# Priority 4 patients (DOA) and your agency?



## CANMAN (Mar 11, 2011)

So I am just curious as to how other states, departments, etc go about pronouncing a patient priority 4 on location and what requirements must be met. Also as a provider what assessment findings do you obtain before calling someone a priority 4 ie: just a pulse check or do you place a 4 lead and run a strip.

This may sound like a silly post but I recently started to work in a jurisdiction that allows Law Enforcement to pronounce patients priority 4 prior to EMS arrival. This is for both medical and trauma patients. This county is a very home grown type county in which most providers who work for my department are from the area and have come up in the system. I am pretty much the only provider who finds this odd and was wondering what other places are doing as far as PDOA protocols and if LE is able to pronounce or not. 

For example: We were responding to a GSW to the chest the other day, LE on the scene about 3 minutes ahead of us cancelled us because they called the pt. priority 4 upon their arrival. To me this is a trauma code is it not? There have been plenty of document cases of people being pronounced and later on it is found they aren't as dead as the providers thought........


----------



## MrBrown (Mar 11, 2011)

An Intensive Care Paramedic here is able to sign the deceased person certificate for the Police or Coroner.

If it is clinically inappropriate to resuscitate a patient in cardiac arrest we can decline to intervene e.g. asystole as initial rhythm in an unwitnessed arrest, patients dying from end stage cancer (where it is not in the best interests of the patient)

When the patient is clearly dead eg Nana died in the night at her daughters house we can call the family doctor and ask if he is comfortable signing the death certificate, if not, the Police must be informed and they either inform the Coroner if they think its suspicious or un-natural death (like Brown being found in bed with saran wrap over Browns face and claw marks around the nose and mouth and Mrs Brown going "I dont know he was alive when I left him!") or if they think its OK they can just call the undertaker


----------



## reaper (Mar 11, 2011)

In my service now LEO cannot confirm death, unless obvious it has been days. If it is a fresh death, they we check signs of life and run a strip. If there is obvious signs of death, then we just confirm and call the coroner.

My last service LEO was allowed to confirm prior to our arrival, for obvious death. Most would still call us in to confirm. This was a large city and there has never been a problem with LEO confirming death.


----------



## HappyParamedicRN (Mar 12, 2011)

Where I work the police cannot decide some is dead unless there is obvious decomposition.

We are pretty free in my state, if they are workable, work them for 15 minutes BLS  OR ALS and if no pulses are obtained then leave them.  Obviously it is also a judgement call on the part of the highest level provider on scene.  

We are also allowed to not work traumatic arrests if the are pulseless when we find them or if they should become pulseless during a prolonged extrication.

The statistics are there and AHA promotes the work them for 15 or 20 and leave them if no pulses are obtained theory.  We all know what the statistics are on traumatic arrest, so I will not go there....

Happy


----------



## LucidResq (Mar 12, 2011)

LE and EMS respond on all cardiac arrests automatically when we have info they are not breathing. EMS must respond to confirm DOA... there may be some situations I guess in which they wouldn't but I haven't heard of it even in unwitnessed arrests with days of possible down time, bad lividity, etc. 

Basically, trauma arrests with "injuries incompatible with life" which a bunch of different particulars can be called on scene. 

Medical arrests with no ROSC within 15 min of ALS resus or continuous asystole for 10 min in adults and 30 in peds can be called as well (except for hypothermia, women in late-term pregnancy, etc).


----------



## Anjel (Mar 12, 2011)

Here LE cannot pronounce. 

Paramedics can :
CPR IS TO BE INITIATED ON ALL PATIENTS IN CARDIAC ARREST UNLESS one or more of the following conditions exists:
A. Gross dismemberment of the body.
B. Decapitation.
C. Completely charred body without any detectable signs of life.
D. Obvious mortal wounds/conditions (injuries inconsistent with life – i.e., crushing injuries of the head and/or chest)
E. At least one hour of submersion documented by the licensed health care professional after arrival on the scene.
F. Putrefied, decayed, or frozen bodies and/or lividity with rigor mortis
G. Blunt or penetrating traumatic arrest found pulseless and apneic (without agonal respirations) without organized electrical activity (must be asystolic or other rhythm with rate less than 40/min). Patients with ventricular fibrillation, ventricular tachycardia or organized rhythms greater than 40/min should have resuscitation initiated. Patients not meeting these criteria should have full resuscitation and prompt transport initiated. Special attention should be taken so mechanism of injury is consistent with condition of the patient.
H. Patient has a valid “Do Not Resuscitate” identification bracelet or order.

*Specific Exceptions*
A. Patients who are struck by lightning, are hypothermic or victims of cold water drowning (unless submersion time is over 1 hour) do not qualify for use of this policy.


----------



## DrParasite (Mar 13, 2011)

at my FT job, a person is a cardiac arrest until an EMS providers declares them to be DOA.  once this happens, then ALS reduces their response to non-emergency to officially pronounce.

in Mercer County, ALS does not do pronouncements.  BLS or PD can declare a person DOA if they show signs of obvious death.  

most places outside of Mercer county do want an ALS unit and a doctor's name to officially pronounce a person, at least in NJ.


----------



## the_negro_puppy (Mar 13, 2011)

We can pronounce life extinct after a resus attmept, signs of obvious death, injuries incompatible with life.

The experiences I have had, the cause of death is not 100% certain so a death certificate cannot be issued. In this case police are called and we give them a life extinct form. The body is then taken by a Government contracted undertaker for an autopsy. After this the body is released to family.


----------



## Outbac1 (Mar 13, 2011)

I look for the obvious. No palapable pulse, no breath sounds, no auscultated heart beat, rigor, dependent lividity, cold in a warm enviroment, a body position or structural change incompatable with life. I rarely need to run a strip of aystole. Dead people tend to exhibit several of the above. 
 We don't sign death certificates but we do pronounce and sign our pcr. The time of death is the time we find them VSA, unless the coroner whishes to change it. Here all out of hospital deaths are investigated by the police. Even granny who died in the night. We give our findings to police and they or us call the coroner who decides if the funeral home can come and get them or if they need to go to autopsy. We clear scene and police get to wait for removal.


----------



## spike91 (Mar 13, 2011)

We call them code blacks in my region; and EMS can pronounce with certain obvious signs of death such as lividity, decapitations, and other similar indications of long standing or permanent death. I haven't personally had one (knock on wood), but I think its a matter of contacting med control, saying "This is what I've got, tell me I can officially call it" and viola.


----------



## Melclin (Mar 15, 2011)

Call takers here take into account the description of the deceased by the person calling. If they describe a person who is cold and dead in a warm environment and/or the downtime is reasonably suspected to be quite long, the ambulance response is downgraded so that we can confirm death rather than attempt resus.

I'm not entirely sure how this process differs for police vs a normal member of the public.

For RNs, paramedics, intensive care paramedics and midwives, the law allows us to "verify death" as opposed to "certify". Certification is MD only because it requires a cause of death. Verification was created so that bodies could be moved to more appropriate locations etc after death, without having to have a doctor. The MD can then certify much later. This has obvious benefits when the death is in a public place, happens out of office hours or where the presence of the body is causing the family unusually extreme upset.  

By the book, verification involves: 
-No palpable carotid pulse.
-No heart sounds heard for 2 minutes.
-No breath sounds heard for 2 minutes.
-Fixed and dilated pupils.
-No response to centralised stimulus.  and 
-No withdrawal response or facial grimace in response to painful stimulus. 
-OPTIONAL: ECG strip.

If they have indeed shuffled, the circumstances of death must be documented including taking into account the legal criteria for reportable and reviewable deaths, as well as the who's, whats and wheres of the person doing the verification. 

I heard once that we had toe tags on which to document stuff. I don't think I like that idea much


----------



## LucidResq (Mar 15, 2011)

Melclin said:


> Call takers here take into account the description of the deceased by the person calling. If they describe a person who is cold and dead in a warm environment and/or the downtime is reasonably suspected to be quite long, the ambulance response is downgraded so that we can confirm death rather than attempt resus.



I really wish we could make this judgment call. I truly hate being required to offer and encourage talking the caller through CPR when they're describing very clear signs of death such as lividity, pt being cold to the touch, even rigor.


----------



## Melclin (Mar 16, 2011)

LucidResq said:


> I really wish we could make this judgment call. I truly hate being required to offer and encourage talking the caller through CPR when they're describing very clear signs of death such as lividity, pt being cold to the touch, even rigor.



I'm not sure its necessarily a judgment call. They might have specific triggers that prompt them to ask sets of questions about signs of death etc. I'd like to know more about it. 

In any case though its much better than what you describe. That sounds awful. Not only does it put a person through the necessarily traumatic and messy experience of a resus but it offers false hope. I'd jump up and down and whinge about that if I were able too.


----------



## Pittma (Mar 16, 2011)

This is an extremely hypothetical case, but I am curious to know the answer:

"My husband and I were asleep and I woke up 2 hours ago and he wasn't breathing, I just called now because he is very old like me (87), and he had a DNR"

^ crazy, I know, don't comment on this, but if she called 9-1-1, and wasn't a "licensed professional" to really "call it", would you work him?


----------



## HotelCo (Mar 16, 2011)

Pittma said:


> This is an extremely hypothetical case, but I am curious to know the answer:
> 
> "My husband and I were asleep and I woke up 2 hours ago and he wasn't breathing, I just called now because he is very old like me (87), and he had a DNR"
> 
> ^ crazy, I know, don't comment on this, but if she called 9-1-1, and wasn't a "licensed professional" to really "call it", would you work him?



I'll answer this as if I were a dispatcher, and that's all the information I was able to get out of her. Then I'll answer as a medic who went to the call. 

I'd send the crew L&S to evaluate the patient. It's possible that he is breathing but either very shallow. If so, the crew can be of some help. 

As a medic, if I got there and found him dead and a valid DNR, then it's PDs thing now. Alive: obviously treat. 

Edit: I'm not, nor have I ever been, a dispatcher.


----------



## Melclin (Mar 16, 2011)

Pittma said:


> This is an extremely hypothetical case, but I am curious to know the answer:
> 
> "My husband and I were asleep and I woke up 2 hours ago and he wasn't breathing, I just called now because he is very old like me (87), and he had a DNR"
> 
> ^ crazy, I know, don't comment on this, but if she called 9-1-1, and wasn't a "licensed professional" to really "call it", would you work him?



I don't know that its that hypothetical. I've heard of plenty of calls for people who were known to be dead and were expected to die, but either because they spouse/family wasn't coping or because they didn't know what else to do, they call 000. 

But I'm not sure I understand. He has a DNR. Whats the problem? Did you mean 'doesn't have a DNR'. 

Even if he doesn't. A resus effort will be based on my assessment on arrival, but thats not really what we're talking about. We're talking about downgrading responses not "To work or not to work". Is it the downgrade based on the wife's word that bothers you? I'm not entirely sure what the downgrade criteria are but substantial evidence of being "cold & dead in a warm environment" is a big part of it and I'm pretty sure _reasonable_ evidence of an extended downtime is also. Its the "Oh I just got back from my European holiday and found my elderly father dead in the back yard and hes cold and stiff and smells awful" that gets downgraded not recently alive old men wrapped up in bed with a questionable caller and down time.

I'd reckon upon a cup of tea and a chat with the wife being far superior to ACLS in this scenario.


----------

