another bill being stacked on the family.

 

[bigdogems]

Except for the fact that taking a CPR to a hospital means another bill being stacked on the family.

I do completely agree with that one

 

[Flightorbust]

I brought up this call in class. The entire class turned on me. The mothers in the class said that they would rather have the bill and know everything was done that could be. Personaly I still believe you shouldnt run an obvious death. I dont care who it is. But thats just me.

 

[JPINFV]

So... basically your class has absolutely no idea how medicine works. CPR, defibrillation, drugs, etc doesn't care whether it's an EMS provider doing it or an RN and techs doing it under direct order from a physician. Besides, no one has yet explained how transport changes the outcome in patients who do not have ROSC.

 

[Flightorbust]

So... basically your class has absolutely no idea how medicine works. CPR, defibrillation, drugs, etc doesn't care whether it's an EMS provider doing it or an RN and techs doing it under direct order from a physician. Besides, no one has yet explained how transport changes the outcome in patients who do not have ROSC.

most of them no. There are a couple that work in the hospital, 1 in the ER. Most of them just see that its a kid and then think of there kids. Its sad tho that were almost done with the class and up to this point we really havent even touched on dead bodies in the field.....oh how I miss my old instructor lol

 

[abckidsmom]

I brought up this call in class. The entire class turned on me. The mothers in the class said that they would rather have the bill and know everything was done that could be. Personaly I still believe you shouldnt run an obvious death. I dont care who it is. But thats just me.

I'm agreeing with JP that the mothers your class don't understand the way that medicine works, and there is no difference between ACLS in the field and ACLS in the hospital.

Besides, if it doesn't happen in the first 10 minutes, it doesn't matter anyway.

I just would rather not be in the care of people who don't know what to do and say when dealing with a bereft family. I cannot overstate how hurtful it is as a parent to have a healthcare provider say all the wrong things during a time of loss.

I would always back up the people who transport the baby as an attempt to make sure they are not the ones who have to relay the bad news because they are not up to the task.