Practice (Revisited)

A comment and discussion on my previous post sparked me to revisit a post I wrote 9 years ago about the issue of working a body for the practice.

Practice

Here’s what I wrote back then:

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 have to start right this very instant, 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 may 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’s 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.

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.

***

Eight year older and thus eight years closer to the end myself, and with eight more years of these types of calls, I can say, I do not work cardiac arrests that are a shade over the line. Maybe it is because I don’t need the practice any more, but I think it is more a feeling of respect for the dead than maybe I had before. My heart says just leave them be. A couple weeks ago, I had three dead bodies in one day. Three souls who had passed on and who were beyond our grasp. On one call, the first responders were working the patient — a special needs patient who had passed in the night. It was a bit of an emotional scene, but she was dead, you could barely open her mouth because of the setting in rigor. Stop, I said, she’d dead. After running my asystole strip, we put her back in bed and then we all sat there with her foster mother who had nursed her from a baby when they all told her she wouldn’t live three months. Here twenty some odd years later she had finally come to her end. Her foster mother told us about how she had gotten her eat when they said she wouldn’t, the concoction she’d made for her with juices, tinctures and nectars and all the love in heart. She wondered now what her house would sound like without her daughter’s laughter that used to fill it up. We all told her of the respect we had for her and of our sorrow for her loss, and we stayed and helped her contact the funeral home and her pastor.

We could have tried to pry her mouth open enough to get a tube in, beat on her chest, and drilled her tibia — all just to work her for our sake and for the family’s sake. But I was more comfortable with the way it went down. We all were. It was the right way.

***

I guess some of it depends on how you feel about a body. When the person dies, is their soul released? And does all that made them who they were fly off? And is the remaining body then just inanimate? Like a stone. Or is it a memorial to the life they lived? To the lives we all lead?

If they are dead, I say, and they are not coming back, leave them in peace.

3 Comments

  • Tanner says:

    I agree completely with this. One thing I’d like your opinion on Peter is pedi codes that are obviously dead. I’m an AEMT and have only been in EMS for 1 1/2 or so. Had my first pedi code a few weeks ago. 3month old M had been put down to sleep around 6 hours before we got the call at around 4am so we weren’t sure how long he’d been unresponsive. A touch of rigor like you said with the big woman in your post and cool all over, but we worked him anyway. IO, tube, ALCS, all the marbles. But he was pronounced shortly after we got to the hospital. My partner told me that he works every pedi code. Even ones he believes are more than likely hopeless. He said he does this because it gives him a chance to do skills he doesn’t get to do very often, ie. Intubating an infant and such. In the hopes that it prepares him more so for the time when something may be able to be done for the child.
    What are your thoughts on this approach?
    As always great post, your writings have greatly influenced me in a positive as a young person in EMS and helped shape the type of provider I want to be over my career. I really appreciate what you do.
    Stay safe out there

  • medicscribe says:

    Pedi codes are tough. I have transported a number cold and stiff just because everyone was freaking out. I guess it all depends on your feel for the situation. I know in the ED they will work pedis long after everyone knows they are dead. Still, if I can avoid working someone who is already passed, I think that is better. But it is most often hard to avoid. A tough situation all around. I have written about this in the past I believe. i will try to go through old posts and see what I can find.

  • SueEdRn says:

    My dad donated himself for UCONN with the sole purpose of medical staff being able to learn. When he was signing the papers the staff told him that sometimes they are full and unable to accept his body. I think some people ask to go this route as it is a free way to have your body taken care of rather than paying for cremation (they cremate the body after staying there for one year and return the cremains to the family). Sometimes there are too many donations for one facility so they are transported to other facilities.
    Don’t feel bad or worry about using the body for your airway practice, say thank you. My dad was happy he was going to be useful again.

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