Pediatric codes

[dousaems]

Okay, here's the scoop - you go on an MVA call, another medic unit gets there before you do. They state they have a DOA, and two minor injuries. You get there, and find out that all three victims are minors (under 18) and that the DOA is early teens. The other medic tells you the injuries are "incompatible with life", yet there is minimal damage to the vehicle considering the wreck. The other medic will not let you near the car. Is there something wrong here?
First off, I have always operated under the premise that unless they are decapitated, kids get the whole 9 yards and then some. Kids can rebound from pretty decent injuries, and although they may not be perfect, they can still have a good quality of life.
Second - Although I did not see the patient, I was told is was only an open skull fracture. Someone said there was brain matter all over, but I did not see any when at the car.
So does anyone have any clearer protocols than I do about resuscitating traumatic kids? Maybe this is more about what someone else would have done, but ours protocols state that we work trauma arrests unless the injuries are grossly fatal.

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Todd Dousa
NREMT-P, CCEMT-P

[Quint1Medic]

Okay, let me play devil's advocate:
The other crew didn't let you near the car because they didn't want rubbernecking, not because they didn't want to be second-guessed. Regardless of how much obvious damage there was to the car, it wouldn't have caused a potentially fatal injury if there weren't some sort of serious mechanism going on.
As for "grossly fatal," what sort of patient outcome do you expect if there was brain matter all over the place? If you didn't go near the car, then you didn't really have a chance to see if that was the case or not. Also, I could split someone's head in half with a meat cleaver, and it could still be described as "only" an open skull fracture. Everything is relative!

[dousaems]

Well, I have to agree on the rubbernecking thing. However, I ended up down at the car within 15 minutes of arriving and there was no brain matter to speak of. Sure, there was "a lot" of blood (not in my opinion), but it's just the fact that she was not worked. Not that I expected to save her, however, I thought it warranted a chance. Aero medical was enroute and was cancelled. We sould have tried until we had medical direction to call it.
And not that I hold grudges, but this medic has already been decertified once a few years ago for failure to act on a cardiac arrest. I've been doing this for ten years, and I have never seen such unaggressive medicine. Maybe I get aggravated over non-aggressive people.
But the question still remains: How aggressive are your protocols regarding pediatric arrests? Not necessarily traumatic, but I'd be interested.

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Todd Dousa
NREMT-P, CCEMT-P

[Trauma_Dog]

First of all I dislike doing this because I like to hear both side of the story, with having said that here I go. I think the reason that you dont see a protocal for work vs dont work is that there is a wide array of grey area here ie different causes and such. Second, everyone, let me say it again,EVERYONE should get the same level of care,YOUR BEST. From adults, kids and grandmother we should all be treating them to our highest level of ability.

I was wondering if you had talked to the medic incharge about this subject and letting him know you concerns. Do you guys belong to the same squad and do you have simular certs? Just seems to be some friction there.

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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[dousaems]

We have protocols for adults for not resuscitating obviously dead, or those that fail to respond to initial ALS therapy (electricity and first round meds). And I beleive everyone gets the best care, always have. Just kinda tears one up when it's a kid. And I can understand wanting to hear both sides, but I doubt we'll ever get more than "injuries incompatible with life." There was no elaboration on that subject.
As for the other info, no we are not on the same squad, and there may be a bit of friction, but I guess it comes sown to being a perfectionist.
I think we all try evrything we can for all patients, but I think kids change the scenario sometimes. We work SIDS babies all the time, which is different than an adult protocol (excessive down times). It just seems that there is a bit of difference in the "unwritten" protocols.


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Todd Dousa
NREMT-P, CCEMT-P

[Quint1Medic]

I don't have a protocol book at work, but let me see what I can remember of our "don't bother trying" list:

-Decomposition
-a valid DNR
-rigor/livor mortis
-injuries incompatible with life (the protocol goes on to list possibilities, e.g. decapitation, 100% full-thickness burns, etc)

All of these, obviously, need to be accompanied by a lack of vital signs except the DNR.

I don't think I've seen any "work/don't work" protocols specifically aimed at pediatrics, other than the old one about working SIDS babies no matter what (the trend now seems to be not to work them if they've obviously been down a long time). As far as aggressiveness goes, it seems to me that the difference in the level of effort put into peds resuscitations is an emotional one, not anything related to protocols.

[This message has been edited by Quint1Medic (edited June 16, 2000).]

[BURNSEMS]

We are only First Responder capable here ( ALS Level), Our Med Unit comes from a town 13 mi away,, We work them where they Drop,, We have very specific guidelines, Decapatation,Lividity,Gross Body Injury, Rigor Ect,, we have worked a few Pedi Trauma Codes that have had severe Head injury,, even exposed Brain Matter,, Why,, well by our Med Control that may not be concidered gross Injury,, people has survived with much worse, and why not give a person the benifit of the doubt,, I am not God and I cannot tell thats persons future at that point,, however what I can do is my Job,, Provide aggressive competent Patient care to the best of my ability and within my standard of Care,, I would only hope if it was me or my Child that a EMS provider would do every thing possible, just the family knowing that something was done may be a piece to help the grieveing process,, Yes its a Fact that 95% of Trauma Codes are futile attempts,, but I wont ever have to worry about "what if" and unfortunately I have had a few Partners that were just Lazy and working any Code unless witnessed was just to much to ask... Go figure.

[FFD#60]

I would have to agree with TRAUMADOG. Again, not hearing both sides of the story. It would appear that the issue is more of a conflict between yourself and a coworker. To be professional and to give the best patient care possible a person must be able to put aside feelings and do the job that is required. The scenario itself sounds interesting. And trust me i've been there when you can't actually see the patient and another crew has decided not to at least try. It can be frustrating. But this is EMS and we are put in wierd positions that make us all at one time or another feel as if we need more to do more with.

Take it easy and slow and do it right the first time. Just one of my own feelings.

[de_fibber]

first off,whats this have to do with pediatric codes?secondly,a medic won't let another medic near an accident scene?you guys better get your **** together.

[medic3401]

The protocol that we use where I work (www.co.wake.nc.us/ems/protocols) states that ANY patient with major blunt or penetrating trauma with no signs of life upon initial examination (no respirations, no palpable pulse) is to be considered deceased and not to be worked. Even if first responders have initiated CPR and we arrive and determine that the above exists, we are allowed to contact medical control and DC efforts.

I believe in giving everyone the best chance of survival but I also believe in being realistic. The chances of a pt surviving that is in cardiac arrest from a traumatic event outside of the hospital is 0%. I believe that the main reason obviously deceased patients are worked in the field is that it's difficult to be the one to say that someone is dead. That's why the doctor's get paid the big bucks, right?!? I am guilty of it myself, but am trying to get better about it. Also, (and I know this is not the case here) it's very difficult to deal with family members when you are the one saying their loved one has died. Especially when it's a child!!! As someone else posted earlier, they are trying to get away from working all SIDS deaths because they don't want to give a false sense of hope anymore. Something that would help us with this difficult aspect of the job would be training on dealing with families when they have lost someone they love. I don't know about everyone else, but I have never received such training.

To get back to the question, our protocols are not age specific in this case. They relate to any patient. Also, everyone will have a different opinion but I believe that someone without signs of life with an open skull fracture is dead and working them gives them no better chance of survival.

[This message has been edited by medic3401 (edited July 15, 2000).]

[This message has been edited by medic3401 (edited August 06, 2000).]

[HossMedic]

Once again, It's tough to post a reply without hearing both sides of the story. However there are two issues at hand that sound as if they had been forgotten.

Issue #1 - Was this a crime scene. If this was a crime scene, perhaps this individule didn't let you near the auto because he didn't want the crime scene disturbed before PD had a chance to do there investigation.

Issue #2 - This sounds like it was a scene that required Triage skills. If there were multiple patients (Sounds like there were) perhaps this patient didn't recieve resusitative efforts because there wasn't enough resources on hand. First rule of triage is No airway, breathing, or pulse move on to the next patient.

Just another opinion.

[MemphisSNK13BFFP]

I have to reitterate that one can't pass judgment without having heard both sides.

It sounds like triage was the task at hand.

I can see the rubbernecker thing, but it is peculiar to me to restrict another one of your service's medics from briefly assessing the scene. We're all on the same team. Let's work together.

[fjbfour]

I know two people, personally, that suffered open skull fractures and survived. One was walking and hit by a drunk driver, was clinically dead on scene. Today he has a metal plate as part of his skull, has some mental challenges, lost all of a leg, spleen, and other various major physical damage is evident, but he is no vegetable. He lives on his own. The other was involved in an MVA as a passenger, thrown through windshield into a tree. Half of his face was reconstructed, there is no eye socket on his left, has some speech difficulties, but also lives on his own. His face was pretty much ripped off and facial structure smashed but I don't know if he was lifeless at the scene. He also lives on his own.

I'm not promoting the false-hope idea, nor am I saying you should change your "dead" criteria for triage, but in the case of enough resources on scene, it's always worth a shot.

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Frank Billington, #11
Town of Superior Fire Online (http://superior.isonfire.com)

[spunk639]

Traumatic Arrests usually don't do well on the remote off chance you get them back what do you get back. Lets figure the pt is acidotic post arrest, how long between the other crew not working the pt and your arrival, Ph is probably 7.0 or less, how many no signs of life in the field have come back at a Trauma Center to have a viable out come in 12+ years I haven't seen any. You put everybody at risk transporting a dead person lights and siren over city roads for what. Lets say you get them back now what if they have been acidotic that long 24hrs later are they in ARDS. By all means if you witness the arrest or BLS does work it but this sounds like an issue between you and the other crew.

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REST IN PEACE
NEW YORK CITY EMERGENCY MEDICAL SERVICE

1869 - 1996

[dousaems]

After seeing many of your responses, I will admit that there was obviously a conflict in treatment styles. ALS was on scene within 10 minutes of occurrence, but it is true that it would have been a prolonged transport time (out in the sticks). We had three medic units to treat all of the patinets (three including the DOA), so we had resources. But again, it is very likely that this patient could have been a donor if nothing else. I guess what the issue boiled down to was the question of why do we work patients with unknown down times versus fresh traumatic patients, especially in peds? Maybe this is a jurisdictional thing, but that is the point of the discussion that was intended. I have appreciated all of your comments folks!!

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Todd Dousa
NREMT-P, CCEMT-P

[Throwfoam]

We don't recusitate (sorry attempt) any traumatic arrests, unless they are penetrating in nature and not blunt trauma. Even then it is EMT-P discretion. Even then we just plug the holes and squeeze the bags. Of course we work any blunt trauma codes that choose to go "T.U." in the back of the bus.

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Yugo Wego

[DCFyrMdc]

Okay, this should open the can of worms, but so be it....

Even if injuries were incompatible with life, pediatric trauma arrests should be worked (in my opinion!)....will you get the child back...no, but you will do the following things.

One, the other patients in the vehicle will see you doing something. You aren't giving up on what is probably a frien and to a certain extent our "public relations CPR" helps treat other parts of the patient -- bystanders/family/friends.

Second, you may extend the life of a number of people (kids) by working "non-viable" patients, byu getting the trauma arrests to Level I Trauma Centers that have transplant units. I hate to sound cold, but, where else do you get pediatric organs for transplant from?

Rubbernecking sucks and with limited manpower in a lot of places sometimes you have to triage, but in the case of kids and trauma arrests -- it seems to me a good effort to try.


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Christopher Suprun
Firefighter/EMT-Cardiac
Dale City Vol Fire Dept.
www.dcvfd.org

[firejunkie99]

I have to agree with DCFYRMDC on this one.
ANY pediatric codes, trauma or medical, in my opinion, should be worked. You may get the
child back, and then again you might not.The point is, you work the code, and everyone sees you trying your best. This includes family, friends, and bystanders. If they see you attempting to resuscitate, they know you care about what has happened. We all dislike
working pediatric codes/trauma, but we at least have to give it a shot.

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[AXMAN620]

BOYS IT SOUNDS TO ME THAT YOU ALL JUST HAD A LITTLE PISSIN' MATCH! I HAVE BEEN AN EMT FOR OVER 10 YRS. AND A MEDIC A LITTLE OVER THE LAST ONE. IF I PULL UP ON SCENE AND ONE OF MY MEDICS SAYS ITS A DOA, ITS A DOA! WE HAVE TO TRUST EACH OTHER RIGHT WRONG OR IN- DIFFRENT. HOW ARE THE PEOPLE WE SWEAR TO PROTECT SUPOSED TO TRUST US WHEN WE CANT TRUST EACH OTHER? http://www.firehouse.com/interactive/boards/smile.gif http://www.firehouse.com/interactive/boards/smile.gif http://www.firehouse.com/interactive/boards/smile.gif http://www.firehouse.com/interactive/boards/smile.gif

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SEE YA' @ THE BIG ONE!

[This message has been edited by AXMAN620 (edited November 01, 2000).]

[emt_98]

We were always taught do not try if ther are no signs of life and "if they're cold and dead." Otherwise everyone needs to be worked on until called at the hospital or per medical conrtol w/ telemtry showing no signs of life in all three leads and they give permission to call it enroute to the hospital.

[dsmedic]

I think you should refer to local and state protocols regarding do not resuscitate orders. The emphasis on trauma in the pediatric population is getting a lot of attention presently. Our service uses current PALS guidelines and we will be implementing the PEPP Course into our protocol in 2001. I agree with other responses regarding appropriate triage and the issues of working together and making positive decisions in the best interest of the patient. When in doubt seek supervisory judgements or on-line medical control. Keep up the good work....

[Lewiston2Capt]

I too would like to hear both sides of the story, but here are my two cents.

I agree with dsmedic,local and state protocols should be checked first. In NYS where I work the criteria for pronouncing on scene is Rigor, Lividity, asystole in 2 leads, or, Injury incompatible with life or DNR/Health Care Proxy. Because the Injury incompatible with life can be a grey area (as we have observed here) I prefer to work the code until Medical control has been contacted,an accurate objective assessment provided, and the authorization has been given to pronounce. However I am only an EMT-I and do not have any access to provide drugs, but to the best of my knowledge in NYS cardiac drugs are not in the protocol for traumatic cardiac arrest. If I am wrong let me know.



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Shawn M. Cecula
Captain
Lewiston Fire Co. No. 2