On a cold winter evening, a crew responded to a report of an overturned vehicle on a nearby interstate highway. Injuries had been confirmed at the scene, and dispatch advised the crew that at least one party was not breathing.
The initial EMS responders observed a law enforcement officer, along with an apparent bystander, performing cardiopulmonary resuscitation on a young child on the hood of a police cruiser. The arriving paramedic took over control of this patient and, with the assistance of the officer and bystander, moved the patient to the ambulance after establishing and maintaining cervical spine stabilization. The paramedic's partner, an EMT-B, began scene triage.
Once in the back of the ambulance, the paramedic commenced bag-valve-mask (BVM) ventilations as chest compressions continued. Physical assessment of the patient suggested an approximately 2-year-old female. The patient was not breathing. There were copious amounts of blood, clear fluid and white matter coming from the nose and mouth. No pulses were present without chest compressions. The pupils were fixed and dilated. A monitor strip revealed an idioventricular rhythm at a rate of 40 per minute.
At this point, the paramedic chose to terminate resuscitative efforts. The case was fully discussed with medical control, and the patient was pronounced dead. The officer and bystander immediately left the back of the ambulance.
Almost simultaneously with the pronouncement of this case, and before the paramedic could leave the back of the ambulance, a second bystander entered the ambulance with another small child. This patient was a male and appeared to be about 4 months old. No history was available as to the nature of his injuries. The patient was conscious and crying vigorously. A significant amount of swelling was noted about the left side of the head, and it was assumed the patient had a potentially significant head injury.
At the time of these events, additional EMS resources arrived on scene, including at least one additional paramedic. Investigation of the scene indicated an earlier vehicle had apparently struck and killed a deer on the interstate and then continued on. The accident vehicle later impacted a portion of the animal's remains and overturned as a result. Occupants did not appear to have been restrained.
Scene triage continued and revealed the above children represented two of a total of five patients involved in the single car crash. The driver and two other adults remained in the vehicle. One of these three patients appeared obviously dead, while the extent of the injuries was unknown in the others. Extrication proved to be somewhat prolonged and difficult.
Upon assessment of the full situation, a company officer from a local fire department advised the paramedic in the ambulance with the children that there were "two criticals" in the vehicle, and that two helicopters had been requested for their transport. The helicopters were circling overhead and awaiting an available landing zone (LZ).
The paramedic was informed that her ambulance was holding up the landing of these helicopters, and if "it did not move, it would be stuck indefinitely." It was concluded that her ambulance "needed to get going to a hospital" with the 4 month old.
No law enforcement officer reappeared to take possession of the deceased child remaining in the ambulance during the whole sequence. The paramedic's original partner stayed at the scene, while one of two later arriving EMT-Bs assisted with patient care. The second jumped in to move the ambulance and commence the 30-minute drive to the hospital, utilizing lights and siren.
During the transport, the body of the dead child was moved from the one end of the ambulance cot to the bench seat. As this process took place, an expulsion of air was noted from the child's mouth. The child was immediately reassessed for any signs of spontaneous ventilations or other signs of life. None were detected. It was concluded this episode was most likely due to the expansion of gasses in the body.
En route to the hospital, the infant remained stable. No additional obvious injuries were identified besides the scalp contusion. Oxygen was applied. The unit did not have a cervical collar small enough to fit the patient. Therefore, the baby's spine was manually immobilized and later secured with tape and rolled towels. A trauma team activation was requested.
Upon hospital arrival, the infant was taken directly to the trauma resuscitation area and report was given to the staff. Hospital care proceeded uneventfully for this patient. The emergency physician then advised the paramedic to talk to the emergency department (ED) charge nurse to determine where to leave the body of the dead child.
The body of the child wrapped fully in a blanket and once again on the ambulance cot was wheeled into the ED by the crew. They were then confronted with the question, "Why are you transporting dead patients?" Without waiting for an answer, a nurse stated, "You should have left it there."
The paramedic proceeded to explain the circumstances of the call and what lead up to the decision to include the deceased patient with the infant's transport. The charge nurse said, "I spoke with the coroner and they may need the patient to be taken back to the scene." Further discussion ensued between the crew and the nurse. Ultimately, the body was left at the hospital.
EMS transport of obviously dead, or patients that have been pronounced dead, is generally to be avoided. There are a number of reasons for this. A primary concern is the unavoidable specter of scene disruption, when bodies are moved unnecessarily. Investigations in progress by law enforcement and/or the coroner may be greatly impeded. (I recently had a phone discussion with a disgruntled local medical examiner regarding his perception of the unnecessary disturbance of dead patients encountered by EMS on other, unrelated calls).
An additional issue is the futility of patient benefit in the transport of the dead. Obviously, death is not going to be prevented (since it has already occurred), and transport only puts the public and the EMS crew at risk of a vehicle mishap in the process.
Finally, unnecessary transport of the dead removes available EMS resources for other patients who may truly benefit from them.
I recently reviewed some of the basic legal issues involved when bodies are moved by EMS personnel with JEMS.com columnist W. Ann Maggiore, JD, NREMT-P.
"EMS shouldn't move a body until law enforcement and/or the medical investigator can perform their investigation," Maggiore said. "Moving a body can destroy valuable evidence and can contaminate a crime scene.
"An exception to this might involve a situation in which a body is obstructing traffic flow, and the investigation is likely to be prolonged at the scene," she continued. "In that case, it might be reasonable to move the body off the roadway to facilitate the resumption of traffic flow. In this situation, the body outline should be chalked prior to movement.
If it does become necessary to move a body, like the one in traffic, check with law enforcement on scene whenever possible." Maggiore concluded.
However, the nature of this case made it unique from some of the common circumstances referred to above. Although, the vehicle was badly damaged and the adult patients required extrication, the two small children were able to be pulled from it by bystanders.
Thus, the crash scene was already disrupted by the very understandable efforts of the civilians on scene. Law enforcement, then, arrived at the crash, and the bystander and the officer used the hood of his cruiser as a makeshift surface on which to begin CPR on the child.
It was a cold, dark night and in order to fully assess the apparently pulseless and apneic child, the paramedic needed to move the patient to her ambulance. At this point, it was not determined that, in fact, the patient was dead so no movement of an obviously deceased party occurred.
Once the child was pronounced dead, it was the intent of the paramedic to exit the ambulance and assist in other necessary care for the remaining patients. However, another bystander unexpectedly brought the 4-month-old infant to the ambulance. This delayed and ultimately resulted in little to no communication with the Incident Commander and law enforcement on the scene.
The paramedic later indicated she felt that police were extremely busy managing the situation. She also detected the unease the officers may have understandably felt in the presence of the dead child. Additionally, there were a substantial number of civilians at the accident site trying to offer assistance, but nonetheless adding to the congestion and confusion surrounding the crash. Ultimately, for whatever reason, an officer did not reappear to take the deceased patient from the paramedic before transport was initiated. The paramedic did not feel comfortable leaving the 4 month old in the care of the EMT-B to seek out the police before departure.
The sense of urgency for transport of the victims still alive added to the unusual features of the case. The perceived need to land two helicopters in the area of the ambulance led to the request to begin transport of the 4 month old. Indeed, the paramedic was told that if the ambulance did not move, it would be "stuck indefinitely." Finally, the potential for critical injury in the infant coupled with a lack of history, spurred the ground crew to move more quickly than they might have otherwise.
In hindsight, perhaps the sense of urgency was not necessary, but we tend to look back with perfect acuity. At the time of incident, the circumstances were unclear. The crew was fully aware that in almost all situations dead patients should not be transported.
In the end, circumstances in this case made transport of a dead patient understandable. A later after action brief involving the crew and hospital staff concluded with agreement on this point.
One of the volunteer EMT-B's on this call happened to be an attorney with a federal agency, as well as a former military and police officer. As a result of this call, he offered the suggestions I have summarized below:
- Develop standard operating procedures for the acceptance of human bodies by hospitals;
- Develop policies and procedures defining when the EMS transport of dead bodies to a hospital may be appropriate;
- Familiarize ED staff with tactical EMS operations occurring in an austere environment; and
- Improve EMS training regarding the potential transportation of deceased remains;
What Can EMS Personnel Learn from this Case?
- In the majority of circumstances the obviously dead, or pronounced dead should not be transported by EMS.
- As pointed out above, EMS agencies and hospitals should work together on defining rare circumstances when it may be necessary for EMS to transport deceased individuals to hospitals.
- ED and hospital staff has little awareness of the realities of the EMS scene environment. We need to accept this as fact and be prepared to calmly explain unusual circumstances, as was done very well in this case.
- Take your own pulse first. Often, despite the huge surge of adrenaline flowing in these circumstances, things are not as urgent as they seem.
- Better communications between the ambulance crew and the police and the scene managers (or incident commander) might have helped to resolve some of the issues before departure.
- On occasion, if you have done your best to consider other options, it is not the end of the world if you find yourself having to transport a deceased patient to a hospital.
As readers of this column are aware, I am not an EMT so I have very limited, personal field experience. As such, if there are additional alternatives that come to your mind regarding what might have done in this case, please forward your thoughts to me at the email below. If I have enough responses, I may feature them in a follow-up column on this case. Please send your comments to firstname.lastname@example.org.