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December 7, 2009
Pediatric Care in the Holiday Season
By Bob Waddell
As we rapidly approach the holiday season, it is important to remember that this is not always a "joyous time of year." For some, the holidays bring sadness because their loved ones are not with them, either because they have been deployed to serve their country, their economic situation doesn't allow a trip home, or their a loved one has died.
The impact is significant for many of us, yet I believe none suffer more than the parents of the child lost. As the adage goes, "Children are supposed to bury their parents. A parent is never supposed to bury their child." This season of joy becomes more powerful if we remember those who have lost a precious gift: their child.
When EMS is called to care for the critically ill or injured child who has already died or going to die during this time of year, the impact may be equally devastating for us as it is the parents. The responses can range from emotional to intellectual to visceral. There is no "normal" reaction; everybody reacts differently – from the hysterical fall to the ground to the catatonic non-interactive state. So how can we better care for our patients and their families during such an event? Here are some suggestions:
1. Approach the call location with all the same precautions used on every other call. Scene safety is cardinal to begin a well-conducted response. Just because the dispatch information includes the words "baby," "infant," or "child" does not mean the scene is automatically safe. Caution is the better part of valor.
2. "Rubber Up!" The standard BSI precautions must never be forgotten or ignored, again simply because this is a baby or child. The cause of this child's demise could be contagious. Take the appropriate precautions regardless. If there are any indications that additional precautions need to be taken, take them! You need to finish your shift and go home to your family without the probability of being infected or infecting your loved ones.
3. Conduct your primary and secondary assessments with same meticulous rigor you use for the most challenging case. Attention to detail, mechanism of illness or injury, environmental conditions, and pertinent medical history provide the foundation to develop a quality therapeutic care plan. The causes of death come in many forms; you cannot simply pick the one you feel might fit the situation.
4. Do not make any assumptions. The classic call is "the baby not breathing." Upon arrival, the crew finds the infant either in the mom's arms or in the crib, pale, cold, possibly stiff, and with a definite appearance of dead. As the primary assessment is being conducted, it appears that the infant has a small amount of blood-tinged discharge from the nose and bruising about the low back and buttocks. Child abuse is not an uncommon thought process. As the assessment continues, the questions race through the providers' heads of what MUST have happened to this child. How could the parents do this to their baby?
Even if the abuse scenario is downplayed, how could the parents not have noticed that the baby quit breathing? Make no assumptions as to the cause. Instead, focus on the therapy you're going to provide. Body language, words, and accusations of wrongdoing will haunt both you and the family for many years, especially if you're wrong!
5. If the Pediatric Assessment Triangle (PAT) indicates that this child is sick, your treatment and transport decisions need to be "quick." In this case, if the child is obviously in full arrest and CPR is employed, transport immediately. The concept of "I'm a paramedic and can provide all the treatments the ED can" is not only clinically wrong, but an extremely dangerous behavior to exhibit. If there is any chance of a successful resuscitation, the full medical team will need to participate.
EMS can keep the child viable, but does not have the knowledge, skills, or equipment to provide the longer-term critical care that will be required. As Dr. Lou Romig states when teaching Emergency Pediatric Care (EPC), "if sick, the make it quick." Remember that "quick" does not mean inadequate quality of care or ignoring safe transport practices!
6. Assess the child's ABCs! Failure to properly assess and determine the presence or absence of the ABCs can mean the difference between quality prehospital care and a disastrous event.
7. Confirm the presence of absence of circulation and perfusion. It would seem that this would be covered under the ABCs, but at times our stress level interferes with a proper assessment. Check central and distal circulation simultaneously.
8. Is there a pulse? Is there cardiac activity and if so, what is the rhythm? Conduct an EKG to determine if any electrical activity is present and as part of your documentation. Because children typically have healthy hearts, their ability to endure significant physiological events is well documented. Unlike the adult where resuscitation can be considered the artificial and mechanical means of restoring circulation in an otherwise ineffective or stopped heart, in the child resuscitation is "the prevention of cardiac arrest and termination of cardiac electrical activity."
Once the child's cardiac activity deteriorates to an asystolic rhythm, the potential for a positive outcome is minuscule. The successful resuscitation of a child is a prevention activity, namely preventing their heart from failing or arresting.
9. Determine if resuscitation measures need to be started, continued, or terminated. Local protocol and medical direction will dictate much of the decision. Remember that "MD" after the doctor's name means "My Decision." Some medical direction follows the philosophy that all children need to be resuscitated and transported to definitive care to assure the child is afforded every medical option the system has to offer. Others feel that if the child is obviously dead and the parents are accepting and acknowledging such, the provider should shift treatment modalities to the needs of the parents and other family members.
Another thought process is somewhere in the middle, where if the child is obviously dead yet the parents are not acknowledging or accepting the gravity of the situation, one should conduct "show CPR." Performing a full resuscitation in view of the parents, transporting the child to the ED, and allowing a physician to start the healing mourning process with the comforting words, "Everything that could have been done was done by everyone."
10. If the patient(s) are now the parents, offer them emotional support within your scope of practice and expertise. Maintain a professional attitude and answer any questions they have, again within the scope of knowledge and expertise. Making statements that are not fully supported by forensic science and medical knowledge should be avoided.
One example of an inappropriate statement would be, "There was nothing you could have done to change the outcome." If there is any potential wrongdoing or criminal act, misstatements could present legal process challenges. The reverse is true in stating something else could have been done or done better only to find out that the statement is not supported by the scientific or legal investigation.
11. Despite the emotional overload of the situation, a complete medical history must be obtained. What is pertinent? What may be relevant to other levels of the medical and legal investigation? All the rules of medical documentation apply, including the accuracy of the written report.
12. Never forget the siblings! The magnitude of the situation can create an environment of only focusing on those we feel needs our intervention. This inadvertent tunnel visioning can negatively impact others equally close to the child as the parents. Failure to address the needs and concerns of the siblings may cause them years of emotional and psychological distress. If the sibling is a young child, extra attention needs to be provided to them, including the opinion of professional counselors.
One of the worst statements anyone can make to the sibling of a child who has died is, "I know how you feel," or "I understand what you're going through." Unless you have lost a sibling, you don't know how they feel or what they are experiencing. Be supportive, yet stay realistic. Tell them you feel sorry for their loss, express your condolences, and keep silent then stop trying to say the right thing! Silence often is the best sentence spoken.
The death of a child is never easy, it is never understood by their loved ones, and it is never something that parents anticipate. As adults, we don’t understand the impact that death has on our intellect or emotions, so how can we expect a parent, sibling, or other loved one to do so? Parents are supposed to bury their parents or grandparents — not their children. Keeping that in mind, we're able to provide the best possible care available with the objective of creating a positive outcome.
The outcome is not necessarily connected to our treatments, but if the treatment is incorrect, the outcome is predetermined and poor. As one who lost my sister to a medical error and dealt with my mother being murdered by medical errors, I am one who knows what it is like to watch my parents bury a child and for my siblings and me to lose a sister. As callous as it may sound, the dead child is dead. It is the other children that need your clinical expertise. Enjoy the joys the holiday season brings knowing that you treat the living and show reverence to the dead.