“Just Transport The Baby”

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.

   

Related Posts:

Seven Signs That Say “Do Not Resuscitate”

Too Young For Opiates?

Assessing Dehydration

EMT Burn Management: Part Three

Comments

  1. “There’s nothing more we can do. We’re going to stop this now.” – saying that is probably the hardest thing any paramedic would have to do.

    The two main concerns I would have about transporting kids with no pulse is giving false hope and emotional pain being unnecessarily inflected on the ED staff.

  2. My wife and I are the proud parents of a 2 year old and a 4 year old. Over the last four years we have spent many nights awake as our children struggle with sleeping. As we lay in bed, blood pressure rising, listening to one or both scream, cry, yell, etc. I have often reminded my wife, “well at least we know the airway is patent, breathing is regular and slightly elevated, and a pulse is obviously present.” Perspective is everything. We are so fortunate to have 2 healthy children. I am thankful for that every day.

    Your reminder that little in medicine, as well as life, is black and white is appreciated. Envisioning what you might do in a pediatric arrest situation is a great tip. Also talking to others about their experiences. What they did. What they would do differently next time.

    Thanks Steve.

  3. They just transport the baby because it’s the easiest thing to do. “I missed the tube in the rig” “we were going so fast I couldn’t get a line.”
    in truth transporting a dead baby to a foreign er and inflicting emotional trauma on that staff is the worst thing you could do.
    Follow protocols, which often call for a discontinuation of efforts, be honest, be professional and let the family grieve in their own way, not ours.

  4. As a parent, I had many opportunities to startle awake and run to check the baby. Relief flooding through with a cleansing sigh, listening at the door, placing a gentle hand on the baby’s chest to feel the chest rise, these are normal things a mother will do. I am so relieved that we have six healthy children. Now my panic returns with a very distant grandchild. . . . and the fear is compounded. “What if…..” This unthinkable phrase wreaks havoc on my psyche. How would I want to be treated? How would I want my grandchild treated? I hope I never find out, but it gives food for thought, and careful consideration of all the options. It might be considered cruel to some, but I believe that ASKING is totally appropriate. What does the family really WANT? Almost 20 years ago an acquaintance’s two year old son drown in a public pool. Because they tried to resuscitate and the child was transported via flight to the hospital, the family was given some options. Because they agreed to bury their child within 24 hrs, no embalming was required by that county. They also released the body to the family and the mother dressed him in his favorite clothes, then rocked him all through the night saying goodbye. Would I be strong enough to help assist the family with these arrangements? Could I be a strong advocate for the grieving parents? Good questions. Great topic, thank you.

  5. Without doubt, the vast majority of paramedics view the sudden death of a child as the worst case scenario. There are a myriad of reasons for this being the case. Apart from the emotional maelstrom that it creates, there is the lack of familiarity with the situation. We all feel pretty comfortable at adult resuscitation i.e drug dosages, equipment sizing and protocol. If we are unsuccessful, we can rationalize the outcome to some extent e.g “oh..well, he was 85yrs old and we gave it a good go” etc. The same cannot be said for kids. Most of us, don’t feel comfortable in a pediatric resus because we lack confidence in our own ability. Stress is high as we frantically try to recall sizing and drug dosages during “scene meltdown”. Give me a bus full of hemophilliacs over a bank, who don’t speak English and are all HIV positive and pregnant anyday!!

  6. Excellent work by all three of you.

  7. Unfortunately, I have no ability to stop a resuscitation once begun. And our obvious death criteria specifically excludes lividity and rigor from being considered signs of obvious death in pediatric cardiac arrest.

    You could say we’re a little behind.

  8. I’m curious as to where on earth lividity and rigor are excluded from signs of obvious death?

  9. Here. ^_^ :-p

  10. I…guess that’s…helpful of you?

  11. Wish I could be more so. I hate dangling carrots, I know it’s aggravating. That said, I’ve paid a price in the past for being too specific with my location, and ergo my identity, while participating in online discussions.

    I’d probably have a blog myself if it weren’t for that.

  12. Sean Fontaine says:

    Steve et al, thanks for taking on this topic. I was always taught and have tried to teach others when given the chance that the best way to treat any patient is how you would best treat a family member in similar circumstances. Since, having had our two beautiful little boys I realize that even with that credo, I didn’t fully appreciate how to talk with and treat my young pediatric patients, how to help curb their anxiety, until I understood why my boys were afraid/anxious. Reading this helped me examine the fact that I’m in those shoes again; as a parent I haven’t lost any children to traumatic causes and obviously hope not to, but again I’m not sure if I can talk with those parents as competently as I would like regarding why I didn’t transport their child and have them fully believe that we did do all we could do in our resuscitation efforts before I made the call to pronounce their once joyous child. Great topic this one will stick with me for months.

  13. Steve Whitehead says:

    @Timothy Both valid concerns for sure.

    @Greg Thanks Greg, I really liked your contribution as well.

    @Happy “be honest, be professional and let the family grieve in their own way, not ours.” Great advice and I agree with it . but, by no means is that an easy thing to do. Of course, If we wanted easy work we could have been toll booth operators.

    @Kris, Thanks for sharing. I agree that asking is a powerful tool. I use it often when I’m working adult CORs. I’ve never asked parents what they wanted. I could see some benefits and some negatives to putting that decision on them. You’d need to feel out the situation.

    @Graeme I think the Broslow tape is a God send and I carry one with me. you bring up an excellent point about the complexities of pedi resuscitation. They certainly factor in.

    @Rogue Thanks Tim, I appreciate that.

    @CBEMT It really frustrates me to hear about protocols that prevent EMTs from using good judgement. Sorry dude.

    @Jameson, I agree.

    @ CBEMT I think Greg Friese of http://www.everydayemstips.com is looking for people who have protocols preventing them from stopping pedi CPR. I think he’d be very interested in your protocol. Send him an email.

  14. Steve Whitehead says:

    @Sean “I’m not sure if I can talk with those parents as competently as I would like regarding why I didn’t transport their child and have them fully believe that we did do all we could do in our resuscitation efforts before I made the call to pronounce their once joyous child. Great topic this one will stick with me for months.”

    It’s true Sean. It’s easy to take the high road and say … just tell them. But it truly is delivering the worst possible news you could ever deliver to another human being. It’s earth shattering. Right thing to do or not, it’s unspeakably difficult. And we should recognize that.

  15. Steve Whitehead says:

    As an addition, David Konig has an interesting dissenting opinion on this series.

    http://davidkonig.com/2010/because-its-not-all-motions-and-theater/

    Thanks David

  16. Wow……difficult topic. As a firefighter/medic who has had a child die, I have seen both sides of the issue. My 3 1/2 y.o son died in my arms on the way to the hospital several years ago…..that being said I have also participated several in pediatric arrests in my 21 years of EMS. My last one was an unsuccessful 20 month old that was ultimately classified as SIDS. As for this topic, I fall somewhere in the middle, I can appreciate the efforts of a provider that is not mentally or psychologically prepared to “make the call” and does all he/she can for the patient . I also appreciate responders who, in those RARE situations where there is absolutely no hope, handle it with professional tact and compassion.

    Death is the punctuation of every life and is not foreign to us as humans, we will all grieve and handle the situation in our own ways. You can never predict how a family or loved one will react to this tragic situation.

    My FD brothers handled a call a few years back (I thank the Lord I was not on this call, it was right after my sons death) where a four year old had his head crushed in an elevator that had the safety mechanisms disabled. His head was crushed, he was in arrest, but he had some agonal breathing. They did everything they could knowing it was going to be futile (his brain was hanging out the top of his head), they did the right thing. The mother stopped by a week later and needed to know that they did everything, this was part of her grieving. The fact is, when her son died, she then became the patient and the treatment of her son was, in reality, treatment for her.

    As care providers it is a fine line we all have to walk, as a rule if I have to err, I try to err on the side of patient advocacy and care. In the event of foul play or some other untoward circumstance, this may mean preserving the scene vs. resuscitation. I just hope I never have to make that call……

    Keep up the good work…..discussions like this keeps us all sharp.

Trackbacks

  1. [...] this question about “going through the motions” I invited my friends Steve Whitehead, theEMTSpot.com, and Chris Kaiser, LifeUndertheLights.com, to write on this same topic. They both graciously [...]

  2. [...] David at 7 January, 2010, 2:27 pm 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 [...]

  3. [...] a similar vein, Steve from The EMT Spot considers yet another point of apparent EMT dogma – a “rule” that is often taught to [...]

  4. [...] termination on scene, but because the cardiac arrest patient is a baby we feel the need to “Just Transport The Baby”, as opposed to performing “CPR [...]

Speak Your Mind