# Dispatched to residence "person not breathing"



## rhan101277 (Jul 28, 2008)

You are dispatched to a residence for a "person not breathing." Upon arrival, you find a 78-year-old female with a cardiac history who is apneic and pulseless. She also shows signs of rigor mortis and dependent lividity. The family is extremely upset and asking you and your partner to do something. How would you best manage this situation?


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## MMiz (Jul 28, 2008)

First, I'd hook up the AED and see what it says.  I'd get a background from the family, as to when they noticed the patient's condition, call for ALS for EKG, and possibly move the patient into the ambulance if the scene got too far out of control.  If the patient's family really wanted the patient worked, we'd work the scene until we could contact med control and be told otherwise.

Per our protocols:

*Medical reasons not to start CPR include the following:
*A. Patient *without vital signs*, plus
B. Any one of the following are present:
     1. decapitation
     2. gross dismemberment of the body
     3. full thickness, total body burns
     4. body decay and putrefaction
     5. body frozen solid
     6. *rigor mortis*
     7. *lividity*
     8. head trauma with brain matter exposed
     9. underwater submersion greater than two hours


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## rhan101277 (Jul 28, 2008)

So you would work patient until coroner arrived?


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## MMiz (Jul 28, 2008)

Heck no, no coroner.  I'd contact med control with:
1.  Physical exam results, with vitals
2.  Tell them how the 'ole AED worked out.  ALS would have been on scene before I contacted med control, so they'd present results of 12 lead.
3.  I'd explain the patient's history, advance directives (if they exist), and what the on-scene family, physician, power of attorney wants.  

Med control will either pronounce the patient, have us provide comfort care, BLS, or ALS services, or ask for additional information.

If we end up pronouncing the patient, I'd
1.  Document time of death
2.  Document med control doctor's name and hospital
3.  Call PD
4.  They or dispatch would call local medical examiner.
5.  Body stays where it is until they do something with it.
6.  All medical treatments (ET tube, IVs, etc) will remain in/on patient.


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## BossyCow (Jul 28, 2008)

rhan101277 said:


> So you would work patient until coroner arrived?



okay, stop and think.. re-read the post above.. How are you going to 'work a pt' who is missing a head, or who has rigor and lividity? I think this will become more clear after you've seen a few of these. It's just not appropriate to start thumping on grandma as a show of 'doing something' for the family. Working a code is not pretty and to those unacquainted with EMS can appear pretty brutal. We would be doing no favors to the family by putting their loved one's corpse through that process while they watched. 

The protocols stated say.. 'reasons to not start CPR'
that means we would not start CPR. 

While the family doesn't understand the mechanism of death and is asking us to 'do something' it becomes our role to gently and respectfully inform them that their loved one has passed on. I would not go beyond hooking up the EKG and recording asystole in at least 2 leads per our protocols. If necessary, I would show the family the tape and ask if they needed me to call anyone for them. I would remain on scene until the coroner arrived. In our district that's the local sheriff's department. 

The patient in this case is not the 78yo female, but the family. Denial is part of the grief process, as is anger. You will see both of those often if you stay in EMS.


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## KEVD18 (Jul 28, 2008)

send the probie back to the truck with all the gear we brought in.

sit down with the family and tell them its over. 

call my super and have them start the medical examiner and find out whether or not i ahve to wait for them.

pulseless/apneic, dependant lividity and rigor. they are dead. say it with me, DEAD. theres nothing you can do for them. dont even try. dont pass go, dont hookup the aed/monitor. nada. its all wasted energy and supplies.

i dont need med control in this case. its in my protocols.


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## MedicPrincess (Jul 28, 2008)

Pulseless, Apenic, Rigor....  It would go something like this......


"Med 1, Rescue.....  Signal 7, call TIPS."

No medical control needed.  She is Dead.  78 yo, Cardiac Hx, probably all the Alphabet diseases to go with it.... She's gone.

Thank the FD for all their help, send them off so they can get back in service.  But not before they help my partner carry everything back to the truck.

I would sit with the family and have the "there's nothing we could do" talk.  Answer what questions I can, while getting the information I need.  Depending on the situation, I may stay on scene until TIPS can get there, but usually not.  Give our info to SO on the way out the door and get back in service.

"Standard" DOA, without mitigating factors, On Scene to Available.... about 15 minutes..... maybe 20 if there are problems getting patient info.


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## Ridryder911 (Jul 28, 2008)

Usually Fire Department may beat us and cancel before arriving. If we do arrive get a little H & P and billing info (yes, we can and do charge for declaration) and some counseling to the family until P.D. arrives or F.D. can assume and EMS goes back into service. If I am the Field Supv. I will cancel the unit and get the info, no need for additional people. 

R/r 911


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## KEVD18 (Jul 28, 2008)

im very glad, and not ashamed to say suprised, that nobody is actually working this patient.

then again, most of the responses so far are from the "senior staff" if you will of this asylum.


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## rhan101277 (Jul 28, 2008)

Good job.  I at first though it would be rough to just leave a dead relative in their home with their family.  Which led me to answer, transport them, then I just realized that would probably give them false hope.

Here is the correct answer:

Say, I am sorry. Explain why CPR will be ineffective. Tell them, if you want to cry, it is okay. Notify your supervisor, dispatcher, or coroner as protocols dictate. Offer a hug and just listen.


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## traumateam1 (Jul 29, 2008)

Well.. Just like everyone else has said. *Don't work the patient.*She is obviously in criteria for the med. control to be called and call the time of death, and have the talk with the family about how nothing could of been done for her. As mentioned before I would put on the AED just incase this ends up in court, and also for proper paper work. Allow dispatch to contact PD and coroner to come out.


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## KEVD18 (Jul 29, 2008)

use of an aed isnt not the same as a monitor. what i mean by that is you cant confirm(at least legally) the absence of electrical activity with it. sure, some have a lead II display, but not all. with a monitor you can "confirm the absence of electrical activity in two leads". but application of the aed is providing treatment. you have begun the arrest algorithm. 

now, maybe some of you all have protocols that say to use an aed for this purpose. i know mine sure dont. if i did that, id catch it from all angles. my olmc doc would chew me out for beginning treatment in a patient with signs inconsistent with life. oems would shred my ticket for not knowing my protocols. and to top it all off, my service would write me up for uselessly using a set of aed pads.


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## firecoins (Jul 29, 2008)

rhan101277 said:


> She also shows signs of rigor mortis and dependent lividity.


rnuff said. turn around and go home.


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## firecoins (Jul 29, 2008)

KEVD18 said:


> but application of the aed is providing treatment. you have begun the arrest algorithm.
> 
> now, maybe some of you all have protocols that say to use an aed for this purpose. i know mine sure dont. if i did that, id catch it from all angles. my olmc doc would chew me out for beginning treatment in a patient with signs inconsistent with life. oems would shred my ticket for not knowing my protocols. and to top it all off, my service would write me up for uselessly using a set of aed pads.



Thats ridiculous. Putting on an AED is not providing treatment.   If you have no pulses and no shockable rhythym, we are allowed to call it.


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## reaper (Jul 29, 2008)

firecoins said:


> Thats ridiculous. Putting on an AED is not providing treatment.   If you have no pulses and no shock-able rhythm, we are allowed to call it.



Not talking this pt!

 Just because an AED says "no shock-able rhythm", does not me you can call it! What if they are in PEA? This is why AED's are not used as a final decision maker. 

You need a MONITOR!


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## mikeylikesit (Jul 29, 2008)

Cover up the patient, call med control. the patients family will usually look at you in horror saying that you're not doing your job, you have to explain to them that if the patient had been discovered sooner you may have been able to do more(without making the family feel like it was there fault for not fining the body sooner, very tricky)


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## CFRBryan347768 (Jul 29, 2008)

rhan101277 said:


> Good job.  I at first though it would be rough to just leave a dead relative in their home with their family.  Which led me to answer, transport them, then I just realized that would probably give them false hope.
> 
> Here is the correct answer:
> 
> Say, I am sorry. Explain why CPR will be ineffective. Tell them, if you want to cry, it is okay. Notify your supervisor, dispatcher, or coroner as protocols dictate. Offer a hug and just listen.



I agree...upuntil the hug part.


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## Jon (Jul 29, 2008)

At my full time job - these work really simply. We pull up... PD (almost all EMT-B's) looks at us, tells us they are dead, but would like us to do an EKG to be sure.

We walk in... Rigor mortis in a warm environment and dependent lividity are both enough, on their own, for a BLS provider in PA to presume death. We usually do an EKG to confirm, usually call Medical Command to ensure that they are aware, and then between us and the PD, we contact the coroner's office and notify them. We explain the entire situation to the family and make sure they are OK. (a LEO might remain onscene with a spouse who was alone until someone else can get there to be with them).

If I was approching this from the BLS perspective - I'd call command, let the doc know what my findings are, and as long as he's onboard, call the Deputy Coroner on duty.

Jon


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## MMiz (Jul 29, 2008)

My protocols for BLS termination of care/pronouncement of death read:



> Procedure for obtaining a pronouncement of death, due to cardiovascular unresponsiveness include the following:
> A. Present to the medical control physician results of the physical examination, including vital signs.
> B. Present results of cardiac monitoring or use of AED _(if applicable)_.



Truth be told, at the BLS level I'd probably have the AED on fairly quickly after arriving on scene (per AHA).  I've never seen or felt rigor mortis in person, but I assume that it would be something discovered while doing a physical exam of the patient.  Again, wouldn't the AED be on?


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## rhan101277 (Jul 29, 2008)

So even paramedics have to call to get permission to say the pt is dead?  Or if the protocols exist can you call it anyway?  I thought I remember reading somewhere that only a doctor can say someone is dead.


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## firecoins (Jul 29, 2008)

reaper said:


> Not talking this pt!
> 
> Just because an AED says "no shock-able rhythm", does not me you can call it! What if they are in PEA? This is why AED's are not used as a final decision maker.
> 
> You need a MONITOR!



I am the final decision maker and yes I am allowed according to local protocol.


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## reaper (Jul 29, 2008)

Glad I don't live in that state.


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## BEorP (Jul 29, 2008)

As a Primary Care Paramedic in Ontario I would not need to treat this patient and would not need to call a physician to make this decision for me.


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## MMiz (Jul 29, 2008)

BEorP said:


> As a Primary Care Paramedic in Ontario I would not need to treat this patient and would not need to call a physician to make this decision for me.


That's what I call progressive protocols!


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## MedicPrincess (Jul 29, 2008)

rhan101277 said:


> So even paramedics have to call to get permission to say the pt is dead? Or if the protocols exist can you call it anyway? I thought I remember reading somewhere that only a doctor can say someone is dead.


 
As a Paramedic, I can call it. I do not need to make contact with medical control..... I can also stop and call it after CPR has been started. Sucessful Intubation, 2 rounds of drugs, Asystole still present on the monitor = Signal 7 (DOA). 


Straight from my protocols... And of course, at the end of every protocol we have is the "contact Med Control if any questions arise."



*Resuscitation should not be attempted in the field in cases of*:



Rigor mortis



Decapitation
Decomposition 
Dependent lividity.
Incineration 
Obvious massive head or trunk trauma, which is incompatible with life (provided the patient does not have vital signs.)
If asystole on the cardiac monitor and any four (4) of the following are present: 
Vital signs absent 
Pupils fixed and dilated
Advanced age and/or general physical condition of the patient would indicate no resuscitative measures should be taken.
The length of time in arrest with no resuscitative measures is longer than compatible with life
No independent influences are evident such as drugs or cold
Terminal illness that indicates no resuscitative measures should be taken

Other obvious signs of death 
The victim of blunt trauma who is pulseless, apenic, and without a palpable blood pressure or heart tones upon arrival of BLS or ALS providers.
The victim of a multicasualty incident in cardiopulmonary arrest whose use of prehospital care resources would jeopardize the care, health, or well-being of other critically ill or injured patients or the providers at the scene of accident, injury, or illness.
The patient who, upon arrival of EMS personnel, is attended by a physician licensed in the State of Florida; AND where the physician is willing to write a statement of his relationship to the patient, a "do not resuscitate" order, and a rationale for this order on the run report. EMS personnel must attempt to verify the identity of the physician before withholding cardiopulmonary resuscitation.
A patient whose personal physician communicates via telephone that resuscitative effort should not to be initiated or resuscitative efforts should be discontinued. The physician must agree to accept the responsibility for pronouncing the patient dead to at least two (2) emergency personnel (EMT, paramedic, and law enforcement) via the telephone. The witnesses MUST sign the EMS Run Report.



*IF resuscitation was initiated, consider discontinuing efforts in the field if:*
A patient remains in asystole in three leads despite being properly intubated, ventilated, and given several rounds of ACLS drugs (epinephrine and atropine) and/or failure of early transcutaneous pacing. 
Effective spontaneous ventilation and circulation have been restored.
Resuscitation efforts have been transferred to persons of no less skill than the initial providers.
The rescuer is exhausted and physically unable to continue resuscitation.


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## BossyCow (Jul 30, 2008)

Just some clarification on the semantics here. We in the field can make the determination not to start CPR. Once that determination is made, we call med control, inform them of what we see that supports our decision to not start CPR due to the pt meeting the criteria of "obvious death". At that time, Med control 'calls it' On our reports, we document that med cont. stated time of death as..... attach the strip of asystole in at least 2 leads... document the lividity and rigor and leave the body with the sheriff/coroner.

So technically, I don't think we are calling the code, but the doc is based on what we tell him.


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## MedicPrincess (Jul 30, 2008)

BossyCow said:


> Just some clarification on the semantics here. We in the field can make the determination not to start CPR. Once that determination is made, we call med control, inform them of what we see that supports our decision to not start CPR due to the pt meeting the criteria of "obvious death". At that time, Med control 'calls it' On our reports, we document that med cont. stated time of death as..... attach the strip of asystole in at least 2 leads... document the lividity and rigor and leave the body with the sheriff/coroner.
> 
> So technically, I don't think we are calling the code, but the doc is based on what we tell him.


 

As stated before... I DO NOT have to call med control before deciding to not to work a code.  If CPR has been started, we can also call it without calling med control.  Med Control is only RECOMMENDED if we have intubated, got our line, and pushed 2 rounds of drugs.


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## mikeylikesit (Jul 30, 2008)

Just so were all clear, an AED is not a diagnostic tool to determine a death. i don't care if you have the new one that can show a rhythm off of two leads it is not definitive enough. I will not waste the pads on something that i feel is irrelevant for the matter, i will use my monitor.


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## SCFD8REZ (Jul 30, 2008)

The fact that the person is DOA can only be determined after the initial assesment, obviously the first thing everyone should do in this case is the initial assesment and only after this would you find out that the patient is displaying signs of Rigor Mortis, as well as no pusle, and no active respirations. Everyones protocols are a little different and everybody has different prefrences, there are many people in my organization who would say, " you know what, nobody is ever going to yell at you for trying to save a life.But they will for sure yell at you if they wake up half way to the funeral home and you didnt even try." This type of call is very common in my district being that we have three nursing homes within one mile of the station. If there was obvious RM that is a tell tale sign of death, this person will be cold to the touch and lifeless, which means they have probably been there for a while . You can now only help the family with the grieving process. This is a very clear cut call.


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