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.
