# Nobody dies in an ambulance?



## Tfumes (Dec 31, 2012)

I work as an EMT-B w/IV cert in an ED, and part time as a body remover for a funeral home. Last week, a pt was being transferred from my ED to another facility. Pt was elderly, DNR status and very close to death. not agonal yet but toeing the line. I asked the trasporting Medic "whats protocol if they kick during transport?" rescind DNR? return to origin facility? or deliver a dead pt to receiving facility?. Medic ripped my head off, saying its a stupid question and nobody dies in a bus. Still wondering the answer...Thanks


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## Aidey (Dec 31, 2012)

True story. No one dies in an ambulance. They had a pulse until the second you walked through the door of the building.

Otherwise the ambulance has to park and stay out of service until the medical examiner, coroner or mortuary can get around to taking care of the body. It isn't a pretty situation.


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## shfd739 (Dec 31, 2012)

For us in that situation with a valid DNR they are delivered to their destination and placed into bed. Nursing home, hospital etc can take it from there.


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## epipusher (Dec 31, 2012)

I would probably not leave them dead in a bus, that makes for bad PR.As for the ambulance, if the pt is a DNR we would stop efforts and continue on to the hospital.


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## DrParasite (Dec 31, 2012)

Aidey said:


> True story. No one dies in an ambulance. They had a pulse until the second you walked through the door of the building.
> 
> Otherwise the ambulance has to park and stay out of service until the medical examiner, coroner or mortuary can get around to taking care of the body. It isn't a pretty situation.


exactly.  no one dies in the ambulance, they either get worked as cardiac arrest to the ER or they get worked on scene.   they don't necessarily have a pulse, but they are not to be declared/pronounced dead in the back of the truck

Only time I have had someone die in my ambulance was on a head on collision (3 trauma patients and one walking wounded), we took the first person out and put her in our truck, with the paramedics attempting to intubate her. our medical director jumped the call (as did the #2 and #3 guy in the agency, as well as the shift supervisor), poked his head in the truck, say "umm those are brains, she's an obvious DOA."  we had to wait over an hour for the ME to arrive.


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## Outbac1 (Dec 31, 2012)

We don't work people with DNRs in the truck. We call our dispatch and they tell us whether to continue to the destination or return to the sending facility. Usually we return to the sending facility. The pt is always the responsibility of the sending Dr. until care is handed over to the recieving facility.


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## medicdan (Dec 31, 2012)

Interesting... I've had a DNR patient go into arrest in my truck before. We had been worried about this contingency, and consulted with medical control and spoken with family before the ride, and agreed on the circumstances. When it occurred, I simply called the doc back, and he told us to "turn off the lights, turn on the air conditioning".  Because the death was under the supervision of a physician and in a medical setting, the police had no interest or need for involvement. When we got to the Ed, the doc did a quick exam, and we actually wheeled directly to the morgue.


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## medic417 (Dec 31, 2012)

People die in the ambulance.  Only idiots claim otherwise.  That t-shirt no one dies in the ambulance along with the emts save paramedics t -shirt need to all be piled up together and burned and never mentioned or seen again. 

If you are doing CPR they are dead.  If you are doing CPR while ambulance is rolling you are doing crappy CPR and your system is archaic for allowing it.


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## Aidey (Dec 31, 2012)

Fine. No one is declared dead in the ambulance. 

This discussion isn't about the sentiment behind a catchy t-shirt saying. It is about the fact that it is a logistical nightmare in most systems if someone is declared deceased in the ambulance.


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## medic417 (Dec 31, 2012)

Aidey said:


> Fine. No one is declared dead in the ambulance.
> 
> This discussion isn't about the sentiment behind a catchy t-shirt saying. It is about the fact that it is a logistical nightmare in most systems if someone is declared deceased in the ambulance.



They are declared frequently on board ambulances.  No issues.  Wheel the corpse out and into the hospital or the morgue or move onto funeral homes cot, etc and go back into service just like any other call.


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## Aidey (Dec 31, 2012)

Maybe in your area, which you have made a habit of pointing out is unique. In other areas it may mean a body sitting in the ambulance for 6-8hrs or even longer.


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## CANDawg (Dec 31, 2012)

Is there a reason this is in the "Suggestions, Feedback & Forum Questions" forum? :blink:


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## JPINFV (Dec 31, 2012)

I think the problem is that most system policies (at least that I've seen), don't directly cover death in transit. The only one I've seen is Massachusetts' state wide protocol which says the following. 



> If during transport, EMTs cease resuscitation of a patient in accordance with the requirements above, they shall continue to the closest appropriate hospital for pronouncement of death. This is always a special circumstance that is in the interest of public health and safety, and thus meets the requirements of 105 CMR 170.365.


http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001.pdf

PDF page 155


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## JPINFV (Dec 31, 2012)

epipusher said:


> I would probably not leave them dead in a bus, that makes for bad PR.As for the ambulance, if the pt is a DNR we would stop efforts and continue on to the hospital.




Well, of course. If they're dead in a bus you're screwing up the entire bus route and inconveniencing hundreds of people. 

...now what about dead in an ambulance?


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## DesertMedic66 (Dec 31, 2012)

Had this happen to one of our units. Patient was a DNR. Patient coded in route from his home. Hospital will not accept dead patients who they can not work. 

Body was left on the gurney in the back of the ambulance and covered with a sheet. A/C was turned on high and crew sat in the hospital for 2+ hours waiting for the corner to arrive. 

The patient is ours until we give a hand off to the nurse at the hospital. If the patient codes as we are walking into the hospital then he/she stays on the gurney until the corner arrives. The hospital will not accept.


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## ffemt8978 (Dec 31, 2012)

Moved to appropriate forum.


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## med51fl (Dec 31, 2012)

Aidey said:


> Fine. No one is declared dead in the ambulance.



I have to agree with medic417 that that is not true.  People die and are declared dead in the back of our rigs.  We simply call the ED, get the doc to approve the death declaration, and continue transport routine to the ED to turn the body over for death procedures.  That is all.  No working a futile code, no waiting for the coroner, and no transporting to the ME for sure.


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## CritterNurse (Dec 31, 2012)

I once had a patient ask me if anyone had ever died in this ambulance. I told him quite honestly "Not during my watch" since I've never had a human patient die in front of me. I have no idea if anyone had died in that ambulance when I wasn't there, but at least the patient looked reassured for the rest of the trip.


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## Tfumes (Dec 31, 2012)

I appreciate the input. Working in-hospital as an EMT I havnt been able to see the rules & regs of outdoor medicine. Thanks again


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## MediMike (Dec 31, 2012)

I'm with Medic417/51 here.  We can declare no problem.  I don't think the ability to do so is as unique as some here think.  Unless we're all in the same region.


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## Aidey (Dec 31, 2012)

We can declare also. The issue at my agency is specifically declaring in the back of the amb.


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## Tigger (Jan 1, 2013)

I can't figure out why anyone would be declared deceased in the physical confines of an ambulance. If we find someone in arrest and choose not to work it or call efforts after a rescuitation attempt, the body would be left there. If they arrest in the ambulance, they are going to be worked (pending DNR status). I suppose if you pulled over to work the code and then decided efforts were futile you would be pronouncing them dead in the ambulance, but really how common is that?


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## DesertMedic66 (Jan 1, 2013)

Tigger said:


> I can't figure out why anyone would be declared deceased in the physical confines of an ambulance. If we find someone in arrest and choose not to work it or call efforts after a rescuitation attempt, the body would be left there. If they arrest in the ambulance, they are going to be worked (pending DNR status). I suppose if you pulled over to work the code and then decided efforts were futile you would be pronouncing them dead in the ambulance, but really how common is that?



So if you have a DNR patient who codes while enroute to the hospital do you not declare them deceased while in the ambulance?


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## Tigger (Jan 1, 2013)

firefite said:


> So if you have a DNR patient who codes while enroute to the hospital do you not declare them deceased while in the ambulance?



Sorry I meant to add outside of DNR situations. And for what it's worth no one on my truck will be declared dead since we are 99% of the time straight BLS.


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## medicdan (Jan 1, 2013)

Its worth noting that many states have statutes making it illegal for dead bodies to be transported by an ambulance-- except in the case of extreme public health emergencies. Be sure to note these laws, if you plan on transporting a corpse.


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## fortsmithman (Jan 1, 2013)

Aidey said:


> True story. No one dies in an ambulance. They had a pulse until the second you walked through the door of the building.
> 
> Otherwise the ambulance has to park and stay out of service until the medical examiner, coroner or mortuary can get around to taking care of the body. It isn't a pretty situation.



With my service we are responsible for body pickup.  If someone passes away during transport they are taken to the morgue directly.  My services chief is also a Coroner.


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## Handsome Robb (Jan 1, 2013)

People aren't arguing whether EMS can declare or not, it's whether patients are declared in the ambulance. From the sounds of it it varies from system to system, like most things.



firefite said:


> So if you have a DNR patient who codes while enroute to the hospital do you not declare them deceased while in the ambulance?



Absolutely not. 

Unless you want to explain to my supervisor, for me, why I'm out of service for 5+ hours waiting on the coroner  

I've never been put in the situation before but everyone has told me the same thing Aidey said. 

"They lost their pulse as we were unloading, their a DNR, sorry :-/ "


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## firecoins (Jan 1, 2013)

DNR takes presedence. If they die while enroute to the ER and they code, thats it! We don't work it. We inform the receiving facility MD. ER receives the body. No waiting for a cornoner. 

We don't pick up dead bodies so if its an obvious death, we dont transport unless its in public or the police say so. We go to the ER with it. 

Everyone else who codes enroute is worked up.


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## leoemt (Jan 1, 2013)

Aidey said:


> True story. No one dies in an ambulance. They had a pulse until the second you walked through the door of the building.
> 
> Otherwise the ambulance has to park and stay out of service until the medical examiner, coroner or mortuary can get around to taking care of the body. It isn't a pretty situation.



I had to babysit a body last month because Medics pronounced a death in the back of their rig and had a 2 hour eta from the ME's office. Had the pronounced him on the ground the PD would have babysat him but nope had to do it in the back of their rig. 

Since I am BLS and can't pronounce death (except very obvious like decapitation) noone dies in my rig. Got to get them in the ER for them to die.

In the case of a DNR - if I have the DNR in my possession then I will honor it. If its not in my possession or is invalid then they are treated like anyone else and all efforts will be made. It doesn't matter if they tell me they have a DNR or POLST I have to have it in my hand and it needs to be valid.


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## DesertMedic66 (Jan 1, 2013)

Per our county or company policy (can't remember which one) we are supposed to pull over to a safe spot and contact the Corner and then follow his/her directions. 

The "he coded as we were unloading" won't work in our system. Sometimes the hospital will let us put the gurney into a closed room and wait but the body stays on the gurney.


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## med51fl (Jan 2, 2013)

NVRob said:


> People aren't arguing whether EMS can declare or not, it's whether patients are declared in the ambulance. From the sounds of it it varies from system to system, like most things. "



:deadhorse:


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## VirginiaEMT (Jan 2, 2013)

emt.dan said:


> Its worth noting that many states have statutes making it illegal for dead bodies to be transported by an ambulance-- except in the case of extreme public health emergencies. Be sure to note these laws, if you plan on transporting a corpse.



I wish that applied to us. What a tremendous waste of time for EMS providers and takes away our ability to respond to another emergency if called upon. We will transport to the morgue or even the funeral home if requested to do so. Most time the funeral home personnel comes to the location to get the body.


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## Christopher (Jan 2, 2013)

emt.dan said:


> Its worth noting that many states have statutes making it illegal for dead bodies to be transported by an ambulance-- except in the case of extreme public health emergencies. Be sure to note these laws, if you plan on transporting a corpse.



We transport them all the time (which I find silly...we're an ALS ambulance...).


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## Kevinf (Jan 2, 2013)

leoemt said:


> Since I am BLS and can't pronounce death (except very obvious like decapitation...



Head falls off in the rig... should have held c-spine!


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## Jon (Jan 3, 2013)

I've always made it a goal to have a life-neutral ambulance. They don't die in the truck, and they damn sure aren't born in the truck (that's a MESS). I've been successful on the 2nd half, anyway - so far.

As for "what to do when the DNR patient dies" - If you're doing these runs with a valid DNR, that should be discussed and understood. Options include diverting to the closest ED, returning to sending facility, proceeding to destination, or even going to a different facility (like an ED close to the intended destination).

For example, I did a hospice discharge to home a few weeks ago for a VAD patient w/ a valid out-of-hospital DNR. Plan was to divert to closest appropriate ED, and I had phone numbers for the CRNP that was overseeing that patient's care to consult if I had a issue. He made it home OK, if you're wondering.

In the end, even with a DNR, someone has to fill out the death certificate. If the ME/Coroner has to do it - they need to do some type of investigation. If patient's primary doc is willing/able to sign the death certificate, then the ME might not need to do ANY investigation. These things are best discussed with your management and the sending facility staff BEFORE doing the run. In my case above, I had several names and numbers written on the back of my paperwork envelope, just in case. I didn't need any of them.

I would say that the concept of lying and saying the patient "just stopped breathing" is a bad idea. Your PCR is legal documentation, etc, etc, etc. Should the death be investigated, it might come out that they had been dead for some time on arrival at the facility (my trip referenced earlier was ~90 minutes due to traffic). That would make the whole thing much MORE suspicious than just saying "uh, he seems to have died"


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## WuLabsWuTecH (Jan 3, 2013)

medic417 said:


> People die in the ambulance.  Only idiots claim otherwise.  That t-shirt no one dies in the ambulance along with the emts save paramedics t -shirt need to all be piled up together and burned and never mentioned or seen again.
> 
> If you are doing CPR they are dead.  If you are doing CPR while ambulance is rolling you are doing crappy CPR and your system is archaic for allowing it.



Um... Auto-Pulse?  And you can actually do pretty decent CPR in the back of the medic depending on what kind of roads you are on.  But seeing as how in 2012 I had at least 3 codes that ROSC'ed while doing CPR/ACLS in the back of the medic I think that there are appropriate times and places for it.



medic417 said:


> They are declared frequently on board ambulances.  No issues.  Wheel the corpse out and into the hospital or the morgue or move onto funeral homes cot, etc and go back into service just like any other call.





Aidey said:


> We can declare also. The issue at my agency is specifically declaring in the back of the amb.





Tigger said:


> I can't figure out why anyone would be declared deceased in the physical confines of an ambulance. If we find someone in arrest and choose not to work it or call efforts after a rescuitation attempt, the body would be left there. If they arrest in the ambulance, they are going to be worked (pending DNR status). I suppose if you pulled over to work the code and then decided efforts were futile you would be pronouncing them dead in the ambulance, but really how common is that?



This.  I can't figure out why anyone would pronounce in the back of the medic either.  If they are DNR, you call them on scene or call the coroner on scene.  If you work them on scene for the required amount of time (in our case 20 minutes) then you make a transport decision.  IF you decide to call it, you call it right there.  If you decide to transport, you are committed.  In our protocol, as in most, if they have a spontaneous pulse at any time while the crew is present, they are worked all the way to the hospital.  The only exception I can think of is a DNR patient who walked onto the ambulance and then coded enroute to the hospital.  In our system, they still get sent to the hospital to be pronounced.



JPINFV said:


> Well, of course. If they're dead in a bus you're screwing up the entire bus route and inconveniencing hundreds of people.
> 
> ...now what about dead in an ambulance?


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## medic417 (Jan 3, 2013)

The only time a patient is worked in the ambulance is if they code in the ambulance.  The ambulance stops.  Code is worked in non moving ambulance because despite anecdotal statements science actually backs working them when not moving.  When pronounced we either drop them at the hospital if near it or we meet the funeral home van and move the body over to them.  

If they code before we get in ambulance they are worked on scene.  Body turned over to funeral home.


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## medictinysc (Jan 6, 2014)

kevinf said:


> head falls off in the rig... Should have held c-spine!




rofl. Lmbo


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## medictinysc (Jan 6, 2014)

medic417 said:


> The only time a patient is worked in the ambulance is if they code in the ambulance.  The ambulance stops.  Code is worked in non moving ambulance because despite anecdotal statements science actually backs working them when not moving.  When pronounced we either drop them at the hospital if near it or we meet the funeral home van and move the body over to them.
> 
> 
> 
> If they code before we get in ambulance they are worked on scene.  Body turned over to funeral home.




That is a great idea but in my system it wouldn't work. We have a LUCAS for compressions enroute.  I personally don't drive a true cardiac arrest in code but they are people in my system that do. It's left up to the individual medic.  We get to use our brains instead of a cookbook.


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## Brandon O (Jan 7, 2014)

Clearly this is 100% different everywhere.

I love when people assume that everything they do in their system, no matter how major or minor, is clearly the only way to do it...


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## exodus (Jan 7, 2014)

Pretty much anywhere in the country, BLS must divert to ER to confirm the death. As far as I know in pretty much any system, pulseless, apenic, unresponsive, isn't an obvious sign of death and may not be called by a BLS crew. 

Divert to ER, say you're transporting a patient with a DNR, who appears to be pulseless and apenic, but you are unable to verify this due to the lack of an EKG. You are transporting to the ER to confirm your suspicion.  For all you know, the pt has gone into V-Tach and may convert himself out of it.


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## DesertMedic66 (Jan 7, 2014)

exodus said:


> Pretty much anywhere in the country, BLS must divert to ER to confirm the death. As far as I know in pretty much any system, pulseless, apenic, unresponsive, isn't an obvious sign of death and may not be called by a BLS crew.
> 
> Divert to ER, say you're transporting a patient with a DNR, who appears to be pulseless and apenic, but you are unable to verify this due to the lack of an EKG. You are transporting to the ER to confirm your suspicion.  For all you know, the pt has gone into V-Tach and may convert himself out of it.



A Pt. who is pulseless, apneic, and with a DNR is enough for EMTs in our county to determine death. I highly doubt there is a hospital that would let us hand over the patient to them. 

County protocol (when transporting a patient who passes away during transport is to stop at a safe location, contact the coroners office, give a report to them, and follow their directions.


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## exodus (Jan 7, 2014)

DesertEMT66 said:


> A Pt. who is pulseless, apneic, and with a DNR is enough for EMTs in our county to determine death. I highly doubt there is a hospital that would let us hand over the patient to them.
> 
> County protocol (when transporting a patient who passes away during transport is to stop at a safe location, contact the coroners office, give a report to them, and follow their directions.



REMS Policy 5620.6:
http://remsa.us/policy/2011/5620.pdf


> In the event the patient expires en route, the following should be considered:
> 6.1 Unless specifically requested, the patient should not be returned to a private residence or skilled nursing facility.
> *6.2 Continue to the destination hospital or return to the originating hospital if the time is not excessive.
> 6.3 If transport time would be excessive, divert to the closest hospital. *
> ...


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## DesertMedic66 (Jan 8, 2014)

exodus said:


> REMS Policy 5620.6:
> http://remsa.us/policy/2011/5620.pdf



That policy/protocol is from 2008 (So its a little outdated). The protocols we have been using are different from '08.

http://www.remsa.us/policy/

Policy 4203:



> When the decision not to attempt / to discontinue resuscitation has been made during transport:
> *1. Stop in a safe location without crossing county lines
> 2. Comfort and care for any survivors present
> 3. Contact the County of Riverside Coroner's Office, give report, and answer all applicable questions
> ...


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## exodus (Jan 8, 2014)

Huh that's weird, I used the search policy option at the bottom and that's the first one that it brought up.  Ah well. I guess we sit out of service for hours!


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## Ironman (Jan 8, 2014)

Interesting.


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## dixie_flatline (Jan 8, 2014)

medic417 said:


> The only time a patient is worked in the ambulance is if they code in the ambulance.  The ambulance stops.  Code is worked in non moving ambulance because despite anecdotal statements science actually backs working them when not moving.  When pronounced we either drop them at the hospital if near it or we meet the funeral home van and move the body over to them.
> 
> If they code before we get in ambulance they are worked on scene.  Body turned over to funeral home.



Are you a 911 service?  There's no way we are allowed to offload a body to a funeral home.


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## lilith88 (Jan 8, 2014)

*ummm*

hmmmm that's a good question lol


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## unleashedfury (Jan 9, 2014)

dixie_flatline said:


> Are you a 911 service?  There's no way we are allowed to offload a body to a funeral home.



Good question I know we are not allowed to turn a body over to the funeral home, it must go to the county coroner first since it was an out of hospital death, Similar is if you are admitted to the hospital and die within the first 24 hours of admit. must go to a coroner first.


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## mycrofft (Jan 9, 2014)

In the recent case of the young lady who died and her parents are keeping her on life support nonetheless, the hospital where she was declared had to process it through their coroner's office before theory would or could release the remains/patient for transport to another medical facility.

Back to the initial title: no, people _*die*_ in ambos every day, but they are usually _*declared*_ in the receiving facility. They don't die in convalescent homes because they are slid into an ambulance *just before* their last breaths.


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## Akulahawk (Jan 9, 2014)

I forget which county it's in, but one of the counties where I used to work has a policy where DNR patients can be transported directly to a funeral home if the patient dies during transport. However, such arrangements must be known ahead of time which funeral home we were to go to. I don't think I've ever heard of that being done in practice. If that info wasn't known (never was) we were to divert to the nearest receiving facility. Those facilities were supposed to determine also that the patient was actually dead and then the body would be moved to their morgue. The county did things that way because they didn't want too many ambulances out of service while they waited for the coroner's crew. The patient care report was to be completed so that it could be turned over to the Coroner's Office with the body for their investigative purposes.


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## mycrofft (Jan 9, 2014)

Akulahawk said:


> I forget which county it's in, but one of the counties where I used to work has a policy where DNR patients can be transported directly to a funeral home if the patient dies during transport. However, such arrangements must be known ahead of time which funeral home we were to go to. I don't think I've ever heard of that being done in practice. If that info wasn't known (never was) we were to divert to the nearest receiving facility. Those facilities were supposed to determine also that the patient was actually dead and then the body would be moved to their morgue. The county did things that way because they didn't want too many ambulances out of service while they waited for the coroner's crew. The patient care report was to be completed so that it could be turned over to the Coroner's Office with the body for their investigative purposes.


Sort of flattering to be considered like a physician as far as the "unattended death" thing goes, but also really scary.

http://www.emtlife.com/showthread.php?t=36595


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## ZombieEMT (Jan 10, 2014)

exodus said:


> Huh that's weird, I used the search policy option at the bottom and that's the first one that it brought up.  Ah well. I guess we sit out of service for hours!



Absolutely. Crap happens. Nobody wants to sit out of service with a dead body for hours, but crap happens. Mutual aid exists for a reason. Also have the option of contacting a supervisor to babysit or switch out crew. Its not as bad as it seems.


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## ZombieEMT (Jan 10, 2014)

I do not know if there is applicable state laws, but in all three departments that I work with, we pull over and contact police. The hospitals are reserved for living patients, not dead. Many local hospitals do not have a morgue unit and have to be transported elsewhere when they die in the hospital.

Normally the steps in a DNR patient who dies in route.

1. Pull ambulance over to safe location. 
2. Contact on duty supervisor and/or medical director.
3. Contact police department.
4. Contact patient's PCP, county medical examiner or hospice care physician.
5. Contact county coroner.

(If death occurs on an EMS call, ALS can perform a pronouncement after contacting medical command.)


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## mycrofft (Jan 10, 2014)

ZombieEMT said:


> I do not know if there is applicable state laws, but in all three departments that I work with, we pull over and contact police. The hospitals are reserved for living patients, not dead. Many local hospitals do not have a morgue unit and have to be transported elsewhere when they die in the hospital.
> 
> Normally the steps in a DNR patient who dies in route.
> 
> ...



Here in central CA, just call the office and see if they will make the call to law enforcement. I bet the supervisor will want to do the notifications and document them.


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