As a parent, there is no greater fear than the fear of something terrible happening to one of your children. You play-out that nightmare in your head every night when you peer through the wooden slats of your baby’s crib and watch their chest go up and down. Usually, you try not to let yourself think about it at all, but it’s not something you can turn off.
You live the nightmare when you listen to them breathe on the baby monitor and pray that you never wake to silence where tiny breaths should have been.
EMS affords parents like me a unique and troubling experience. It provides us the opportunity to live our own worst nightmare … while playing a different role. Tonight, Steve will be playing the role of lead paramedic. The unfortunate role of grieving parents will be played by … someone else. Tonight.
It’s simply one of the most surreal and disturbing things I’ve ever done, performing CPR on someone else’s three month old baby while my own three month old child slept quietly at home.
I told you that story to try to put the emotions involved in a pediatric cardiac arrest in some sort of context before diving in to this topic. I’d like to talk about a learning point that you may or may not have been told in your infant CPR training or perhaps even PALS.
“Just transport the baby.”
You may have heard that one before. If you haven’t you probably will someday. It’s an idea that’s been around for a while. It goes something like this.
If you respond on a baby in cardiac arrest, the best thing to do is grab the baby and exit the scene fast. Even if the intervention seems futile, the baby should always be transported.
The reasons given are numerous:
1. It’s easy to do interventions with the baby in tow so why not move fast.
2. You can be more effective when you’re not forced to work in the middle of an emotionally charged scene.
3. The back of the rig is a safer / more controlled environment.
4. Intubating and working on kids is easier on a pram.
5. Even if the resuscitation effort is futile, the activity will give psychological comfort to the parents by allowing them to believe that everything that could be done was done. (This one makes the list most frequently.)
6. Pediatric airways can be difficult to establish and maintain so a BLS airway should be maintained while the child is carried to the rig and the first intubation attempted while enroute to the E.R.
The “just transport the baby” rationale has been around so long now that it’s rarely questioned. It’s just the way we do things. That may be the best reason to question it now. That … and the fact that many of the reasons for immediate transport of pediatric cardiac arrests listed above are highly debatable. Some are just plain false.
I haven’t found it easier to intubate on a pram in a moving ambulance. I haven’t found scenes of pediatric cardiac arrest to be unsafe. I’ve actually had two very well organized pediatric resuscitation efforts take place on a living room coffee table and a center style kitchen island. I’ve also found kid airways to be more predictable than adults for intubation.
Having said all that, I can’t remember ever performing CPR on an infant or child and then leaving them on scene. I’ve transported evey one of them. Yes, even a few that could have been considered futile.
So why does the myth persist? Why have I, just like every other first responder out there, always insisted on transporting the baby?
Perhaps the training myth is more embedded in my subconscious than I would care to admit. Perhaps I couldn’t bring myself to look at two parents and say, “There’s nothing more we can do. We’re going to stop this now.” Or maybe it’s something else. Something very non-clinical and unsupportable with research and perhaps even unprofessional.
Maybe I transported those kids baecause I wanted to believe too. I’ll admit it. I wanted to believe that they still had a chance, the way a kid wants to believe in Santa Claus.
After all the rational arguments are done and the obvious conclusion is drawn, that we should stop resuscitation attempts on children when they appear futile, we are still left with that question. Who gets to play the role of the rational clinician? Who gets to say, “we’re done?”
I’ll leave you with these three thoughts.
1.) Some infants and children will meet our obvious death criteria and they should not be moved from where they are found. No resuscitation attempt should be made in the presence of obvious death. Period.
2.) Some infants and children will meet none of the obvious death criteria and a resuscitation attempt should always be made. No questions asked.
3.) Many of the infants and children you encounter will not fit neatly in to either of the above categories. They will fall somewhere in between. And you will have to decide. When it is your turn to walk that path, you will likely find that your clinical objectives and your human emotions come together in awkward conflict. It’s worth thinking over before the moment comes. You’ll need to decide for yourself what to do next. Such is the role of the prehospital caregiver.
Now it’s your turn:What do you think? Were you taught to always transport the baby? Do you? Should you? I wrote this post in tandem with Greg Friese of Everyday EMS Tips (Do you ever go through the motions?) and Chris Kaiser of Life Under The Lights. (CPR Theatre)You can click through and see what they wrote on the topic too. But before you go, I hope you’ll post a comment and add to the discussion.