On January 31, 2022, beginning at about 1730hrs, southern Saskatchewan was overtaken by an extreme blizzard affecting a population of approximately 600 000 people.

As the snowstorm raged, the team working at Medical Communications South was closely watching the provincial Highway Hotline website for a real-time view of road conditions. This website displays a map of the Saskatchewan road network, with roadways color-coded to indicate current driving conditions. The team watched as the map rapidly changed from yellow, the color of common winter conditions, to white--travel not recommended—and again to red—complete road closure. Under red conditions, all EMS interfacility transfers are suspended until the situation improves; for emergencies, EMS will attempt a response wherever possible, however it doesn’t mean that EMS will physically get there. In the medical communications center, tensions rose quietly as it sunk in with everyone that it was going to be a long, difficult, evening.

At 1805 hours, the call came from a location in a rural area south of Moose Jaw.  The caller immediately informed the emergency medical dispatcher (EMD) calltaker he had found his 80-year-old father outside not conscious and not breathing. Outside in the extreme weather. Outside in a rural location where the roads to get there are all closed. The EMD call evaluator entered the case as a 09D02 determinant code and began Dispatcher-Directed CPR using the compressions-first dispatch life support (DLS) pathway contained in the software version (ProQA®) of the Medical Priority Dispatch System (MPDS™).  

9 minutes later when the patient hadn’t shown any signs of life, the caller’s family realized the futility of the situation—by then they understood that EMS responders could not make it to their residence due to multiple road closures. And they couldn’t load the patient into their own vehicle and head out on the road under near-zero visibility conditions with all routes virtually impassable. Giving in to the inevitable, the family made the otherwise unthinkable decision to stop resuscitation, effectively letting go of all hope for patient survival.

 The EMD call evaluator provided timely and important reassurances to the family, noting that they did everything in their power given what was presented to them— “If you think he is beyond any help, that is okay. You’ve done everything that you can and that shouldn’t be forgotten at this time. I know this isn’t easy for you guys.” Ten hours later, when the roads were finally cleared, EMS responded to the residence. They were able to confirm the death and notify the coroner.

This case presents some tough issues for the EMD. What if the family wanted to continue compressions indefinitely? Could they have taken turns by rotating persons and continued for 30 minutes, an hour, or more? Should an EMD ever spontaneously advise a caller to discontinue CPR? And what post-incident support is available for the emergency dispatcher who handles such a difficult case and may be emotionally invested in its outcome after working so closely with a family in those critical minutes while the life of their family patriarch ended.

The available research tells us that bystander CPR improves survival significantly in cardiac arrest patients—however this effect is greatest when combined with a very short EMS response time.¹ As EMS response time increases, the benefit of bystander CPR decreases, and when EMS response time is greater than 15 minutes, survival is near zero in cases where the patient remains in cardiac arrest.¹

Given that there was virtually no chance for EMS responders to reach this patient in anywhere near 15 minutes, or even 30 minutes, or an hour, the family almost certainly made the best possible decision. To continue CPR could have put other family members at risk both physically from exhaustion, and mentally from the ongoing stress, turmoil, and uncertainty associated with an extended period of resuscitation.

To be sure, there are scenarios one could imagine that would motivate bystanders to continue resuscitation for much longer. Consider, for example, a previously healthy patient in his 30’s, instead of 80—or perhaps a child that had experienced a respiratory arrest from drowning or asphyxiation.  No one would fault a bystander, particularly a family member, from risking their own well-being and safety to try and save such patients—even to the point of total physical and emotional exhaustion.

The MPDS gives us numerous instructions and scripts for encouraging callers on a prolonged CPR call, including “Prepare the caller to quickly switch places with the rescuer after 200 compressions.,” and caller reassurance statements such as “It’s Okay, we can do this together.”, “You’re doing great.”, “This will keep them going until paramedics arrive.”, “Keep doing it over and over, don’t give up.”, etc. However, there will be those rare cases such as this where the caller, on her own, makes a rational and prudent decision to stop resuscitation.

While it is not proper for the EMD to spontaneously direct a caller to discontinue resuscitation once it’s been started, there are special cases where, in the interest of the caller’s own health and emotional well-being, the EMD should support the caller’s decision to end their rescue efforts. While there isn’t always a scripted protocol to tell us what to say in those very unusual cases, we should consider statement that we would like to hear if we were in the caller’s shoes. Comforting caller management statements, however mundane and insufficient they may seem at the time, can make a huge difference to a person in despair who may greatly benefit from a little sympathy in the moment, and in the long term.

Finally, consider the emotional effect on the emergency dispatcher for a case like this. Are there available and sufficient support systems for dispatch staff after handling an extremely disturbing call?

At Medical Communications South in Saskatchewan, there are several programs in place to help. Within the communication centre, there are 2 persons that have formal peer support training. Employees can contact these members in private to discuss and work through their questions and emotions. In addition, professional counsellors and psychologists are available through a program called EFAP – employee family assistance program. And the most common form of debriefing is informal discussions within the team, that are encouraged by all. It turns out that it is therapeutic for emergency dispatchers to sort through their successes, doubts, emotions, and questions with those who are performing the same job alongside each other.

Not every emergency dispatch center will experience a severe blizzard as happened in Saskatchewan Medical Communications South this past winter. But every center should anticipate an unexpected extreme event in its future. We can learn to be better prepared for situations of severely delayed response by developing sound policies and procedures, following protocols to the best of our ability—and showing a lot of compassion for both our callers and ourselves.

 

References

1. Rajan S, Wissenberg M, Folke F, Hansen SM, Gerds TA, Kragholm K, Hansen CM, Karlsson L, Lippert FK, Køber L, Gislason GH, Torp-Pedersen C. Association of Bystander Cardiopulmonary Resuscitation and Survival According to Ambulance Response Times After Out-of-Hospital Cardiac Arrest. 2016;134:2095-2104. https://doi.org/10.1161/CIRCULATIONAHA.116.024400Circulation.