Do you ever go through the motions?

by Greg Friese on January 5, 2010

in EMS Education Tips, EMS Tips

A common question from students in classroom training programs, especially when I teach CPR, goes something like this:

“My last instructor told me that sometimes they go through the motions of doing CPR, even when they know it is futile, for the benefit of the family. Do you ever go through the motions?”

Many times the student will offer an example that is some variation of “the instructor said they responded to a SIDS baby. ‘The infant was cold to the touch, had obviously been dead for hours, but since mom or dad were so upset we went through the motions’ of doing CPR.”

In the moments I realize the question is being asked and the student finishes asking the question I usually find myself breathing in deeply and trying to maintain my composure because this question always makes me angry. After an uncomfortable pause at the end of the question this is how I begin to answer:

“No.”

Another uncomfortable pause.

“No. I never go through the motions. Never.”

Another uncomfortable pause.

I want that last statement to really soak in … I never go through the motions … so they consider what going through the motions means. Not just for CPR but for all the possibilities like patient assessment, equipment checks, washing the ambulance, or writing patient care reports.

As they think through the final uncomfortable pause I begin the full explanation.

“This is why I never go through the motions …

Going through the motions to do CPR when the patient is obviously dead assumes that the family wants you to go through the motions. Are you willing to look over at mom, dad, son, daughter, spouse, life partner, whoever and say “I am just doing chest compressions or sticking this tube in their mouth because I am assuming you want me to go through the motions even though I for sure know and you probably know that this person – your wife, husband, son, daughter, friend, life partner, whoever – is obviously dead.”

The other reason I believe that some EMS providers go through the motions of doing CPR on a corpse is it delays the difficult and uncomfortable conversation that their loved one is dead. That conversation is never easy. Most of us have had little or no training on how to start that conversation. Don’t substitute going through the motions to provide the most appropriate action.

Explaining that the patient is dead is not doing nothing. It is doing the right thing at the right time. By going through the motions you are delaying what you should really be doing – having a plain English no cliché conversation, that the patient is dead.

Sometimes doing all you could, is explaining the patient is dead. If asked, you can also explain how you know the patient is dead.

Going through the motions can also be wildly dangerous for the EMS crew, firefighter or police officer that gets drafted to drive the ambulance, and the citizens driving and intersecting with the route of travel to the receiving facility. If your service is transporting pulseless patients – with very few exceptions – you need to have a very serious conversation with your service director and medical director immediately to discuss why going through the motions to transport pulseless patients is dangerous and potentially lethal.

So there are three reasons to never go through the motions:

1) Don’t assume the family wants you to go through motions when you know better.

2) It delays the difficult conversation to inform the family/witnesses that the patient is dead.

3) Transporting pulseless patients is wildly dangerous.

After that recap I conclude the answer by asking the class to tell me reasons not to start CPR and reasons to stop CPR once it started.

Never go through the motions.

Since I feel so strongly about this question about “going through the motions” I invited my friends Steve Whitehead, theEMTSpot.com, and Chris Kaiser, LifeUndertheLights.com, to write on this same topic. They both graciously accepted. Please visit their posts and leave your comments on the topic here or at their posts. If you decide to write your own blog post on this topic let me know and I will add your post to the list of links.

Tim Noonan, the Rogue Medic, responded to our posts with an explanation of why he wants to be the one to break bad news and how important it is to be there for the family. Read his post a Trilogy on Termination.

David Konig, after reading our three posts, also weighed in on this topic. His post is thought provoking in that he makes a case for almost always (maybe always) transporting pediatric cardiac arrest patients. Read David’s excellent post Because its not all motions and theater.


Bookmark and Share

Read related posts and tips:

  1. Step Off the Path to Mediocrity Share Have you ever had a partner that said, “just...
  2. Geriatric Patient Assessment Tips Share Everyday EMS geriatric assessment tips for any geriatric patient:...
  3. Product Review: Act+Fast Anti-Choking Trainer Share With a sharp inward and upward thrust – just...

Tagged as: Blog, CPR, Death, Education

  • Martha Bonnie
    Well done. The way you present your perspective EMT students and the way your write about it makes it vivid and real. No matter what someone's role in EMS is, you present a point to think about in the way that we treat people in our jobs. As an emergency dispatcher, I may not meet the parents of the PNB 3 month old, but I may be responsible for getting an ambulance on scene as quickly as possible or sending the nearest paramedic or taking the phones for my partner so that she can do all of the above. Or I may just be a little more compassionate and thoughtful in general.
  • Unomi
    Sorry. I'm not a medic, I just stumbled upon this article via Hacker News. None the less, I do thank the writer for the article to make it very clear about the motions. And as such, it appears more professional to know what you're doing than just hesitate and make some theater for nothing. The dead ain't coming back and the grief will not go away. Theater in such conditions is like lying without a gain for anyone involved. Step up and be a professional, concider consequences but cut the crap and stick to the facts.
  • Anon
    If I was in the situation of the family, I would have preferred the medics to tell the truth. It could actually make it worse if they started CPR. That implies that they actually thought they had a chance of saving that person. This would leave a lot of open questions, such as "should I have called them sooner?" etc.
  • I have updated the post with links to blog post on the topic of "going through the motions" from bloggers Rogue Medic and David Konig. There posts are both excellent. Check them out and share your thoughts with them as well.
  • I never do the "courtesy code."

    If I start, I do it right.

    If I think it's going to be futile, I don;t even start, and explain to the family why. In over 15 years as a medic, I can only think of a handful of calls where a family didn't accept my reasoning.

    Too many people "go through the motions" because they lack the courage or communications skills to address the subject.
  • Excellent work by all three of you.

    There are some patients who should be transported with CPR, but they are rare.

    The patients transported should be transported slowly and safely. Crashing an ambulance is not likely to lead to a resuscitation.
  • Rebecca
    This article hit close to home, too close. In Oct. 2008, the service where I had worked for six years as a medic merged with the fire department. I made one of the most difficult decisions of my life and chose to stay home with my two year old son. In March (just 5 months later), my seemingly healthy little boy presented with a fever one afternoon. The following morning he was not better and we took him into see the pediatrician. He was diagnosed with a "virus" and sent home. He had absolutely NO symptoms other than a fever and a little bit of vomiting...his belly had been palpated by myself and the ped. multiple times. Less than a couple of hours after returning home my son went into cardiac arrest. I began CPR immediately. Fire rescue arrived on scene and did absolutely everything they could, including transporting him to the local hospital. My son died. It was found on autopsy that he had a volvulus of the caecum. It is not known why he did not present sicker than what he was or have severe abdominal pain, and we will probably never know.

    I never in a million years dreamed that this would happen to me, to my family, but it did. I agree way too many times we transport patients who are dead and when we transport them we put ourselves and the public at risk. But I don't feel that all pulseless patients should not be transported. From the time of arrest until the doors of the ED was less than 15 minutes for my son. He was asystole the entire time and never responded to treatment from EMS or the ED. Yes, he was dead when he was transported, but as his mother I am eternally grateful to the entire crew that cared for my son, for them giving it their all and not "going through the motions"...for giving him the greatest chance at life possible.

    It is easy to sit in judgement when you are not grieving the loss of your son. Not all pediatric codes, not all adult codes should be transported...but considerations should be made such as down time and length of time before CPR was started. Paramedics need to be taught in school about grief and how to handle grieving families. Many hospitals have grief counselors, chaplains, or social workers on staff to assist families through this crisis...although this is not a reason to run lights and sirens to the hospital and risk lives, it is something that as a profession we need to consider and be prepared to handle appropriately in the pre-hospital setting before we go telling someone their loved one is dead and then running out to the truck to grab the next call.
  • Rebecca, thanks for sharing your story. I am so sorry for your loss. Steve Whitehead writes very eloquently about how pediatric patients rarely fit neatly into the category of transport or don't transport. Steve's post at theEMTSpot.com.
  • Timothy, thanks for your comments and question. Regarding exceptions for pulsesless patients a pregnant female in cardiac arrest would be a rare encounter and a consideration to make with online medical control.

    Other exceptions might include severe hypothermia and drowning with submersion time less than 60 minutes. In the end it will be situational dependent.

    In 2010 I think the trend will continue to analyze the risks in the patient care compartment and improve safety for caregivers. I will put this on my list for a future "analysis" post. Thanks for your encouragement.
  • Timothy Clemans
    "Non-tip posts? Timothy I read several good tips in there. ;-)"

    I have too. But these analysis posts are extremely interesting to me and hope Greg keeps writing them.
  • Non-tip posts? Timothy I read several good tips in there. ;-)
  • Timothy Clemans
    "Transporting pulseless patients is wildly dangerous." Even though I'm not in EMS yet I often rant about systems where dead people are transported to the hospital. Manual compressions in a moving ambulance are ineffective. ACLS in the hospital is the same ACLS outside of it. It ties up resources which could lead to medical errors involving other patients thanks to multitasking. It gives false hope. The general public is put at risk.

    On the issue of safety in an ambulance I might not even apply to King County Medic One many years from now if they don't do something about the safety of their personnel. There is no reason ambulances can't be configured so personnel can do their job while buckled in. I was extremely ticked off recently when I saw a Medic One unit going lights & sirens not to the trauma center but to the local hospital with at least two medics in the back probably unbuckled. Don't even mention air medical services to me.

    Would a reasonable exception to the no pulseless transport rule be pregnant females in order to attempt saving the unborn child?

    I'm enjoying these non-tips posts.
blog comments powered by Disqus

Previous post:

Next post: