# Calling death in the field



## rhan101277 (Jun 23, 2009)

I know there are protocols of when this can be done in the field i.e. decapitation, dependent lividity, rigor mortis etc.  But there are a couple more that paramedics can do.  I am starting up medic school in the fall, and what concerns me is, what if I am wrong?

I mean the obvious is obvious, sometimes the family wants you take them really bad but I think this gives false hope to someone obviously dead.

I know this may seem a stupid question but even if obvious signs exist, do you still take a EKG strip, check for respiration's, check pupils etc.

If I can get through medic school fine, maybe I will be more confident of my abilities after these next 4 semesters of instruction.

One dead person I have seen, he was pale, pupils fixed and dialated, no breath sounds no heart beat, asystole EKG.  Even though all that was done he wasn't dead long enough for obvious signs to show and this is where I worry.  He was warm, but it was due to him being under a blanket.

Maybe I am just over thinking things...


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## Shishkabob (Jun 24, 2009)

Any decent MC will have you print an EKG strip from atleast 2 leads.


You can still have lividity and be alive, not breath and be alive, etc.


"They are only dead when they are cold and dead"


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## firemedic31075 (Jun 24, 2009)

> I know there are protocols of when this can be done in the field i.e. decapitation, dependent lividity, rigor mortis etc. But there are a couple more that paramedics can do. I am starting up medic school in the fall, and what concerns me is, what if I am wrong?



Don't beat yourself up too much. If someone is obviously dead (decapitation, dependent lividity, rigor mortis etc.) then don't work the code. But when in doubt just work the code. You wont get in trouble for working a code that you probably shouldn't have but you sure as hell will get burned for not working one you should have.



> I know this may seem a stupid question but even if obvious signs exist, do you still take a EKG strip, check for respiration's, check pupils etc.



Why not? It's not going to hurt anything. Those are all things your going to document in you report anyways. I like running an EKG just to put with my report, some people don't but I do.



> One dead person I have seen, he was pale, pupils fixed and dialated, no breath sounds no heart beat, asystole EKG. Even though all that was done he wasn't dead long enough for obvious signs to show and this is where I worry. He was warm, but it was due to him being under a blanket.



I don't know the specifics of this call but sounds like a situation where I would just work the code for 20 minutes or so and if stayed in asystole then call medical control to discontinue.


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## PapaBear434 (Jun 24, 2009)

The other day, I called my first on scene death as an ALS.  We worked on the guy for 20 minutes, did two rounds of Epi and a full monitor scan to confirm that there was no cardiac activity.  At that point, we called the closest hospital, explained to an online Doc what we did and what the current status was, and asked if he wanted us to continue working and bring him in, or just call it on scene.  He told us to go ahead and call it, unless we didn't feel comfortable with it, in which case go ahead and run him in.

We called it.  Lots of paperwork.  Went to our next call.  

Everyone's protocols vary depending on their MD, but I think that's the way it goes most of the time.


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## Ridryder911 (Jun 24, 2009)

My philosophy is if you have to run an ECG to make the determination, then you should had worked them. No, we do not require or endorse an ECG. Obvious physical signs should be documented to make the determination. If one wants to run an ECG, so be it, but our medical director wants the determination factor be based on conclusive physical signs ..traditional signs i.e. lividity, decapitation, etc. 

All deaths (without gross evidence) as well are documented as apical heart beat, with high encouragement of least two medics noting nothing. 

R/r 911


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## TomB (Jun 24, 2009)

We run a strip to document the death. Just out of curiosity, do you work unwitnessed asystolic arrests without obvious signs of death? If so, is it a brief trial of ACLS and then discontinue resuscitative efforts?

Thanks,

Tom



Ridryder911 said:


> My philosophy is if you have to run an ECG to make the determination, then you should had worked them. No, we do not require or endorse an ECG. Obvious physical signs should be documented to make the determination. If one wants to run an ECG, so be it, but our medical director wants the determination factor be based on conclusive physical signs ..traditional signs i.e. lividity, decapitation, etc.
> 
> All deaths (without gross evidence) as well are documented as apical heart beat, with high encouragement of least two medics noting nothing.
> 
> R/r 911


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## Ridryder911 (Jun 24, 2009)

TomB said:


> We run a strip to document the death. Just out of curiosity, do you work unwitnessed asystolic arrests without obvious signs of death? If so, is it a brief trial of ACLS and then discontinue resuscitative efforts?
> 
> Thanks,
> 
> Tom



We don't have an offical ..."cessation of resuscitation" protocol. We can call and receive an DNR order. We are though more aware of "down time" without CPR and assessing for any early signs of lividity. 

I am in the midst of renewing our protocols and will be asking for field termination, with the standard attempts of two rounds of pharmacological agents, if no success ( > 20 minutes) aysotle verified in >2 leads, cessation of efforts. Verified by pulse check and apical doppler. 

R/r 911


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## lafmedic1 (Jun 24, 2009)

When deciding on if to work the code also remember the location (ie swimming pool) or hypothermic arrest can sometimes be revived after long periods of being in arrest. And I have seen a few  "warm" dead bodies. When its 100 F room temp comes into play. Preservation of a crime scene is a smaller issue but remember Life comes first and as the other people mentioned to you if you have a strong doubt work it.


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## Ridryder911 (Jun 24, 2009)

lafmedic1 said:


> When deciding on if to work the code also remember the location (ie swimming pool) or hypothermic arrest can sometimes be revived after long periods of being in arrest. And I have seen a few  "warm" dead bodies. When its 100 F room temp comes into play. Preservation of a crime scene is a smaller issue but remember Life comes first and as the other people mentioned to you if you have a strong doubt work it.



Good points, we attempt to train Officers in the academy on the rules and how to determine death so EMS will not be tied up on such events. Less hassle and less detriment to the crime scene. 

R/r 911


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## LucidResq (Jun 24, 2009)

According to our protocols all pulseless and apneic pts must be worked unless:
decapitation, decomposition, 3rd degree burns over 90% BSA, lividity, rigor mortis, DNR present or "evidence of massive blunt head, chest or abdominal trauma." 

Medical arrests can be called after no ROSC during 15 min of CPR with ALS (intub., meds) and no reversible causes identified; or continous asystole for 10 min. in an adult, 30 min in a ped. after ALS resusc. (intub., meds) and no reversible causes identified. 
Exceptions include hypothermia, drowning w. submersion < 60 min with hypothermia, and pregnant pts. > 20 wks GA.


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## SurgeWSE (Jun 26, 2009)

*Death*

If it's obvious, it's obvious.  If they're incinerated, decapitated, hemicorpectomized (I'm pretty sure I just made that up by :censored::censored::censored::censored::censored::censored::censored:izing a real word), etc., then there's no point in grabbing a strip because regardless of what you see, they're going to stay dead.  If you suspect hypothermia, barbiturate coma, hypoxic arrest without extended down time, or something else with a high likelihood of success, work them.  If you're unsure or uncomfortable, work them.

For blunt trauma (assuming I'm reasonably certain that the arrest resulted from the trauma, not vise-versa), if there are no apical heart tones, palpable pulses, or spontaneous respirations I'll call it without a strip.  On penetrating trauma I grab a strip and usually work ones in PEA unless there's extensive, confirmed downtime.

As far as medical arrests go, experience and level of comfort are the keys.  If you have an extended, known downtime then there is really no reason to attempt (see this one in nursing homes a fair amount..."They coded and I started bagging and stuff started coming up so I stopped."  How long ago and did you do CPR? "Fifteen minutes and no."  Toodles!).  Rigor or livor mortis is a no go.  DNR makes it easy.  Elderly with extensive history or terminal illness, talk with the family.  For any situation that isn't obvious, use good clinical judgement and come to a decision with which you're comfortable.

Something in which you can take solace is that for a lot of medical arrests we see, death is an end to suffering, so though it is hard for the family, it's an improvement for the patient.  Calling codes in the field and talking to families will always suck.  After doing it a few times, the motions you go through to explain the situation to the family become easier and the process becomes less complicated, but until your heart is cold and dead, you'll always feel some empathy.


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## rhan101277 (Jun 26, 2009)

Well thanks for all the replies.  On that death I spoke of patient was down for 15 minutes and family didn't want any resuscitation done.  The patient didn't have a DNR, but family was adamant.


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## SurgeWSE (Jun 26, 2009)

rhan101277 said:


> Well thanks for all the replies.  On that death I spoke of patient was down for 15 minutes and family didn't want any resuscitation done.  The patient didn't have a DNR, but family was adamant.



Sounds like withholding resuscitation was the correct call.


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## Hastings (Jun 27, 2009)

rhan101277 said:


> Well thanks for all the replies.  On that death I spoke of patient was down for 15 minutes and family didn't want any resuscitation done.  The patient didn't have a DNR, but family was adamant.



Risky, but probably okay this time. Just remember that at any time the patient's family can change their mind and complain that you didn't make any attempt. And you have no defense without a DNR.


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## SurgeWSE (Jun 27, 2009)

Hastings said:


> And you have no defense without a DNR.



At 15 minutes of downtime, I'd consider my trip report to be a pretty adequate defense.  I suppose the hoops you have to jump through depend on local protocol, but I can't imagine any locale requiring personnel to work someone who's been down for 15 minutes and against the family's will.


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## wyoskibum (Jun 29, 2009)

How many stories have there been of patients that have been "declared" dead and then later someone notices signs of life, etc.....

If the patient is obviously dead with onset of rigor, lividity, pupils F&D, etc..  you should always confirm asystole on two leads, ascultate for heart sounds and document, document. 

Just my humble opinion


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## medic417 (Jun 29, 2009)

wyoskibum said:


> How many stories have there been of patients that have been "declared" dead and then later someone notices signs of life, etc.....
> 
> If the patient is obviously dead with onset of rigor, lividity, pupils F&D, etc..  you should always confirm *asystole* on two leads, ascultate for heart sounds and document, document.
> 
> Just my humble opinion



Asystole is a workable rhythm.  So you hook up leads on the guy whose head is 10 feet away, theres asytole better start CPR.


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## Ridryder911 (Jun 29, 2009)

wyoskibum said:


> If the patient is obviously dead with onset of rigor, lividity, pupils F&D, etc..  you should always confirm asystole on two leads, ascultate for heart sounds and document, document.
> 
> Just my humble opinion



Why? If you’re that incompetent not to know what lividity, rigor mortis is then you don't need a monitor to help you out, *you need a new career!*



medic417 said:


> Asystole is a workable rhythm.  So you hook up leads on the guy whose head is 10 feet away, theres asystole better start CPR.



Do what? You’re kidding right? You start CPR or start any resuscitation on a decapitation I will ask to see your license or cert card and tear it up! You have no business in EMS! 

Asystole is also known as being [size=+3]Terminal Rhythm[/size].
As well there are the rules of declaring death as signs incompatible with life.. i.e head off the body.

[size=+5]Treat the patient, *NOT* the monitor![/size]


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## wyoskibum (Jun 29, 2009)

Ridryder911 said:


> Why? If you’re that incompetent not to know what lividity, rigor mortis is then you don't need a monitor to help you out, *you need a new career!*
> 
> I feel very competent and l'm in the right career.
> 
> ...


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## medic417 (Jun 29, 2009)

Ridryder911 said:


> Do what? You’re kidding right? You start CPR or start any resuscitation on a decapitation I will ask to see your license or cert card and tear it up! You have no business in EMS!



Yes kidding because no reason to need a strip if decapitated, rigor, lividity, etc.


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## Ridryder911 (Jun 29, 2009)

wyoskibum said:


> Ridryder911 said:
> 
> 
> > Why? If you’re that incompetent not to know what lividity, rigor mortis is then you don't need a monitor to help you out, *you need a new career!*
> ...


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## Hockey (Jun 29, 2009)

Please see this thread

http://www.emtlife.com/showthread.php?t=13436


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## medic417 (Jun 29, 2009)

Ridryder911 said:


> wyoskibum said:
> 
> 
> > They are called conclussive signs for a reason. If one does not understand that, then no monitors in the world will help them out in court.
> ...


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## paccookie (Jul 1, 2009)

Ridryder911 said:


> My philosophy is if you have to run an ECG to make the determination, then you should had worked them. No, we do not require or endorse an ECG. Obvious physical signs should be documented to make the determination. If one wants to run an ECG, so be it, but our medical director wants the determination factor be based on conclusive physical signs ..traditional signs i.e. lividity, decapitation, etc.
> 
> All deaths (without gross evidence) as well are documented as apical heart beat, with high encouragement of least two medics noting nothing.
> 
> R/r 911




I agree with R/R on this.  

A couple of shifts ago, we got called to an unresponsive man on a roof.  He was working on the roof when he collapsed.  The family had not seen him for at least an hour prior to calling EMS.  When they finally found him, his face was blue and they could not get on the roof to initiate CPR or check further for responsiveness (he would not answer their calls from the ground).  When we arrived, he was lying supine on the roof with his head lower than the rest of his body.  He had some lividity in his back and his lower extremities were very pale (the blood had all drained to his head).  His hands were stiff and he was beginning to have rigor all over.  By the way, the temperature was about 100-105, estimated to be about 120 on the roof.  The man was 66 or 67.  The family told us not to work him if it didn't look like we could get him back.  We were not going to work him anyway.  It took about 45 minutes to get him extricated from the roof and moved to the truck.  And no, we did not run a strip.  We talked about it and decided that it was unnecessary since he had very obvious signs of death.  The coroner asked if we ran a strip and said that we should have, but our supervisor agreed that it was unnecessary.


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