Sudden Death: Intervention Skills for the Emergency Services

This book considers the practical management of sudden death and offers first-hand reflections of how emergency physicians, nurses, and allied health professionals cope. Sudden death is one of the most difficult aspects of emergency care, and the traumatic nature of some deaths can be devastating for the family and the emergency team. This book shows how practitioners confront the sudden death and the essential steps taken to manage the event that may have a critical impact on the grieving relative. The book explores the unique interactions between emergency and allied health practitioners and nurses, those who grieve and, the body itself. By understanding what is involved in sudden death work, and the practical, psychosocial and spiritual tensions that arise from managing the event and sequel, it may be possible to provide a more responsive service.

The book addresses sudden death from the multi-professional emergency and allied services perspective to guide either the seasoned practitioners or the new and apprehensive recruit. National emergency response systems have been strengthened to cope with the increasing trauma and disease burden which, for many unfortunate individuals, results in an immediate or swift death trajectory. This multidisciplinary teaching text uses first-hand detailed stories of sudden death encounters. By reflecting on these ‘happenings’ and illuminating on how specific events were handled, it is possible to build a picture not only of what sudden death workers ‘do’ when sudden death occurs but also how they feel about what they ‘do’. At the end of each chapter a series of activities will be posed to encourage the reader to make sense of their own practices when handling the legal and practical aspects and when supporting families and colleagues.

• Language: English
• Publisher: Springer
• Release date: Feb 28, 2020
• ISBN: 9783030331405

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© Springer Nature Switzerland AG 2020

T. Scott (ed.)Sudden Death: Intervention Skills for the Emergency Serviceshttps://doi.org/10.1007/978-3-030-33140-5_1

1. Sudden Bereavement: A Wife’s Perspective

Lorraine Mulholland¹  

(1)

Seamill, Ayrshire, UK

Lorraine Mulholland

Abstract

Living through the anguish of the sudden death of a spouse remains acute in the mind of the partner for a long time after the event. This chapter provides a reflective account of the sudden death of a man who one moment was enjoying life with his family and, the next, collapsed due to a heart attack. Despite immediate effort by the cardiology department, he died unexpectedly during surgery. This chapter reports on the suddenness of the situation and how the relatives were able to get to the hospital swiftly in order to be at their loved one’s side at the time when he most needed them. It also provides an authentic account of his wife’s journey toward widowhood.

1.1 Reflection

On 28 April 2008, we’d been married for 31 years. Scotland was home to us where we raised our three children who were 26, 22, and 21. My husband had worked for 40 years for a multinational company, and during that time, we enjoyed three international assignments. Two of those included having the children with us while posted in USA and Hong Kong. Jack had retired 3 years earlier and happily divided his time between continuing to be involved in our children’s lives, generally pottering about the house, gardening, and travelling. Now, I feel so grateful that that’s how he spent his time. He was interested in most sports, soccer in particular, and he followed Celtic Football Club with a passion. That day, I dropped him off to catch a train to Glasgow where he was to watch Celtic host Rangers Football Club at Parkhead Stadium.

He enjoyed what appeared to be perfect health visiting his general practitioner only for health checks. Unfortunately, he had been a smoker for most of his adult life, although for the last 8 years had made great effort to cut back, but not to stop completely. It had always caused me distress, and I now blame his early death, aged 60, on this ghastly habit. It was a Sunday when he traveled to Glasgow to have lunch and a pre-match drink with our younger son though on this occasion they both went to the game but unsually were not sitting together on that paticular day. My son’s memory is of Jack jumping into a taxi heading to the game and giving him a ‘thumbs up’ as he was driven away.

I had picked up my older son from the airport, and we were driving toward Glasgow when I received a phone call to say that Jack had taken ill during half time at the game and was being transferred to hospital. The hospital was only 10 mins away from the stadium. I asked what symptoms he had as I wanted to know whether it was perhaps a heart attack, a stroke, or hopefully just a faint. My son reassured me that as he was seated near the stadium dugout he would have had immediate attention while waiting for the ambulance and that he was sure that Dad will be fine.

I called our son who was in the stadium, although not seated near Jack, to let him know that his dad was going to hospital, and with hindsight, I am so grateful that he didn’t witness his dad having a heart attack. At this point, I would love to point out just one of the many positive elements of that day. When my son tried to leave his seat, a police officer stopped him because, due to the heightened security at these Old Firm games, fans are not allowed to move from their seats. However, when my son explained his reason for leaving and, concurrently, the officer heard in his earpiece that there was a medical emergency in the crowd, he not only escorted my son from his seat but also arranged for a police car to take him to the hospital. For this, I am eternally grateful.

By then, I had contacted my daughter who was studying for her final degree examination at a university library in the city. Fortunately, my three children and I all met up in the accident and emergency department not long after Jack had arrived by ambulance. I remember speaking to a receptionist, and I explained who we were and why we should be allowed quickly to wait in a very small room together rather than the general accident and emergency department waiting room. A doctor, who I believe was the receiving doctor that afternoon, came to see us and explained that Jack had a heart attack in the stadium and went into cardiac arrest in the ambulance but that they were ...working on him, though he wasn’t out of the woods yet. I took that to mean that although seriously ill he would be fine.

My memory of that room is of it being very small, windowless, with bare painted walls and just enough chairs for the six people present. My husband’s friend who had been with him at the game had joined us too. I remember noticing posters either there or in other areas encouraging people to be cancer aware. Later in the afternoon, I made a note that nowhere was there a prompt/reminder for organ or tissue donation which, for some reason, seemed to be significant at the time and for some time afterward.

This doctor suggested that I go to see Jack in the resuscitation room and that the children join me one at a time, which they did. Jack managed to speak a couple of sentences to each of them. My thoughts on seeing him were that he looked well. His face and chest were flushed red which I misunderstood at that point to be a good sign even though his pale extremities were not a good sign. His skin was really tanned as we had just returned from a six-week holiday in Asia. So all of these aspects led me to a false sense as to how he actually was.

I was aware that the medical staff seemed to be working with a sense of urgency, but again, by not anticipating the worst, I don’t think I was very upset by this. When the cardiac consultant arrived (she had been working in another hospital that afternoon), she seemed visibly concerned about Jack’s condition and wanted immediate updates on his condition and treatment thus far. She explained that Jack would be taken to a catheter lab for investigation and would be away for an hour or two and I would be told where to wait until I could see him again. I remember I asked that should he need a bypass, it would be helpful to know when the procedure would be carried out, and she assured me that he would have any necessary treatment as soon as possible and very soon.

Before Jack left for the catheter lab, I asked him how he felt, and he said he wasn’t in real pain but felt … a terrible tightness in my chest. He asked me to … give my feet a wee rub, something I did almost every night as we sat relaxing at the end of our day. I turned back the blanket which was covering him, and it was then I was struck by the desperately white colour of his feet. I did massage his feet and lower legs till it was time for him to be moved. This especially personal moment between us in his last hours turned out to be the last thing he said to me and has become a hugely positive experience for me.

We took the time to call his sisters who happened to be in the city; hence, they were able to get to the hospital quite quickly. We were planning shopping for toiletries, pyjamas, etc. assuming that he was going to be admitted to this hospital. I can’t remember who directed us to the second relative’s room near the catheter lab, but we sat and waited mildly concerned as I guessed that all the years smoking had caught up with him and perhaps he would require stents or a bypass. It never ever crossed my mind that he was in danger even having heard the doctor saying He isn’t out of the woods yet.

When the cardiac consultant came along the corridor, I was struck by her demeanor, and when she sat down beside me, I somehow and suddenly wasn’t surprised when she said I am so sorry to tell you that your husband didn’t survive the procedure. I can still feel the utter disbelief and incredulity in what she had just said. However, with my mother’s instinct to protect, I immediately focused on my daughter who was so terribly upset, and I felt a need to console and take care of her before my own needs. I have no memory of other medical staff being around or involved.

Despite no one suggesting donation, I offered organ donation immediately, although my son and sister-in-law were not very happy about it. It was something I felt strongly about and knew that Jack had expressed a wish to be a donor in earlier conversations. As it transpired, he wasn’t considered suitable for organ donation due to having recently traveled in Asia and the associated malaria risk. I had a call later that evening from the organ donation/tissue retrieval coordinator who took me through a lengthy questionnaire with great sensitivity. I agreed to Jack’s corneas being retrieved and have since heard that they were transplanted successfully which is a huge consolation and yet another positive element to this sad story. At times like this, we search for meaning and that something good will come from the sadness.

I have no memory of any offer of spiritual support or of any support come to think of it. I suppose by then Jack’s sisters, brothers-in-law, and niece had joined the children and me, and perhaps, it looked like we were supporting ourselves. I will never know. We are practicing Catholics, and perhaps, we would have been happy to have had the opportunity to have a priest present to offer the last sacraments. After Jack had died, we were offered the opportunity to be with him, but only my younger son and one of Jack’s sisters went to see him. I recalled being very upset as a teenager when I saw my father in an open coffin and had vowed never to view anyone who had died in future. I had been with my mother and an aunt when they died, but once I left them, I didn’t return to see them. This is something I feel strongly about and have no regrets about at all.

Our children and I drove from the hospital to visit Jack’s elderly parents who had already heard the sad news from a family friend. It was a very controlled sad feeling in their sitting room, and you could feel that everyone was being stoic, although it was very early in the bereavement process. The children and I then continued to our home, although they no longer lived in the family home all having moved to Glasgow for university and work. They all stayed with me that night and for several nights thereafter. We then began the sad and difficult task of calling our extended family and friends to tell them that Jack had died. That is such a heartbreaking task. You know that as you dial you are about to make someone feel so very sad in a second. In a very practical way to help, my daughter transcribed all phone messages as back then most calls were to the landline and not the mobile and printed these along with emails. I have kept all of these pages in a file, and I find comfort when reading them from time to time.

I was asked to visit the hospital the following day to collect Jack’s belongings and his death certificate. I found that difficult, but we took the opportunity to thank some of the medical staff we encountered. Although I don’t remember interacting with many of the hospital staff, those who did speak to us from that first receiving doctor to the cardiac consultant were considerate, caring, and kind. The death certificate was ready for us as arranged. Jack’s belongings were in a black plastic bag which isn’t a pleasant way of collecting, but I’m not sure of alternatives. I do not remember a recorded property list, though I had already taken his watch and wedding ring from him in the accident and emergency department at his suggestion.

Having collected the death certificate, we drove directly to the City Registrar’s Office to register his death. I found driving between hospital and home and hospital and Registrar’s Office and other car journeys in the days immediately after his death really difficult. Not wanting others to drive me is a vivid memory. I wanted the independence and privacy of driving alone or with our children and not with anyone else even family or close friends. Someone mentioned Auden’s (1938) poem which begins Stop all the clocks and that resonated with me. I found it surreal to be driving around feeling so utterly devastated when the world was carrying on without a clue as to how I was feeling as my life had been changed completely in an instant.

So, on reflection, I feel the emergency/medical personnel with whom we had contact were each wonderful in all respects, truly, and that’s a great thing to be able to say, from the staff within the Parkhead Stadium who I hear all did a remarkable job in caring for Jack while he waited for the ambulance to arrive. Apparently it did not take long. The staff in the accident and emergency department at Glasgow Royal Infirmary were all caring and efficient. I have since heard from someone who was working in an administration capacity that at the time a doctor had commented that we or perhaps I was not taking the information on board. I only heard this the other day, and I’m not sure how I feel about it. Perhaps, I feel frustrated that if this was the case, more effort should have been made to make me aware of the reality and seriousness of the situation, a difficult one.

As we left the hospital that afternoon, we met the cardiac consultant, and I remember speaking to her about how she felt and hoped that she would have some specialist support to help her having ‘lost’ a patient she was treating. I was able to thank her for her care as I had gathered myself and thoughts a little by then.

Learning Points

Consider how to prepare a suitable relatives’ room in the emergency department.

Consider how to prepare relatives regarding the seriousness of the event.

How might you improve on the process of handing over property to relatives?

Reference

Auden WH. Funeral blues. In: The year’s poetry. London: Readers’ Union; 1938.

© Springer Nature Switzerland AG 2020

T. Scott (ed.)Sudden Death: Intervention Skills for the Emergency Serviceshttps://doi.org/10.1007/978-3-030-33140-5_2

2. Sudden Death: A Pre-hospital Perspective

Nick Brown¹  

(1)

London Ambulance Service, London, UK

Nick Brown

Email: [e-mail]

Abstract

The ability to deal with complex scenarios is the hallmark of a proficient paramedic practitioner. Sudden deaths occur regularly in the course of clinical practice and call upon the paramedic to handle not only the patient’s clinical condition prior to and after the patient’s death but they must also be able to handle the emotional reactions of the people at the scene including those of their colleagues who may be less experienced. The following chapter reflects on the paramedic’s preparedness for dealing with a range of sudden death encounters.

2.1 Introduction

The sun had not been up for long since starting my shift. I drove the Fast Response Car out of the ambulance station and headed south. Somewhere in South London a man in his mid-forties had returned home after a run where his wife was preparing breakfast and his son had started another day of homework. Having announced that he was feeling unwell, he went upstairs and collapsed. It is not always obvious why paramedics recall events surrounding certain call-outs over others after so many years, but in the following case, it is. The next 3 hours were about to have a huge impact on me emotionally and intellectually. Indeed, the events acted as a catalyst for significant changes to the way I thought about and managed the various factors around out-of-hospital cardiac arrest and subsequent death. I remember my exact location when the mobile data terminal mounted to my car dashboard jumped into life with details of an emergency call 10 miles away to a 45-year-old male who wasn’t breathing.

It is estimated that UK ambulance services respond to 60,000 out-of-hospital cardiac arrests each year (OHCA Steering Group 2017), where half result in active resuscitations (Perkins and Brace-McDonnell 2015). Approximately 10,000 cardiac arrest 999 calls are responded to by the London Ambulance Service alone, of which 4500 result in continued resuscitation attempts following ambulance arrival (London Ambulance Service 2017).

London’s Critical Care Advanced Paramedic Practitioners (APP) are tasked to the more seriously ill and injured patients in the capital. On average, within a 12 hour period, one APP attends 1.6 cardiac arrest patients, many of whom die (London Ambulance Service 2016). My 22-year career as a paramedic has afforded me a deep appreciation of the multidimensional aspects of unexpected death in the widely varied pre-hospital environment. Reflecting on these experiences has helped me to better understand sudden death in the community and develop key knowledge and skills to manage these events, aside from the clinical care that paramedics deliver.

For paramedics, dealing with sudden and unexpected death is usually part of a continuum which involves a 999 emergency call, arrival on scene, a resuscitation attempt, management of various on-scene factors, a decision to stop resuscitation and formalise death and the conveyance of that decision to family members or friends. Additionally, there are medico-legal requirements. It is therefore unrealistic to explore how we should deal with unexpected death without providing a wider context and meaning to these events. For paramedics, dealing with sudden death usually comes after an attempt to save life. It is important to recognise that what we do and say from the moment we arrive on scene will have an impact on our overall ability to optimise ongoing decision-making and care and our own sense of accomplishment. Although key themes will run throughout this chapter, for clarity, it might be useful to explore paramedic involvement around death under four main headings: family-witnessed resuscitation, breaking bad news, preparing the body and staff welfare.

2.2 Family-Witnessed Resuscitation

After 20 min of blue light driving, I arrived on scene at a family home where local ambulance crews were already inside. As an APP, I was there to administer advanced clinical care, but on this occasion, it wasn’t required. On entering, the first people I saw were the patient’s wife and son, clearly upset. I remember the smell of breakfast. Upstairs, the ambulance crews had established advanced life support in a bedroom, but sadly, the prognosis was poor. In fact, I intervened very little clinically before asking if anyone had updated his wife and son. Interestingly, one of the attending paramedics couldn’t even remember seeing anyone else on entering the family home.

I didn’t really have much of a plan of what to say which mostly reflected my then lack of appreciation for having a clear, considered and practiced approach in these situations. On explaining that a death outcome was likely, the reaction from both wife and son was immense. There was instant screaming and howling, quite feral in nature. Walls were being punched to my left, and homework was thrown across the room. The patient’s wife literally clung to and then hung off my uniform, pleading and begging me whilst using the most emotive language, to save her husband. She told me that she and their children could not live without him. He was ...their rock. She asked me how she could possibly tell their younger children who were at primary school and completely unaware of events at home. Although not fully appreciated at the time, in a handful of apologetic words, I had taken them from mild concern to abject horror. I was hit by an emotional tidal wave of raw grief, and as I stared across the kitchen at three plates of uneaten breakfast, I had absolutely no idea of what to say next.