More Voices on Family Presence During CPR

It's absurd how easy this blogging stuff is when you have experienced and articulate people who are willing to voice their thoughts for public consumption. This comes from Andy, an old friend and a current emergency-medicine resident. He was good enough to put this together in spite of the fact that I remain openly and abidingly jealous of his current assignment doing air medical transports.

Matt:

So, here is my less-inspiring, public-educated personal opinion on the subject.

Watching CPR being performed on a loved one can be absolutely devastating. Let's be honest. If you've done CPR on a real, dead human being, you feel the ribs seperating from sternum. Sometimes, you even get the full-on sensory onslaught of bodily fluids and gasses. They don't put this stuff on Sesame Street for a reason. Even so, the American Heart Association has advocated the early presence of family at the bedside for a reason.

Like Mary, I have recently started overseeing full arrests in the emergency department and when I first started, I was very hesistant to bring family members into the resuscitation. In these chaotic situations, I'm all about trying to control all the variables and bringing more people into the room just seemed like a bad idea.

Having seen more cardiac arrests and being more comfortable now, I try and think about what the family is experiencing. By that I mean most of what the general public perceives as real medicine is really nothing more than a patchwork construction of scenes from "ER," "Scrubs," and "Grey's Anatomy." Its a bunch of big-headed people with stereotyped flaws running around electrocuting and assaulting their loved one in distress. Worse yet, lay public seldomly understand that if CPR and ACLS hasn't worked by the time a patient gets to the hospital, the chances are slim to none that they will survive. Truly, what little more can a hospital do with a pulseless patient than hasn't already been done in the field? We push the same medicines and perform the same first-line interventions.

Anyway, that was kind of a tangent. So, to provide my own little anecdote. I was in the department in the other day and I took a radio call from local paramedics that were transporting a young Down's syndrome patient that was found face down in the pool. Mom started CPR and called 911. Needless to say, my stomach turned and I knew this was going to be hard. When the patient arrived, she was very cold and very dead. We warmed her and continued CPR and started giving medicines. The family arrived and I talked with them and gave them a very grim prognosis. They were in shock but I told them I would return with an update. When I got back to the bedside, there was staff everywhere and despite the exponential increase in the amount of care the child was receiving, her condition wasn't improving. At this point I dreaded the thought of bringing her parents to the bedside.

I went out again to give them the update and they were confused and unsure about what to do. I let them know that it was unlikely that we would be able to provide much more for their child. I could tell that nothing registered. They couldn't fathom the condition of their child. So I brought them to the bedside and even I couldn't take it all in. The ER tech, a 160-pound paramedic, was dripping sweat and nearly exhausted from performing CPR on a 30-pound body. Nurses were getting warm blankets and fluids. There were other residents rushing to start lines and administer medicines. I think this is when the parents understood. They saw everything that was being done to save their child. I can't imagine how hard it is to give up hope that your only child will live again, but seeing this amount of effort being amassed without any result had to have helped. After only a few minutes, the patient's mother looked to me and asked us to stop. All she wanted was for us to stop and let her hold her child.

Even for the medically trained, I can see how being secluded from the resuscitation efforts of a full arrest leaves doubt and confusion as to what else could have been done. Rarely have I had to fight family to terminate resuscitation efforts. CPR can be a traumatic event for families to witness. However, it gives an understanding that after a prolonged resuscitation - especially those with very poor prognoses - continued treatment is often futile and potentially "hurtful" for patients. It gives families a very good reason to let go and assist in the decision to continue or terminate efforts.

So, anyway, that's my take.

Family Presence During CPR- An Update

I'm surprised and excited at the great responses I got to yesterday's post. I appreciate all of the posts that people shared, from EMS providers and civilians as well.

I wanted to share a post from Mary, an old friend and one of my mentors in EMS. She epitomizes the term "black cloud," and is well on her way to becoming one of America's leading emergency physicians, but she was still somehow incapable of managing Blogger's "comment" function. (Just kidding!)

In all seriousness, thank you Mary for sharing this. She brings up an important point- not about whether or not they should be allowed to watch, but about whether we can make it a worthwhile experience by allocating a rescuer to explain the process to the family. I'll also be reposting some of the other responses I got later on.

I will start off with an anecdote of the last code I worked as a physician in the ED. It was one of those scenarios we all dread--where the pt starts off alert and talking to you and then just crumps right in front of you. He was a very pleasant gentleman who had cancer that had metastasized everywhere. However, he still wished for everything to be done, so as his heart rate dropped to zero, we started CPR. We all knew our efforts were in vain, so after we had intubated the pt and the initial craziness of a code being called had worn off, we brought in the family to watch.

As I did compressions, someone else was at the airway bagging the pt, and another doctor explained to the family everything that was going on and encouraged them to go up and hold his hand. After several moments, the son stated, "Look ma, look at his eyes. He's already gone."

With that, the family themselves were the ones who asked for CPR to be stopped and thanked us. It was by far one of the codes I have felt at most peace with because the family themselves were at peace with it and had closure as they realized everything that could be done was being done and they knew that despite our best efforts, their loved one had passed.

So, in short, I echo the previous sentiments that family should be present during a resuscitation, if they wish to be and if they are able to handle it emotionally (i.e. without being a danger or disruption to the staff). With that said, I do recall my previous life as an EMT and I realize that the ED is (relatively) less chaotic than the prehospital environment. It works in the ED because there is always an excess of staff standing around gawking and at least one of these people can actually be put to use speaking to the family. Resources are more limited in the field and there may not always be someone available to ensure the family members' well-being.

I feel like it would be wrong to have family feeling abandoned and alone while witnessing such a brutal and violent event, but if someone is able to talk them through it, I don't see why they shouldn't be allowed to be present, if the provider is comfortable with it.

Family Presence During CPR

The majority of EMS providers have experience, in one role or another, in providing real-life CPR. Anyone who has knows the following five things:

1) CPR is chaotic and often confusing, even for trained professionals.

2) It is a violent and ugly spectacle replete with torn clothing, cracked ribs and vomit. The patient's body is battered by tubes, needles and electrical shocks.

3) It has nowhere near the success rate that TV leads our patient population to expect.

4) Successful resuscitation in the field doesn't mean they'll survive their time in the hospital, let alone be discharged with the same level of neurological and physical function.

5) EMS providers often begin CPR without the faintest glimmer of hope.

Aside from following protocol, it seems we are often motivated to perform CPR in order to be able to look the patient's family in the eyes and honestly tell them, "We did everything we could." This has led to a real question, both within EMS and in hospital environments- should family members be allowed to witness the chaotic, technical and often nauseating moments that constitute the end of their loved one's lives?

There has a been a lot of qualitative research (or subjective, if you want to be judgmental) done on this subject. There's no real agreement; some medical professionals think it aids in the healing process, others think it complicates the grieving process unnecessarily. The same thing goes for patient's families, although few ever think about it until they're faced with the decision.

I'd like to post a couple different points of view on this, both from EMS providers and the general public. So...what do you think? Leave a comment or drop me a line on Twitter @squirrel325. I'm interested to hear your thoughts.

Your Patient Assessment Is A Matter Of Homeland Security

The title is true. America's national security could depend on your patient assessment and transport decisions. Here's how.

A good percentage of the time- maybe 30%, but it all depends on the day or the territory you're working- we'll arrive on scene to find a patient who doesn't want to be transported, or in some cases, to even be evaluated or treated. We've all got different terms for the form or procedure for allowing a patient to decline care, but I'll use the commonly-recognizable "refusal."

Most of our patients (at least, the ones who aren't frequent flyers) hold the misconception that the decision about hospital transport is mostly up to us, the EMS providers. But unless they've passed out or are exhibiting obvious cognitive impairment (alcohol, severe mental illness, head trauma, etc) it's really up to them to make that decision. So we're left in an odd sort of limbo- a patient with a minor complaint that doesn't appear obviously life-threatening being told the decision to go to the hospital is up to them.

So our patient has all the decision-making power, but not as much of the expertise. We've got the expertise, but in the field, we may not have all the information. It makes for a gray area, especially with those patients with minor complaints. Add to that the fact that on our end of the stethoscope, we're privately weighing a couple of different factors on whether to recommend transport. These include-

1) Enlightened self-interest. We want what's best for the patient, because we'd rather not have to explain our lack of suspicion that Grandpa's indigestion would later blossom into a massive MI. This is the exception to the rule, however; the majority of these on-the-fence incidents turn out to be nothing, and we'll probably face down a baleful glare from an overworked charge nurse. But from a purely risk-management point of view, if they call, we should really haul.

2) On-scene time. If our patient gets into a lengthy discussion with a significant other, a child, a caregiver or a recently-departed relative who they're SURE they see over their shoulder, our judgment may be clouded by the fact that dispatch is going to get grumpy about how long we've been out of service. We may be pushing the patient one way or the other, even subconsciously, just to get the call resolved.

3) Personal priorities. It's a lot easier to clear a call with a refusal than it is to transport to the hospital, fill out a patient care report, wait for a bed, give report and clean up the unit before returning to service. We may be hungry. We may be exhausted. Shift change may be right around the corner. It may be hot or cold and we just want to get back somewhere comfortable. We may not admit it, but we're thinking about it.

4) Hospital status. No one wants to take a patient with a sprained ankle or chronic constipation across the county because all the local hospitals are on bypass, or to wait on a nearby ED for two hours because they haven't got any beds available for your Priority 3. Patients don't like long hospital waits either, so if we say "You'll wait a long time to be seen," we're prejudicing them against transport.

Are any of these considerations bad things? Of course not. We're humans. But it helps to take an honest look at the factors we consider in the field beyond simply patient interest.

I would propose one other factor to consider. (Hauls out his soapbox.) Good patient assessment by EMS in the field will help our healthcare system. If we as EMS providers, ALS and BLS, bust our backsides to do a comprehensive, quality assessment of our patients, and document the hell out of it too, then we'll have a lot more support in making our decisions. That charge nurse may not be quite as displeased when we arrive, and if our patient refuses care for something that ultimately requires hospitalization, we have facts to back us up.

So why does this help the healthcare system? If we cut loose a truly non-emergent patient to seek help from their primary care physician or to simple recover without hospitalization, that reduces the strain on hospital emergency department beds and keeps costs down. If we transport a patient who doesn't look THAT sick, but manages to avoid complications due to early hospital care, we alleviate the strain on the healthcare network those complications would have imposed. EDs across America are swamped with nonemergent cases. If you can responsibly steer your patient to alternative therapy, you help- in a small way- to alleviate that strain.

In short, don't just transport because it's safest for your career and risk-free for your patient. A high-quality patient assessment is the best factor in your transport decisions, and it helps keep the emergency department prepared for true emergencies, like floods, disasters and terrorist attacks. And that's a homeland security issue. So get that second set of vitals- your country is depending on you.

The Siren Poll

Just added a poll to the side of the blog to gauge reader reaction to yesterday's post about using your audible warning gear during the nighttime hours. Please vote and feel free to comment, too- I'm looking forward to learning about everyone's experiences.