Death & Dying in the Pre-Hospital Environment

“Our care is not over after our resuscitation ends.”

 

When the stakes are between life and death, do we care about family on scene? I think at large, we do not. “We have bigger fish to fry and life saving techniques to perform. I don’t have time to hold this old woman’s hand. I need to intubate, defibrillate, medicate, and suppress all of this in my memory in a timely manner. If she wants help, she should know to call family and leave me out of it.” Unfortunately, I caught myself thinking this as a new and scared to death paramedic. I let my fear replace my kindness. I let my focus on the task at hand overwhelm my sympathies.

A while back, my partner and I were sitting in a fire house and enjoying some recliners, when we were dispatched emergent to a residence for an unknown problem. It was a 25 year old man down. The man’s mother was on scene, and she made the call to 911. Once we arrived, I walked in to a familiar scene: My partner and I immediately knew that this was going to be an arrest situation. I started with what I say on every run: “Hi, my names Jeff. I’ll be your paramedic. What’s going on today?” The mother is pacing around the room and saying her son was eating and started choking. She couldn’t get the food out, and now she doesn’t think he is breathing anymore. “He’s in the kitchen. Follow me.” Sure enough, there’s an unresponsive, apneic, pulseless male lying prone on the ground. He has been down for approximately 5-10 minutes already without CPR being performed. At that moment, I do what medics do, and I clear the airway. I also direct fire to jump on the chest, my partner to put pads on, and we begin our resuscitation. I did two minutes of CPR, and the rhythm check showed asystole. I directed everyone to continue, and then I did the most important thing I could have done for that family that day: I walked up to the mother in the other room, and I asked her if she would like to watch what is going on.

I used the same practiced speech that I’ve told other families. Fortunately, it has become more fluid and less fearful over the years. I told her that her son did not have a pulse, and he wasn’t breathing on his own. We were doing everything we can to help. I told her that she didn’t have to watch, if she didn’t want to, but the option was there. I said that she could stay as long or as short of a time as she needed. The mother listened to me and sat in a chair next to us. She then spoke with us about her son. As we tried our best to resuscitate the man, his mother told me her son’s life story. She told me how her son had fallen ill. The mother told me how upset with life she was, and how unfair it was that her son was sick at such an early age. She was so afraid that this would happen. Now she feels guilty, because her son’s quality of life was so poor due to his disease.

As we worked on this woman’s son with no delay in care and no detriment to our work, she got to watch every ounce of effort that we put forth. She watched me intubate her son as I explained the need to protect his airway. She watched us repeatedly check to see if her son’s heart had started beating. I explained to her that his heart was in a complete standstill. She watched as we pushed all of the medication that we could. Finally, when the time came, I looked at her and said, “We aren’t going to get him back.” She believed me. She knew that we had done everything possible to try to save her son’s life. We were just too late. A man down with no CPR performed for 10 minutes has a very low viability, and an even lower chance of a good neurological outcome. The best thing that I could offer this woman, who had the incredible misfortune of watching her son die, is the knowledge that we exhausted all possibilities before stopping our efforts. This mother received a measure of closure that she would never have had if we had made her stay in the other room or simply not invited her in.

Every time that I try to explain why it is important that we invite families in to view our work, I get push-back. I believe that it mostly comes from a place of fear. I completely understand it, too. Every time that I invite a family member in a room when I have a critical patient, I have some level of fear. I do not want to make a mistake in front of the family. I do not want to look foolish or possibly get sued, because the family perceived an error that may or may not have even occurred. I work through the fear, though, and I invite them in. I do it, because the family gets closure. Being allowed to see what we are doing, helps to heal their wounds. The same way we allow mothers to hold their babies if they die in birth, allowing families to be a part of our resuscitation allows them to say goodbye, if the need is there.

Our care is not over after our resuscitation ends. It is our responsibility to then tend to the family. We can accomplish this by making sure that someone is there to sit with and provide support for the family. We need to clearly explain to them that we have stopped resuscitation attempts and their loved one is dead. We need to make sure we actually use the word “dead”. Depending on your local laws, police and the coroner are going to come and perform an investigation. After that, either the coroner or you are going to transport the body to the funeral home. This all needs to be explained to the family. As long as it does not interfere with the investigation, it is important that we allow the family to spend as much time with the body as necessary. It is also important to learn the person’s name and use it when referring to them with family members. Dehumanizing people can work for us as healthcare providers, but the general public does not respond well to it. After everything is said and done, it is now our responsibility to care for ourselves.

Being a pre-hospital care provider is hard. It can leave us emotionally crippled. We bear witness to the horrors of this world, and that can put a stigma on ourselves to the point of not talking about it. Show me a medic who doesn’t have demons, and I’ll show you a medic who either has great coping skills or the ink hasn’t dried on their license yet. We, as a whole, need to protect each other from the stigma of asking for help. If you have been in this environment for a while, more than likely you know or have seen someone from your area commit suicide. More than likely, they were suffering from depression and/or PTSD and were afraid to talk about it. We honor our dead, but then run away from our feelings, because it is a sensitive subject. We find humor in the terrible things that we see, because the truth scares us. We push our emotions down, and bottle them up where they can’t hurt us…yet. The time will come, though, when our bottles are full. When there’s nowhere else to hide our nightmares, they’ll come bursting out from the seams. So please, help your patients’ families, and help yourselves to cope with death and dying.

 

Safe Call Now – 1-206-459-3020

A 24/7 help line staffed by first responders for first responders and their family members. They can assist with treatment options for responders who are suffering from mental health, substance abuse and other personal issues.

Fire/EMS Helpline – 1-888-731-3473

Also known as Share the Load; a program ran by the National Volunteer Fire Council. They have a help line, a text-based help service, and a list of other good resources for people looking for help and support.

Crisis Text Line

A service that allows people in crisis to speak with a trained crisis counselor by texting “Start” or “Help” to 741-741.


About the Author

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Jeff Lee, NRP is an Indiana paramedic, ACLS/PALS/CPR instructor, NAEMT multi-discipline instructor, primary instructor, specialty care medic, and CISM officer.

 

*Some details have been altered to respect the privacy of all those involved in the above mentioned case.

2 thoughts on “Death & Dying in the Pre-Hospital Environment

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  1. Jeff, you have shared wonderful counsel. I am sure the helmet does lie heavy. I just want you to know that I too am very proud of you. My prayers are with you and your fellow first responders. Gramma Jane

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