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September 8, 2009

Code 3 and a Rocking Chair

"Doctor's Medical Center, this is AMR Unit 12. We're 10 minutes out, Code 3 for pediatric drowning; four-year-old male found at bottom of pool. CPR in progress. We'll give more report when we arrive."

The radio report from the paramedic is already painting a bleak picture.

As I wait for the ambulance to arrive, I begin to mull over in my mind what I've learned about drowning. Drowning is always a tragedy, with several thousand deaths each year in the United States.

In my home state of California, as well as in several other states, drowning surpasses all other causes of death to children aged 14 and under. The U.S. Consumer Product Safety Commission reported that a swimming pool is 14 times more likely than a motor vehicle to be involved in the death of a child under the age of five years.

An additional statistic runs through my head: Nearly all who require CPR die, or are left with severe brain injury. Per the CDC, there are some predictors for neurological recovery. A study by Quan in the Journal of Pediatrics showed 100 percent neurological recovery in those patients who arrive conscious in the ER.

In the past, a big deal was made about fresh water versus salt water drowning. As medicine has advanced, so too has our understanding of the pathophysiology of drowning, and the differences seem to be less important than previously thought. It seems that the chlorine in pools can play a big part in the development of a chemical pneumonitis, but is not really critical in the first few hours of the resuscitation.

The pre-hospital management of drowning is fairly standard, although slightly variable depending upon the EMS system. It's back to the basics: Airway/Breathing – initially with BLS, then proceeding to intubation and PPV. Many EMS systems will routinely apply C-spine precautions, although actual spinal injury is usually only found in diving accidents. Drying the patient and checking the blood glucose are part of the pre-hospital management.

I find that the paramedics are often instrumental in providing details of the history that are important, including information about just how the accident occurred. Was there any suspicion of child abuse? Sadly, a not insignificant percentage of pediatric drownings are thought to be intentional. Additional details such as length of time in water, water temperature, and bystander CPR all play a part in the management of the drowning patient.

When the paramedic team arrives in the emergency room, CPR is in progress, the child is intubated, and interosseous lines are already placed. A quick report is given, and our own team begins its work.

As I do ACLS/PALS on the child, I review all the other possibilities: making sure the child is warmed, trying to correct the acidosis, NG, foley, and chest X-ray. The initial blood gas shows a pH of 6.83, a profound acidosis with a dismal prognosis. The electrolytes are essentially okay, with normal blood glucose.

Unfortunately, asystole is the only rhythm we get. The paramedic crews are staying near the bedside, unable to tear themselves away from this tragedy.

Social Services comes in to announce, "Family has arrived, what should I tell them?" In my mind, I already know the ultimate outcome of this resuscitation, but I also realize there is work still to be done.

I ask Social Services to bring the mother and father back to the bedside while we continue the resuscitation. I inform the resuscitation team, and a deepening quiet falls over them.

Mother and Father arrive by the bed. As they round the corner, I can't describe the look of despair on both of their faces. A wail of grief emerges from their lips, and I move in to talk with them. I tell them who I am, and that we are doing everything we can for their child. Despite all that I have said, I realize only a fraction gets heard. With tears in her eyes, the mother asks me to "please save my child."

"We are trying very hard to do that," I tell her as gently as I can. In my heart I know death has already taken this child, but my years of experience have taught me that giving the family an opportunity to see our efforts is a critical part of what is certainly going to be the beginning of a grieving time for them. I tell the mother and father to get close to their child, and to put their hand on the child. They do, and now they speak directly to the child, alternately begging and cajoling the child to live.

Additional rounds of medications are given while the family looks on. I cycle some new people in to continue CPR, and allow some of the others to rest. When I pause CPR, asystole remains on the monitor. The family sees that, and knows what that means. I have the team resume CPR, and stand by the family, giving them more time to assimilate the tragic reality.

In cases like this, I have come to realize that I have two duties – one is to the patient, and the other to the survivors. It quickly became apparent that my interventions were not going to save the child, and so all that was left for me was to help the parents with these last moments.

The resuscitation continues with no response to our interventions, asystole evident on the monitor whenever we pause CPR. With each pause, I am quietly telling the family that the heart isn’t responding. They already can see that, but my words begin to sink into their hearts, and I can feel the hope slowly drain from their souls.

Finally, I think the time has come. I look around the room at our team, and quietly ask each one if there is anything else they think we can do. They all respond, in an equally quiet voice, "No."

I then stand next to the family, and in a hushed voice tell them, "His heart isn't responding. We are going to stop now."

With the last vestiges of hope quickly slipping away, they ask, "Isn't there anything else you can do?"

"I'm so sorry, there is nothing else we can do," is my sad reply.

I signal to the team to stop. It's important that the monitor be disconnected quickly, since a rare beat may emerge from the dying heart, and may give false hope to the family.

Out of ear-shot of the parents, I tell each team member that they did a good job, knowing that all health professionals question themselves with such cases, often prompting the question, "Did I do everything right?"

The paramedic crew is still hanging around, so I go up to them and ask about the call. With precision, they review the dispatch, the scene when they arrived, and all of their interventions. I already know this, but they too need a chance to tell their story.

We find a rocking chair, let the mother sit in the chair, and hold her child one last time. Inside me there is some ill-defined ache, but now is not the time, nor the place to explore it. The paramedic crew gets toned out and races out the door, and I move on to see the next patient.

 

About the Author

Robert Donovan, M.D., FACEP, is an emergency physician working at a busy Level II Trauma Center in California’s Central Valley. He obtained his medical degree in Alabama before moving out west. In prior years, Robert has served as an EMS medical director and ED medical director. Currently, Robert is the medical director of PHI California, an air ambulance program, and still works full-time in the ER. Robert has a broad background in both pre-hospital and hospital medicine. To contact Robert, email robert.donovan@ems1.com.
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