Second Thoughts On...

[firedoc5]

There was a situation that might make some Medics give a second thought of what they would do. There were three boys, ages 10-13, who was caught shop lifting and ran out of a store. One was hit by a car causing a high spinal chord injury. I was on a coal mine call at the time so I wasn't there, but we were all effected. The first arriving ambulance had my "boss" and an EMT. The first thing Denny, the boss, did was notice the boy was not breathing and he started ventilations. The boy was immediately paralyzed from the neck down. To make a long story a little shorter, the boy was air-lifted to Cardinal Glennon Childrens Hosp. in St. Louis. I forget how many spinal fx. he had. But he was confined to a mechanical wheel chair with respirator and bed ridden at home, totally on a home respirator. We wound up having to transport him regularly back and forth to St.Louis which was a real challenge every trip.

The main point I'm meaning is that Denny tended to hint that he might have regretted starting ventilations and have let him go instead of being in the state he was in. Never really knew for sure how he felt, but I think he always had second thoughts of what his actions were that day. The boy did pass away about five years later from pneumonia. With all the activities with the family we actually became close to them. So it was a mixed blessing for everyone concerned.

[CBEMT]

I understand where he's coming from, but it'd be hard to justify legally in a situation like that. Yes, the next 5 years were hard on everybody and NO ONE deserves to live like that, but he could've lost everything for that decision . Our protocols pretty much put decapitation as the only criteria for not initiating resuscitation of a pedi.

[VentMedic]

At the scene one would not know level of injury, the extent of injury or permanance of paralysis. A spinal fx in itself does not alway mean permanent damage. A contusion to the cord can bring apnea which can even resolve in a few days, weeks or months or not.

While a quad's life span may be long, they can accomplish much during that time. Of course, it can also tear a family apart as well as bring them closer together.

I have worked with many quadriplegic patients as an RRT and it is very rewarding when I can decannulate some pts to where they will be free of the trach. Every patient is different and each will face their own unique circumstances their own way.

Every family is also different. Some may want a chance to say good-bye while there is still some life in their child's body and some may prefer that the child was killed out right without any chance for prolonged suffering. Of course, a family may not know what their preference is unless they have experienced such an event.

Also, if an EMT(P) did not do something at scene, they could also be charged with negligence if the injuries are determined to have not been life threatening by a Medical Examiner.

[Just Plain Ruff]

my question and of course this is armchair quarterbacking but the comment of upon initiating ventillations the child was immediately paralyzed.

Just how did the person doing the ventillations ventillate him? Head tilt chin lift?

If he was just hit by a car wouldn't you have held in-line stabilization and ventillate?

It's a question that needs to be asked.

[firedoc5]

my question and of course this is armchair quarterbacking but the comment of upon initiating ventillations the child was immediately paralyzed.

Just how did the person doing the ventillations ventillate him? Head tilt chin lift?

If he was just hit by a car wouldn't you have held in-line stabilization and ventillate?

It's a question that needs to be asked.

My understanding was he first attempted the "spinal in-line" mouth-to-mask and intubated ASAP. Denny is not the brightest bulb so I'm not sure how well he attempted to keep the c-spine immobile. Like I said I wasn't there, and the EMT with him really hadn't had enough experience to really understand the situation. I know the c-spine was compromised, but also upper t-spine was an "obvious multiple fractures". Not only was he hit by the car but ran over him and he rolled under as the car attempted to stop. He was also a "big" kid for his age, about 80-85 kilos, which didn't help much.

[VentMedic]

These situations are not easy but how much are you willing to play God? I have seen patients badly broken from accidents that pull through with few if any deficits.

Anybody here who has ICU experience, especially pedi, can tell you about some amazing recoveries. Of course, there is also the sadness.

Myself, I cringe every time I intubate a 90+ y/o during a code. Yet, I know I have a job to do and it is not my decision to decide who lives or dies.

[paramedicmike]

my question and of course this is armchair quarterbacking but the comment of upon initiating ventillations the child was immediately paralyzed.

Just how did the person doing the ventillations ventillate him? Head tilt chin lift?

If he was just hit by a car wouldn't you have held in-line stabilization and ventillate?

It's a question that needs to be asked.

In line with Ruff's questions, was the kid not breathing but still purposefully moving? And then ceased moving on attempted ventilation? I realize the OP wasn't there and this happened more than five years ago, but the set up for the scenario is a bit puzzling.

If that was, in fact, the case (movement up until attempted ventilations), I'd have a hard time dealing with myself after the call knowing that I probably didn't help this kid as much as I potentially could have.

I know this is a bit of a tangent, too, but 80 kilos on a kid between the ages of 10 and 13? Wow!

If the kid had been fully coded on scene, no pulse and not breathing, an argument could be made to not work the code. If there were movements or a pulse but no breathing, you don't have a choice. You work it. You don't get a lot of time to think about it. Once you make your decision, however, you're committed.

Tough call.

-be safe

[HellsBells]

I have pretty much the same question as paramedicmike, How did your supervisor know for sure that he caused this childs spinal damage?

[DwayneEMTP]

These situations are not easy but how much are you willing to play God? I have seen patients badly broken from accidents that pull through with few if any deficits.

Anyone see that show with the woman that had, I believe they called it an 'internal decapitation'? (Something on discovery, not sure what)

Man, the xrays showed her c-spine stretched out to about the length of a pony! But they went in and sawed, and screwed, and duct taped....or whatever they do, and she's now a fully functioning human being. (After about a gazillion surgeries.)

(Edit: My apologies if I lost some of you with the advanced technical descriptions and and complex mathematical and physiological terminology in this last paragraph. Feel free to Google the parts you didn't understand.)

My point being that if you'd run on her, (Can't remember MOI) you'd almost certainly have seen deformation of the entire c-spine, leading one (at least this one) to believe that there was no possibility for a positive quality of life outcome. Ooooops.

I agree with Vent....on an accident scene with very little vital information is not the time to play viability triage. And the one piece of vital information you need, that is never likely to be gathered on an ambulance is, "what will this patient's condition be 24/48/168 hours from now?"

I think in most cases, of this type at least, it's time to go to work and let the chips fall where they may...

Dwayne

[firedoc5]

I have pretty much the same question as paramedicmike, How did your supervisor know for sure that he caused this childs spinal damage?

Paralysis was immediate with the impact and rolling under the vehicle. Even though he was on a vent he could speak. He said that he remembered at first trying to breath but couldn't, or move at all, then everything "went black". It wasn't for a few months before he did remember. And the first x-rays showed the severity of the multiple spinal injuries which reinforced the immediate paralysis. It was a very complicated case.

And it did effect his family. Mom was too stung out, dad no one knows, and an aunt who worked at a nursing home as a CNA got custody of him but had to become a foster parent during his long stint in the hosp. I saw in the paper a few months ago that she passed away too. I knew she had a long hx. of diabetes. Like I said, we became close to the family. Some of the guys had gone by and played chess with him. Since he couldn't move he had to tell his opponent where to move his pieces. Very smart kid, too bad he was shop lifting. The other two boys were charged with it. They didn't him, needless to say.