# EMS and the holy water



## Stevo (Dec 28, 2005)

i thought i'd ask around here, seems different locales have a slightly different take of declaring death. 

where and when is it appropriate for ems to call  it quits?

may i start off with a popular joke.....

_*Cross Examining The Coroner*


A defending attorney was cross examining a coroner. The attorney asked, "Before you signed the death certificate had you taken the man's pulse?" The coroner said, "No." 

The attorney then asked, "Did you listen for a heart beat?", and again the coroner said, "No." 

Then the attorney asked, "Did you check for breathing?", and again the coroner said, "No." 

"So when you signed the death certificate you had not taken any steps to make sure the man was dead, had you?" 

The coroner, now tired of the brow beating said, "Well, let me put it this way. The man's brain was sitting in a jar on my desk, but for all I know he could be out there practicing law somewhere."_

~S~


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## Jon (Dec 28, 2005)

Dependant lividity, decapitation, non-survivable trauma (in arrest and entrapped), full evisceration, and SOMETIMES rigor mortis in a warm enviroment.

Cold-water drownings get worked, usually.


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## SafetyPro2 (Jan 4, 2006)

For BLS, here's our criteria. If the patient is pulseless and apneic and has the following, we can "determine" death and withhold treatment.

Decapitation
Incineration
Decomposition
Massive crush injury
Evisceration of heart, lung or brain tissue
Extrication >15 minutes and unable to provide resuscitative measures
MCI with insufficient resources (i.e. a black triage tag)
Drowning with submersion >1 hour 
Rigor mortis
Post-mortem lividity

For the last two (rigor and lividity), we're also required to do the following:
- open the airway, look/listen/feel, then auscultate the lungs for 30 seconds
- auscultate the apical pulse for one minute and palpate the carotid (or brachial for infants) for 60 seconds
- check pupil response and response to painful stimuli (which for us is limited to interdigital pressure)

For ALS, they can use the same criteria, or upon contacting the base hospital, the base physician can "pronounce" death based on the ALS unit's findings and report.


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## TTLWHKR (Jan 4, 2006)

*DEAD ON ARRIVAL (DOA)
STATEWIDE EMS PROTOCOL​Criteria:
*A. Patient presenting with the following
1. Decomposition.
2. Rigor mortis (Caution: do not confuse with stiffness due to cold environment)
3. Dependent lividity.
4. Decapitation.
5. Unwitnessed cardiac arrest of traumatic cause.
6. Traumatic cardiac arrest in entrapped patient with severe injury that is not compatible with
life.
7. Incineration.
8. Submersion greater than 1 hour.
B. In cases of mass casualty incidents where the number of seriously injured patients exceeds the
personnel and resources to care for them, any patient who is apneic and pulseless may be
triaged as DOA. 
*1 Exclusion Criteria:
*A. Obviously pregnant patient with cardiac arrest after trauma, if cardiac arrest was witnessed by
EMS practitioners. These patients should receive resuscitation and immediate transport to the
closest receiving facility. See Trauma Patient Destination Protocol # 180.
B. Hypothermia. These patients may be apneic, pulseless, and stiff. Resuscitation should be
attempted in hypothermia cases unless body temperature is the same as the surrounding
temperature and other signs of death are present (decomposition, lividity, etc…). See
hypothermia protocol #681.
*Treatment:

*A. *All patients:
*1. Initial Patient Contact – see Protocol # 201.
2. Verify pulseless and apneic.
3. Verify patient meets DOA criteria listed above.
a. *If any doubt exists, initiate resuscitation and follow Cardiac Arrest Protocol # 331
and consider medical command contact.
*b. If patient meets DOA criteria listed above, ALS should be cancelled.
4. If the scene is a suspected crime scene, see Crime Scene Preservation Guidelines #919.
5. In all cases where death has been determined, notify the Coroner or Medical Examiner’s
office or investigating agency. Follow the direction of the Coroner or Medical Examiner’s
office/investigating agency regarding custody of the body.
*Possible Medical Command Orders:
*A. If CPR was initiated, but the medical command physician is convinced that the efforts will be
futile, MC physician may order termination of the resuscitation efforts.
*Note:
*1. In the case of multiple patients from lightning strike, reverse triage applies, and available resources
should be committed to treating the patients with no signs of life unless they meet the other criteria
listed above.


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## Stevo (Jan 4, 2006)

interesting .....


what about _unwitnessed_ codes, the ones where lividity hasn't quite taken place yet

what would it normally take anyways?  

~S~


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## nyc.ems (Jan 4, 2006)

if its a peds or infant,for the sake of parents and family,i would continue with cpr.lividity,rigor, and or obvios death on adultsits different.if no signs and not sure work them up...


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## TTLWHKR (Jan 4, 2006)

Stevo said:
			
		

> interesting .....
> 
> 
> what about _unwitnessed_ codes, the ones where lividity hasn't quite taken place yet
> ...


 

Call the funeral home.


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## FFEMT1764 (Jan 4, 2006)

Our protocols say the same thing as you guys already said with the addition of anyone in asystole that did not have a witnessed arrest...example you call freddo on the phone and tell him you are coming over...takes you 5 minutes to get from your place to his...you get there he is dead...he is not going to get worked...asytsole is asystole- it rarely changes back to something more workable...


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## coloradoemt (Jan 4, 2006)

FFEMT1764 said:
			
		

> Our protocols say the same thing as you guys already said with the addition of anyone in asystole that did not have a witnessed arrest...example you call freddo on the phone and tell him you are coming over...takes you 5 minutes to get from your place to his...you get there he is dead...he is not going to get worked...asytsole is asystole- it rarely changes back to something more workable...


 
I just had this conversation with the training instructor yesterday. Dead id dead unless it is a child and then it is situational. When it comes to kids, the parents are looked at as patients as well... sometimes.


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## FFEMT1764 (Jan 4, 2006)

Yes, unless the parents deaded the child, then the are suspects and contaminating a crime scene!


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## TTLWHKR (Jan 5, 2006)

> deaded


 
What'ed?  :unsure:


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## ffemt8978 (Jan 5, 2006)

Our criteria are the following:

Decapitation,
Inceneration
Evisceration of heart or brain
Rigor Mortis
Decomp


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## emtff376 (Jan 5, 2006)

Our BLS protocols do not spell out "death in the field", but ALS protocols do.

Here they are:

This protocol is designed to be used when EMS personnel encounter patients who are
dead at the time of arrival in which resuscitation is medically inappropriate or for use
immediately after the Cease-Effort Protocol 9102 has been performed.
A. Perform initial assessment as per any patient.
B. Determine history.
C. Criteria: The decision to not begin resuscitation may occur under the following
circumstances if ordered in consultation with MCP.
1. When there are changes to the body which indicate a prolonged postmortem
interval, i.e. decomposition, rigor in normothermic body.
2. Injuries incompatible with life such as decapitation or transection of torso.
3. Pulseless, apneic patients in multiple casualty situations where available
resources are required to maintain living patients.
4. Proper DNR documentation.
5. Resuscitation efforts pose a danger to the health and/or safety of the
rescuers.
D. Criteria: The decision to not begin resuscitation may occur under the following
circumstances by direct verbal contact and order of MCP.
1. Victims of trauma who are pulseless and apneic at the time of arrival of first
responders or EMS personnel.
2. Blunt trauma patients who become pulseless and apneic, cannot be
extricated quickly, and the entrapment precludes medically effective
resuscitation efforts.
3. Circumstances where beginning or continuing resuscitation is not medically
appropriate as determined by EMS personnel and direct contact with the
Medical Command Physician.
E. Procedure:
1. Contact Medical Command immediately and consult with MCP as required
in “C” and “D” above. Discuss situation and obtain confirmation that no
resuscitation is indicated.
2. After consultation with MCP, note exact time and date of declaration of
death.
3. Protect and preserve the scene until jurisdictional authority has been
determined as in #4 below.
4. Notify the Medical Examiner Authority (County or State) on all out-of-hospital
deaths except those registered with and receiving hospice care.
5. If the county authority is unavailable or does not call back within 10 minutes,
then contact the State Medical Examiner’s Office at 1-877-563-0426.
6. Unless hospice death, notify local law enforcement.
7. While awaiting return call from Medical Examiner Authority, collect the
following information:
a. Has patient been under the care of a regular attending physician. If
so, note the name and contact number. If death was expected,
attempt to contact physician and inquire if he or she will certify death
and sign the death certificate.
b. Past medical problems.
c. History and circumstances of death.
d. Inquire from family or those present about anatomical gift
documentation including drivers license or living will. Check for medic
alert tags concerning anatomical gift.
8. When Medical Examiner Authority calls, give above information. Medical
Examiner Authority will determine if case meets criteria for Medical Examiner
case. If yes, follow instructions from Medical Examiner.
9. If death does not meet criteria for Medical Examiner investigation, the
Medical Examiner Authority will release the body. Contact patient’s attending
physician and confirm the history and circumstances of the death. Assure
that the attending physician will certify the death and sign the death
certificate. Document the time and name of the physician. Assist family with
transport arrangements for the body to morgue or funeral home. If
anatomical gift information was discovered, then notify Medical Command
of the name and type of donation.
10. If the deceased has no attending physician or the physician refuses to certify
and sign the death certificate, then the case must be a Medical Examiner
case. Follow instructions of Medical Examiner.
11. EMS personnel are not required to transport the body, but may do so if
instructed and this is standard practice as a courtesy to the local community.
12. EMS personnel should document carefully the signs, symptoms, and vital
signs which confirmed and allowed the declaration of death. These facts
should be recorded in the patient care record.
13. For Medical Examiner cases, the hospital copy of the patient care record
should be completed and given to the Medical Examiner Authority if they are
on-scene or left with the body at the morgue if transport is made.

And here is the cease effort protocol (also ALS)

This protocol is designed to be used when in direct consultation with the Medical
Command Physician (MCP), the medical decision is made to discontinue resuscitation
efforts in the field and proceed to the Death in the Field Protocol 9101.
A. Criteria: EMS personnel may request orders to cease resuscitation efforts on a
patient in the field when any of the following are present:
1. Resuscitation initially started by first responders, family members, etc. is
determined to have been medically inappropriate (i.e. terminal cancer or
traumatic arrest).
2. Full cycle of ALS treatment has been unsuccessful and patient has been
confirmed pulseless and apneic by EMS for at least 20 minutes.
3. Proper “Do Not Resuscitate” documentation has been discovered or clarified
by family or power of attorney.
4. BLS resuscitation has proved unsuccessful and no ALS is available for an
extended period of time. Patient has been confirmed pulseless and apneic
by EMS for at least 20 minutes.
5. Physical exhaustion of available providers to provide care.
6. The scene environment is judged to be unsafe for rescuers to continue
resuscitation.
7. Extremely remote areas where evacuation may require hours or days.
B. Procedure:
1. EMS personnel will contact Medical Command and speak directly to the
MCP.
2. Specific history and details of care will be discussed and MCP will make final
decision, give final order to cease resuscitation, and note exact date and
time.
3. Proceed immediately to Death in the Field Protocol 9101.
C. Exceptions: The following situations may necessitate transport of patients and
continued resuscitation efforts per direct MCP order:
1. Volatile or potentially dangerous situations where movement of the patient
and exit from the scene is required for the safety of the rescuers.
2. Hypothermic patients. Treat per Cold Exposure Protocol 4503.
3. Pediatric patients less than 12 years of age.
Special Note: If patient is removed from scene and resuscitation continued, the
resuscitation efforts should be continued until arrival at the hospital.


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## FFEMT1764 (Jan 5, 2006)

TTLWHKR said:
			
		

> What'ed? :unsure:


Deaded= killed, murdered, aided in dying, etc...


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## TTLWHKR (Jan 5, 2006)

Yeah.. I got that..


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## coloradoemt (Jan 5, 2006)

FFEMT1764 said:
			
		

> Yes, unless the parents deaded the child, then the are suspects and contaminating a crime scene!


 
Exactly... Thats why I said sometimes...


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## FFEMT1764 (Jan 5, 2006)

Last pedi code I went to was 18 m/o that was found DRT...apparently baby was in bed with family and mom or dad rolled over on top of him and thats the end of that...very sad and tragic, but also very suspicios...:unsure:


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## ffemt8978 (Jan 5, 2006)

Just got back from a code.  We were toned to difficulty breathing, and when the chief gets there the guy collapses and goes into cardiac arrest.  Pt. shocked 9 times on scene with 4 rounds of CPR in between shocks.  Early ALS rendezvous and transport to hospital.  Pt. had pulses and was breathing when we dropped him off at the hospital.  1st shock delivered within 1 minute, and an average of 1 minute between shocks.  Pt. went into asystole then some type of idioventricular (sp) rate then back into v-fib.

Doc at the hospital is hopeful, especially considering our long transport time.


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## Ridryder911 (Jan 5, 2006)

Ours is somewhat unique... the usual conclussive signs of death however; our medical director does not want us to hook-them up of ECG. SHe describes that if you have to hook them up for conclussion of death, you should had worked them. 

We also have a policy of known documented pulseless activity of >15 min no resucitation efforts to be made unless special circumstances ( i.e cold water drowning, electrocution, etc).......
Be safe,
R/R 911


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## Stevo (Jan 5, 2006)

interesting replies.

what comes through as universal here, is that there IS no universally accepted method for those grey areas where a code _could_ be worked, or _could_ be called....

i don't suppose anyone has a (read-vieled copout) protocall in place merely for the sake of organ perfusion/donation? 

~S~


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## TTLWHKR (Jan 6, 2006)

FFEMT1764 said:
			
		

> Last pedi code I went to was 18 m/o that was found DRT...apparently baby was in bed with family and mom or dad rolled over on top of him and thats the end of that...very sad and tragic, but also very suspicios...:unsure:


 
That seems to be what happened in most of the infant deaths I've attended to. Bad place for a child...


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