Practice

My preceptee needs a code. He probably needs a couple. He hasn’t done one as a medic yet. He’s intubated “ Fred the Head,” but mannequins just aren’t the real McCoy. While managing a cardiac arrest is about more than just intubating, a medic needs at least one intubation to get cut loose to practice on his own.

A week ago we were called for “a fall, not breathing,” then updated that it was a dead body with no one doing CPR. When we got there, we found a four hundred plus pound woman face down on the carpet in front of her motorized lark. She was just a big blob of flesh. You couldn’t even see her face. It took a moment to make out where it was. We rolled her over, and quickly assessed her. She was in the gray area between being dead and workable by protocol and being dead and not workable by protocol. In either case, she was dead and not coming back. Asystole in three leads, unknown down time. Warm, but with a touch of rigor perhaps in the jaw, a touch of lividity.

Many things go through your head in the split seconds that you have to decide to start CPR or withhold it. If you are going to start, you havetostartrightthisveryinstant, but if you aren’t, you obviously have all the time in the world to do nothing but call the time.

Here’s what went through my head (as my preceptee looked to me for direction):

She’s dead. I have a preceptee, my preceptee needs a code, but she’s dead, plus she’s huge. No neck, difficult tube. It might take us awhile to get the tube, much less find her sternum to start CPR. Damn, she’s big. We do need a code. But she’s not coming back. Getting a tube in her would be a feat. My preceptee might have a hard time. I would have a hard time, but getting a tube in her, that’d be a feat. I’d be the man – but who would I show it too other than my preceptee and my partner. Look at me, I got a tube in her. She surely isn’t going anywhere. We’ll work her for twenty minutes and call her. We’ll probably break her sternum, and who knows what make come out of her stomach, and maybe we’ll chew up her throat and break some teeth trying to get a tube into that jaw and mouth. All for what? Valiant effort. She’s dead. Let her be. There’s enough stiffness in the jaw to call it. Give her her peace. Her dignity. No, we should code her. No, no, she’s dead.

“No, no,” I said to my preceptee. “She’d dead.”

***

That call and a comment I received on this blog set me to thinking about the subject of “practice.” Practice on bodies.

Another medic told me about a medic he knew who told him when she was precepting after she brought in a code, which was declared dead at the hospital, the doctor pulled the curtain and let her practice intubating the deceased patient. Perhaps the doctor said, “He’s all yours, Go nuts!” He said she got an hour practice before they came and took the body away.

This is not the first time I have heard of this happening. It may not be common, but it is not unheard of. The theory is practice on a dead person may save a live one someday. Along with that goes the belief that the dead are dead.

I was on a call where a paramedic worked a code for twenty minutes, and then presumed the still asystolic patient. Then with no bystanders in the room, he extubated the patient, and then let the partner, who was a paramedic student, intubate the dead man.

(On a slightly different issue, I know another paramedic who let his partner, a paramedic student intubate a working code so he could get some practice. He did it successfully on the first try, but because he wasn’t functioning as a paramedic student at the time, a member of the crew backing them up complained, and they were both suspended. Another time a medic let his partner, a paramedic student, do an IV on a code when he couldn’t get one. The partner got the IV, and together, they saved the patient. A member of another crew reported him to the state and he nearly lost his license. You can only do paramedicine when you are working as a paramedic student, not when you are working your regular EMT shift.)

Matters are grey for some, black and white for others. While I might not cross the line in the cases above, I wouldn’t feel comfortable reporting it to authorities, either.

I have been considering taking an airway class down in Baltimore where you get your own fresh cadaver to practice on for the day. There is a disclaimer, something about you may have to share a cadaver in the event of a shortfall in supply. They don’t know in April, how many cadavers will be available on a certain date in November.

I suppose they get them at the city morgue – people who have checked organ donor on their license plates.

Maybe its okay then, if after checking the patient’s wallets for organ donor status, for medics to practice on them – to do extra intubations after the code has been called or to work them even though they are pretty much dead. People could have a DNR that says, they can be coded, but you have to stop after twenty minutes no matter what the outcome and let them go back to the shadows, the dying light.

***

It all leaves me…uneasy.

6 Comments

  • Steve says:

    I hate to sound so cavalier about it, but the saying “what happens in Vegas, stays in Vegas” comes to mind; If it’s not going to harm the body,if there is no family to object and if it will help an aspiring medic to hone his or her skills so that they might save more lives, I see no harm in it.I would have no problem with someone doing that to me, so long as it was to save the lives of others anyway. But I suppose it goes against all the moral and ethical considerations EMT’s & Paramedics are supposed to have, doesnt it?They really ought to have a box on a donor card application where you can specify something like this.

  • southpawmedic says:

    I agree with Steve as well on his comment! If it is to hone skills for a student and not just so they can say “I got a tube”, then I don’t see much harm in it either. It’s a difficult decision to make. Also Peter…I tried emailing you to check you my blog as well but your email kept saying undeliverable. check it out…www.paramedicdays.blogspot.com

  • Anonymous says:

    if you haven’t read “stiff”, you should – a great book on dead people. might be more food for thought about practicing on them.

  • Anonymous says:

    I live near two teaching hospitals. All the professions that intubate, CRNA, Medics, and MDs rotate through surgery to get their tubes. I know that it’s only a matter of time till I’m at a call and someone says, “Well, you want to try the tube?” and the person is dead. But I guess I’m still not convinced of the necessity of it. As long as there’s a more experienced medic, why not let the junior medic try the tube on the living and then if they miss the first shot, let the other medic try?I’d have a hard time, as a junior medic, saying no to someone more experienced, particularly if I needed more experience with the tubes. But jeez, I’d be less worried if I could really get 95% of the real thing in surgery, and take my other 5% as needed.The medics and nurses that work on the fixed wing and rotary wing aircraft in this system are required to get a specified number of tubes per month, as it’s a perishable skill. To achieve this, they routinely scrub into surgery if they’re lacking in the field. It’s not the cold dead bodies they work on.In a sense, I stil think about the whole patient advocate thing. They might be dead, but they’re still my patient. By tubing them a few times, am I being a good patient advocate? Some would say yes, but for future patients. I don’t know what I think.

  • CB says:

    Not the most terrible idea ever to come out of EMS/medicine, butif you have a protocol that states all tubes and IVs must remain in place if the code is terminated (both in the field in the case of a verified DNR after efforts are begun, and in the hospital after the patient is pronounced if transported), it’s much less grey, unfortunately.On the other hand, as long as “the tube is in place” when the body gets picked up, and an intubation was documented as part of the call, then….

  • Anonymous says:

    I am a military EMS/CPR/ACLS instructor, and I would love if what steve said would work in practice.Personally, I’m trying to get some practice in. I can take Ned for a spin whenever I would like, but it’s not the same. And, if I were in your position, I would go through the same contemplations.It’s tough as hell teaching. We’ve got unreasonable expectations to live up to.

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