Resuscitation: Nuremberg

This is not a story of heroism.

Danse Macabre by Michael Wolgemutin

People stop you and thank you for the work you do, they tell you that you are a hero, that you save lives, how you are doing God’s work and that what you do is just and right and good. You politely shake their hand and tell them you are just doing your job. Some days you can barely stop yourself from telling them that you are a god damn fraud.

Once, you believed the world to be black and white; assured that you would be able to decipher right from wrong.  You were more idealistic then, perhaps even naïve; you thought saving people from death would always be the right thing to do.

You walk in to a trailer; there is a pale ghost of a woman in a chair. That lack of lung sounds that the first responders told you about when you walked in the door, well, technically dead people do not have lung sounds. Had you taken more time to get here, the decisions would be easier, you might have even been able to do the right thing if you walked through that door five minutes later.

But this is what you wanted, isn’t it? To save lives?

She is on the trailer floor now. Your coworkers are slowly getting things out of the jump kit, making preparations for what is to come. A brief moment of hesitation occurs, everyone is silent as you ask the husband if she has a DNR, he stumbles over his words, he does not know. “She doesn’t want to be kept alive on machines…I know that” he tells you. You push him a bit harder, needing an answer. “She is not breathing right now and does not have a pulse; do you want us to do CPR? Do you want us to try and resuscitate her?”  He says yes, how could he not?

There is a slight sting as you remember that you promised yourself to use the word “dead” the next time you had this talk. It is too late now, the scissors are out, packages are being opened. She is exposed, stripped naked except for her white underwear. You wish you could somehow cover her up, not for her sake of course, she is no longer capable of feeling embarrassment, but for the husband’s sake. There is no modesty in CPR.

The lady on the floor may have been many things in her life, a wife, a daughter, a mother, a teacher, a friend, but now she is none of those. Now she is simply a plumbing problem that must be fixed.

Her ribs and sternum break with the first few compressions, but you knew they would. Pink foam is inching up the ET tube, soon it will clog the capnography line and the alarm will sound. There is no rush of adrenaline with this call; in fact, bystanders could mistake you for being almost bored. There is only a vague sense of discontent and anger, anger that you are in this situation again. Maybe, if you weren’t such a pussy and had used the word dead when you spoke to the husband, if you had said she is dead, you would not be in this situation.

Every chest compression, each intervention that you perform is followed with a silent apology.

Every milligram of epi is pushed with the hope that she stays in asystole, not because you are lazy but because you know how this ends. The only question left to answer is the one of location; will her life end here in her home, at an ER, or in a day or two when relatives have flown in and in an  ICU the life support is removed.

You lay out the options to her husband again, trying to not sound like you favor one choice over another. “We can stop the resuscitation attempt at any time you want or we can keep going” you explain. You tell him that “she is not breathing on her own and does not have a pulse… yet.” What you don’t tell him is that we can still stop now, before things go too far and there is no turning back, before you will become committed and your hand will be forced.  You don’t tell him that no matter what his wife is not coming back to him.

She is naked and broken . She has been dead for at least 15 minutes now. After the fourth epi she gets a pulse back. “Shit.” She deserved a better death than this but you have passed the point of no return now.

He is a bed confined 80 year old man who spends his days shitting himself in a diaper while staring at the ceiling, tethered to a ventilator. He had a stroke years ago and this is as good as he will ever get, there will be no more recovery than this. He will never walk or talk again; for all intents and purposes the person he was is gone.  Every time I look at him I cannot help think of Terry Schiavo; brain-dead but somehow his heart and organs did not get the message, kept alive because of the miracle of technology.

Just before we would transport him for the 3rd UTI of the month the son would remind us that the patient was NOT a DNR and they wanted everything to be done. Keeping him alive seemed like cruel and unusual punishment.  I want to tell the son he is an asshole, but I don’t.

Thankfully he never arrested with me but if he had I am unsure what I would have done. Would I have actually worked him? Would I have done a show-code or slow-code on him, a practice which I am morally opposed to? Would I have simply let him go and rolled the dice on disciplinary or legal action? I honestly do not know the answer. I want to tell you that I would let him go peacefully; perhaps I might even lie about it, I can justify it to myself as it would be the right thing to do.

Why the hell am I working futile arrests? I can’t really answer that. There are some factors out there, my lack of confidence in my decision making, fear of “the lawyers,” a duty to act, and it just is not something that is talked about, some lip service about how it is not up to me to determine what quality of life is and this whole thing was not something I was ever trained on…but none of those reasons make it right.

Odds of an adult  surviving an unwitnessed cardiac arrest (with CPC 1 or 2) – 3.4%. From 2015 CARES Survival Report

We have to let people die. We need to become comfortable with it. There are people who arrest that we should fight the good fight for and try to save them but there are an alarming number of people who we should fight for them to have a good death.

What should you do as a provider when you are presented with a patient that has arrested from a terminally ill disease or has virtually no chance of surviving resuscitation but the correct paperwork is not filled out.

How should you proceed when the family looks to you for direction in their decision making and it is obviously futile to attempt resuscitation? Should you tell them your feelings? Should you tell them what you would want if this was your family member? God, what if they ask what you would do if this was your wife or husband?

At what point do morals and ethics outweigh a duty to act? Are we acting out of fear of litigation, criminal charges and disciplinary action by employers? Have we created a no-win situation? Is this how those men felt in that court room in Nuremberg?

I don’t suffer from many of the ills that seem to be going around EMS right now. I’m not burnt out, at least most days, but this one aspect of the job is starting to wear on me. It could eventually be the thing that makes me switch careers. I’m tired of doing the wrong thing.

In EMS we rarely inform the patient’s family members, POA’s and proxy decision makers about the outcomes from CPR.  We let them have the  illusion that there are only two options for the outcome of resuscitation, dead or alive. We do not speak of the third possibility,  that we are prolonging the dying.

Nursing has beat EMS to the punch on getting a dialogue going on many of the issues we face, (and just about everything else too) and this is no different. Moral distress and moral residue are the term used for these situations. It stems from being forced to do something we feel is wrong. Each time this occurs it leaves a bit of residue. Over time the residue builds in a crescendo effect

I searched on the internet for “Moral Distress and EMS” as well as “Moral Residue and EMS” and found nothing that had anything to do with EMS, but many things to do with nursing.
I’m not going to rehash what others have written better than I could, you can read about it here.

What should be done about the whole mess? Part II will have my suggestions on what we need to be doing and will go in to detail about talking to family members, why CPR should be contraindicated in certain patients, and how EMS providers need to improve in order to do the right thing and to make sure we are okay with our own actions.

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