Pediatric Cardiac Arrest-Stay and Play

I just watched a fantastic and very thoughtful lecture of pediatric cardiac arrest given by Dr. Peter Antevy as part of the Refresh2021 free national registry program, which I encourage everyone in EMS to sign up for.

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 When I precepted as a paramedic in 1995, my preceptor told me when we had a baby code that we should “OJ Simpson” it.  This was in reference to the old OJ Simpson Hertz commercials where the former football star and future killer ran through the airport, leaping benches and cutting through the crowds like he was on a 100 yard touchdown run.  The point was, waste no time, get moving– that way we don’t have to deal with everyone freaking out at the scene, and we can get the baby to the hospital and do what we can on the way. 

My first baby code I intercepted with a basic ambulance crew.  No sooner did I climb into the back of the ambulance, then the driver hit the gas and I went flying.  When I recovered myself, I saw his partner and a police officer doing CPR on an infant.  I managed to get the pedi pads on the infant and stop CPR long enough to see the baby was flatline on the monitor.  By the time I got my intubation kit out we were already at the hospital.   I had done nothing to help.  I hadn’t even had time to get much of the story other than the baby  was found not breathing in his crib.  The BLS crew took off so fast, they even left the family at the scene.  They didn’t even have the kid’s name.  Later I was congratulated for not delaying the transport.  You had a one minute intercept time.  That’s awesome.  It didn’t make me feel any better.  If time was what mattered, they shouldn’t have even stopped for me.  I hadn’t done anything to save the baby and that was true.  I hadn’t.

Still I held to the OJ Simpson mantra even sharing it with new paramedics I precepted.  We get a dead baby, I told them, snatch it and make feet to the ambulance.  Intubate or try to in the back of the ambulance hurtling through traffic with lights and sirens blazing.  In the old days before EZ-IOs we had the Jamshidi bone needle which he had to twist into the baby’s legs while holding it down.  Not the easiest thing to do when you are airborne.

Now it is true in many of these cases, the patients were already dead.  Many times I have run down stairwells holding a dead baby stiff as a doll in my hands and giving mouth to mouth to its cold lips, running from the screams in the apartment.  In other cases they were still warm, and I moved my fingers up and down on the chest in between breaths as I walked carefully down to the ambulance, and then the race was on again.

It is important to understand the chaos on many of those baby code scenes.  People are screaming and out of their minds.  I remember vividly one of the first ones I did.  A mother had rolled over her baby while they slept together and suffocated her.  The baby was dead, but everyone was screaming at me.  The firefighters were screaming at me.  What the hell took me so long to get there!  Do something! Get moving!  And the crowds — it seemed nearly everyone who lived in the housing complex was screaming at me.  “Move, W-Boy!  That baby’s dead!  Do something!  Move!  I OJed it to the ambulance.  Even after we shut the doors, they banged on the ambulance until we peeled out.

Recently I had a baby in arrest, but this time I elected to stay on scene.  It just seemed like the right thing to do.  We cleared off space on the top of a dresser and laid the baby down.  We managed the airway, and epi through an IO.  We worked the child for at least twenty minutes with no luck –still asystole– before we finally decided to make our way to the hospital.  I felt terrible leaving like we had given up, even though I knew the baby was dead.

I have had very poor luck with pediatric resuscitations.  I don’t know anyone who has.  There are many reasons for this.  Many of the children were already gone, others had died from congenital defects.  I guess also, I was always taught that pedis once they arrest, they are nearly impossible to bring back.

I have been complimented on my calm at many pedi-codes but that calm came largely from knowing the baby had either died or had little hope of recovery.  We were just going through the motions.  I never thought for a moment the babies would come back.  I had never seen it happen.

Dr. Antevy, in his lecture, advocates that we treat pedis in arrest, not like pedis, but like little adults. (The dogma for years has been pedis are not little adults and need to be treated differently).  Not in this case, Antevy says. They deserve the same stay and play attention.  Work them on sight until you get ROSC or until you have exhausted every hope.  Explain to the family why you are not running off to the hospital, that you are making your stand there.  Use pit crew CPR.  Know your pediatric dosing in advance, so you don’t have to lay them on a Braslow tape and do your calculations.  Get epi in early.  

A number of years ago when we adopted the stay and play for adult resuscitation, I started having people come back who I had never expected to make it.  Good CPR, defibrillation.  Early epi at least if you want pulses back.  Kids deserve the same chances, not just in the ED, but in the field.  Stay on scene.  Defend your ground.  Take a stand.

Antevy also advocates improving local dispatching to help them be quicker in giving CPR instructions to 911 callers.  His lecture concludes with an excellent section on bereavement, making certain you talk to the family at the hospital, explain what you did and why, let them know you care.   Administrators should follow up with the family, even in unsuccessful cases, offering to attend the funeral and send memory cards on birthdays.  

I am great at explanations on adult scenes.  I let the family watch the codes.  I narrate what we are doing and explain everything.  If we get pulses back, I let them kiss the patient before we go.  And in those cases where we finally decide to stop if we are unsuccessful, I let the family members hold the patient’s hand and say their goodbyes before we stop. Afterwards I stay on scene awhile and make certain they are okay.  But with pedi codes, I leave the grief counseling to the hospital and make myself a ghost.  Never again. 

Thank you, Dr. Antevy, for the fine lecture.  I can’t say I look forward to practicing the lessons, but if my number is called to respond, I will do my best to demonstrate what I have learned.  I only wish I had learned those lessons thirty years and too many resuscitations ago.