Crib Death

     EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. E-mail ideas to Nancy.Perry@cygnusb2b.com.

     It's about 8 p.m., and you've just finished the 12th call of your 24-hour shift. You haven't had dinner, you're tired and you're four charts behind. You wolf down a cookie and sit down to write the charts, but the alarm goes off again-this time for a child not breathing. Dispatch information directs you toward a new residential neighborhood, where it sounds like you have an infant in full arrest.

     Sure enough, an engine soon arrives on scene and the crew briefs you about a three-month-old who is apneic and pulseless. CPR is in progress. Cindy, your training officer, looks away from the map and grimaces in your direction without meeting your gaze. Damn! SIDS calls are nightmares, and, for a moment, you wish you could be diverted to just about anything else, no matter how difficult.

     In a blur of intersections and street names, you're on scene and reaching for the pedi-kit in your compartment. You trace Cindy's steps through the front door of a nice home and follow the sounds of a man and a woman sobbing hysterically. A fire captain is begging them to accompany him to the living room so his crew can do their jobs. The crew is performing CPR, but things don't look good. The child has the appearance of a brown wax doll. Without a touch, you can see that she is in rigor. Mom put her down after feeding her three hours ago and found her like this.

     The sudden realization of unanticipated death is an awful thing, and the sounds of it will never be far from the surface in your memory. There is no anguish worse than in parents who have lost an infant. No matter how it happens or how seasoned you get, these calls always feel brutal, bitter and perverse. Cindy checks the monitor and surprises you by casually pronouncing the child. "It's all yours," she tells a young police officer, and begins packing the gear as though this event is the most natural thing in the world.

     Q. Cindy is a much-respected paramedic. What's wrong with her head?
     A. Cindy shifts gears pretty hard, sure enough. Lots of experienced paramedics postpone their personal feelings about some things and sort through them later in their own best ways. Everybody's different. Certainly, she will share her thinking with you after the call or next shift. Now, although further resuscitation isn't warranted, your crew's work is not finished. This is a multiple-casualty incident, and there are two badly injured people in the living room.

     Q. There must be a better way to terminate a code. Isn't there?
     A. You bet, but every one is a little different. The captain made things easier for you by removing the family members. But whether they're present or not, it's a good idea to verbally go over the signs of obvious death for the first responders-walk them through the patient's color, apnea, pulse-lessness, cardiac rhythm, pupil signs, temperature, presence of rigor and so on. Then ask if anyone has a problem with you pronouncing; if not, verbalize and record the time. You should take responsibility for the ultimate decision, though, to keep them from feeling guilty later on. (It would be good professional etiquette to include the police officers, too; they're part of your team.)

     It's not absolutely necessary to remove the parents from the scene when you go through a sequence like this. The only thing you would do differently in their presence is direct what you say to them in addition to the first responders. In fact, if they're present, that's essential. Speak gently, and make lots of eye contact with both of them. It's not easy, but it's your job. Well handled or not, you can be sure these folks will remember your part in this night as long as they live.

     Q. Wouldn't it be better just to transport this kiddo to the hospital?
     A. You could. It's what we used to do in most systems-leave the dirty work to somebody else. But that prolonged the families' agony, subjected them to unnecessary costs, forced them to drive their cars under impossible circumstances, and did no one any earthly good at all. Incidentally, it would be a grave mistake to presume there are no siblings, or that this isn't a horrifying and confusing experience for them as well.

     Trust me. I'll never forget it.

Thom Dick has been involved in EMS for 35 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar414@aol.com.

Although the incidence of SIDS seems to be in decline, American children still experience the world's highest mortality as a result of this tragic anomaly (some 2,500 deaths every year). You can learn more about it at the American SIDS Institute's website (www.sids.org)