Infant resuscitation in the ED

by VeronicaB, MD

A baby died today;  a very small infant.  One minute I’m excited by the end of my overnight shift quickly approaching, and the next I am hearing the words you never want to hear come over the radio, “En route to home for infant not breathing.”  I think the whole ED staff stopped for a minute waiting for the next report.

Then we begin to organize.  Prepare a room, grab the pediatric resuscitation cart, where’s the Broselow tape, get respiratory alerted.  The on-coming attending arrives, and I tell him what is going on.

The next report comes over the radio, “Attempted intubation, bagging via BVM, chest compressions ongoing, no IV access.  Five minutes out.”  Ok.  Grab the ultrasound, do we have the right sized needle for the EZ IO, call an overhead infant code.

The infant arrives.  One, two, three, gently over to the gurney.  Let’s take a look.  Intubation attempted.  Ultrasound shows no cardiac activity.  Temperature is 31 rectally.  The parents are hovering expectantly, holding onto each other tightly, watching our every move.  The other attending and I look at each other.  We know there is no hope.  We try to make our attempted resuscitation last as long as possible for the sake of the parents.  But soon the staff understands our motions.   We take one last look with the ultrasound.  Silent snow.

We turn to the parents.  They have a sense of what they’re going to be told before a word is even said.  They look around at us and our staff and see our eyes looking down, looking sad, tearing up and looking at them wordlessly.  Cries of anguish fill the ED.  The infant is gently wrapped and the parents are brought to the bedside.  We file silently out to give them their last moments with their child.

I go to dictate my last patient’s chart, stopping to hug the nurse who stepped into my work area to “get it together” before heading back out to the other waiting patient in the E.D.  She apologizes, and I tell her it’s ok to show her emotion.  She starts to shake as tears run down both of our cheeks.  She quickly recovers and steps out.  I take a deep breath, dial the familiar number, and begin my dictation.

VeronicaB is an emergency medicine resident who blogs at The Central Line, the blog of the American College of Emergency Physicians.  Reprinted with permission from the ACEP.

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  • http://www.drjshousecalls.blogspot.com Dr, Mary Johnson

    In situations such as these, I personally think that the jury is still out on letting parents “hover” and watch a resuscitation such as this – especially if the “attempt” is more aggressive than what you describe here – and it usually is.

    It is human nature (of most humans anyway) not to want to give up on a child.

    It’s also human nature for those of us who’ve managed these kinds of cases to need a little bit more time than we generally take to absorb/process what has happened . . . before we “shake it off” and go see the next patient – in the “factory” that modern medicine has become.

  • http://www.chrisjohnsonmd.com Chris Johnson

    I’m a pediatric ICU doc and I always encourage the parents to watch a resuscitation of their child. They actually participate, in a sense, just by being there. You do need to delegate someone to be standing (or sitting — have chairs handy) with them to explain what is going on; one of our chaplains or an experienced nurse generally does this for us. I also try to break away from the bedside at intervals to explain the situation.

    I assume from the time of day (early morning, end of night shift), the rectal temperature, and rest of the clinical scenario that this was a SIDS case. Those are always difficult. Even if you get a heart rate and perfusing rhythm back, the outcome is nearly universally bad.

  • http://www.lisafieldsassociates.com/ Lisa Fields

    Dear Veronica,

    Thank you for such a tender and profound post. While not an emotional person, I found tears streaming down my face. You did a wonderful job clearly describing the events of that evening.

    My former Husband is a minister and there were times when his voice would sometimes shake with emotion during some funerals. While it’s important to “get it together” it’s also important to be able to show empathy and perhaps some emotion during tragic situations.

    We had a close friend who is an ED Doc and I often remember him telling us how much he appreciated
    clergy and chaplains during situations like the one you described. I hope your hospital still has chaplains available for families and individuals in need.

    Again, thank you for this post.

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