Transport of cardiac arrest patients who fail to achieve return of spontaneous circulation (ROSC) on scene is usually associated with futility. Consequently, many EMS systems have developed policies and practices to minimize these futile transports. However, determining the appropriate disposition of patients who are ultimately pronounced dead in the field can pose unique challenges for prehospital providers. There has been very little in the medical literature to guide us in handling the decedent under some of these circumstances. This article will discuss how Los Angeles Fire Department (LAFD) EMS providers have dealt with some of them.
LAFD provides EMS to the second largest city in the U.S. Its EMS configuration has been previously described in the literature. Recent published data from LAFD show that as paramedics remain on scene longer attempting to resuscitate non-traumatic cardiac arrest patients, the rate of termination of resuscitative efforts in the field has increased from 9% in 2000 to 27% in 2007. These rates describe those patients found pulseless and apneic with no criteria for determination of death by prehospital providers that would prevent resuscitative efforts in the field.
Criteria for determination of death in the field by EMTs or paramedics in LA County are stipulated by the Los Angeles County EMS Agency. These include absence of respirations, cardiac activity and neurologic reflexes, in addition to one or more of the following conditions: decapitation; massive crush injury; penetrating or blunt injury with evisceration of the heart, lung or brain; decomposition; incineration; blunt traumatic arrests without organized ECG activity or with extrication times exceeding 15 minutes; drowning victims, when it's reasonably assumed that submersion has been greater than one hour; rigor mortis; or post-mortem lividity. In addition, paramedics may determine death in the field for patients found in asystole whose estimated time from collapse to initiation of CPR by bystanders or EMS exceeds 10 minutes.
The standard practice for patients who either meet criteria for field determination of death or who are pronounced dead by an on-line medical control (OLMC) physician is for paramedics to leave all tubes and lines in place, complete their ambulance call report, and wait for law enforcement to arrive to take custody of the body prior to leaving the scene.
Common scenarios our crews encounter include 1) the patient has been placed in the ambulance and it's then determined that they meet field criteria for death determination, 2) the OLMC physician pronounces the patient prior to or during transport, or 3) a patient meets field determination of death criteria but paramedics opt to transport due to concerns over scene safety (e.g., gang-related shootings). These cases all pose logistical dilemmas for EMS.
The following cases highlight some scenarios paramedics have encountered after terminating resuscitative efforts on scene. In two of these cases, the patients did not initially meet criteria for determination of death in the field (which would have precluded the initiation of resuscitative efforts), and in the third, concerns over scene safety prompted paramedics to load the patient into the ambulance. The issues raised by the disposition of these patients after the pronouncement of death are relevant to many EMS systems.
A paramedic ambulance and a fire engine were dispatched to a nursing home for an 82-year-old female with difficulty breathing. Paramedics found her with agonal respirations, and she was assisted via bag-valve-mask ventilation. The patient was quickly moved to the ambulance, after which she stopped breathing.
Nursing-home staff came out to the ambulance prior to transport and produced both do-not-resuscitate (DNR) and advanced health-care directive (AHCD) forms. The crew contacted an OLMC physician, who then pronounced the patient. The captain on scene requested an EMS supervisor to respond to the incident.
A family member of the decedent arrived on scene quickly and requested that their deceased family member be taken back inside the nursing home and not be transported to an emergency department (ED) or to the coroner's office. Nursing-home staff were comfortable with this decision.
The decedent's family informed the paramedics that they had already made arrangements with a funeral home and made the necessary notifications. The patient's primary doctor was contacted by nursing-home staff, and he agreed to sign the death certificate.
The fire department medical director was contacted, and he directed the paramedics to return the decedent to the nursing home, ensuring the body was placed in a bed in a private room, not in view of other residents, and that the decedent was treated with respect and could be accompanied by family members.
The decedent was moved back into the nursing home into a room with no other patients. Prior to moving her, paramedics ensured no one was outside in the general area and no other residents were in the hallways watching. The decedent's family was able to sit in the room with her until the funeral home staff arrived. Law enforcement arrived on scene for their report.
Paramedics were dispatched to the scene of a reported shooting, where they found an unconscious patient down inside an apartment building with two gunshot wounds (GSWs) to the chest. The patient was pulseless and apneic.
Police officers on scene informed the paramedics that the patient had been down at least 20 minutes prior to arrival of EMS. Base station contact was made, and the patient was pronounced by the OLMC physician.
During this time, police found a second victim in a parking lot adjacent to the apartment building and the paramedics were directed to this patient.
The second patient was also pulseless and apneic with a single GSW to the right chest, in the anterior axillary line at the third intercostal space. BLS was initiated and the patient was moved to the back of the ambulance. While paramedics were getting ready to begin transport, law enforcement advised them that this patient had also been down at least 20 minutes prior to their arrival.
This patient was also pronounced by the OLMC physician. Per new department policy (2009), the decedent was transported to the coroner's office, and the body was transferred to coroner's staff without incident.
An ALS ambulance and a BLS engine company, along with an EMS supervisor, were dispatched to a reported shooting just after 5 p.m. in a residential neighborhood. EMTs and paramedics found an approximately 25-year-old male down in the street with multiple GSWs to the chest and abdomen. His pupils were fixed and dilated, he was apneic, and he had no palpable pulse.
Firefighters initiated CPR, and paramedics began to assess the patient. At this time, the fire department medical director arrived on scene. Due to the presence of a large crowd, the patient was quickly moved into the back of the ambulance. Closer inspection revealed no signs of life, with asystole on the cardiac monitor. The medical director pronounced the patient deceased and advised the ranking law enforcement officer on scene of the situation.
The medical director called the coroner's office and explained the situation. The on-call coroner's investigator confirmed the circumstances with the ranking law enforcement officer and agreed to accept the decedent. Paramedics were directed to transport the decedent non-emergently to the coroner's office, with the EMS supervisor following to ensure a smooth transition of custody.
As the health-care system is challenged by shrinking reimbursement, a decreasing number of EDs, hospital overcrowding and increased demand, the prehospital system is facing prolonged turnaround times in EDs due to lack of available beds and widespread ambulance diversion.
The approach to non-traumatic cardiac arrests has undergone major changes over the past few years. Since the introduction of the 2005 American Heart Association BLS and ALS Guidelines, the emphasis has changed from bystander CPR to quality CPR, the timing relative to defibrillation, hyperventilation and such post-resuscitation care as therapeutic hypothermia.
Multiple published studies have made it clear that for adult, non-traumatic arrests, the patient's chances of neurologically intact survival are virtually zero if there's failure to achieve ROSC in the field after 20 minutes of attempted resuscitative efforts. These findings have led to the creation of guidelines for termination of resuscitative efforts in the field.
Futile transports of patients are associated with the risks inherent in emergency (lights and sirens) transport, potential exposure of prehospital providers to blood and secretions with possible infectious disease and exacerbation of the situation in already overburdened EDs.
LAFD established a policy that allows EMTs or paramedics to transport decedents directly to the coroner's office in two situations: The patient is either pronounced dead (by an OLMC physician at a base station) and has already been loaded into the ambulance, or if the patient meets criteria for declaration of death by prehospital providers in the field but concerns over scene safety prompt them to remove the patient into the ambulance. Under California Government Code, the county coroner may authorize the movement of deceased human remains by persons other than the coroner.
The protocol that was developed stipulates that on-scene paramedics must do the following:
- Request an EMS supervisor to respond to the scene.
- Notify the coroner's office watch commander by calling prior to transport.
- Complete an ambulance call report, which should include the decedent's name (if known), approximate age, race and gender.
- Document the exact location of the incident.
- Document the location of death (where the patient was pronounced).
- Document the circumstances of death.
- Document the name of the investigating law enforcement agency and name and badge number of the primary detective or ranking officer on scene.
- Transport all personal property, including clothing, medical or physical evidence on or with the decedent, or ensure that such property is temporarily secured on scene so that the coroner can retrieve it later.
- Leave all medical devices placed in the field in place (e.g., IV lines, endotracheal tubes, defibrillation pads, etc.).
- The value of the option to transport directly to the coroner_s office is that paramedics don_t have to burden an ED with the decedent. At the ED, the "patient" must be registered, placed on a gurney and examined by the ED physician and triage nurse. The ED must then be prepared to deal with any family members and law enforcement officers who may follow up. These activities can often be better handled at the coroner's office than a busy ED.
Although many EMS systems are incorporating policies and practices to terminate resuscitative efforts in the field under these circumstances, little in the medical literature describes care of the decedent after field pronouncement. This is particularly problematic if the patient has already been placed in the ambulance prior to termination of resuscitative efforts.
Proper handling of decedents in the field is particularly important in cases of traumatic cardiopulmonary arrest, especially if the patient was a victim of a violent crime. Standard operating procedures may include determining death in the field based upon the absence of a pulse, spontaneous breathing or any neurologic reflexes.
Prehospital providers should be careful to not disturb any evidence, including avoiding stepping in blood or on bullet casings, and have minimal personnel enter the crime scene.
The other scenario involves initiation of resuscitative efforts, whereby the patient does not meet the criteria for field determination of death. In these instances, if the patient is pronounced dead by the OLMC physician after the patient has been placed in the back of the ambulance, paramedics must have clear policies that dictate where they should transport the decedent.
As described in the third case, paramedics might respond to incidents in which patients are victims of violent crimes and meet criteria for field determination of death, but a hostile crowd requires EMS to transport the patient for scene safety concerns. These volatile scenes can then spill over in the ED, especially when the incident involved a gang-related shooting.
Once prehospital providers determine death in the field or the patient is pronounced dead by OLMC, attention must be given to the patient's friends and family members who may be on scene. Prehospital providers have traditionally received little to no training on grief notification. This lack of comfort and available support may lead EMTs and paramedics to transport such patients for whom further or continued resuscitative efforts are futile.
EMS systems should work with volunteer organizations and local political and religious leaders to make crisis counselors available to respond to these types of incidents. The availability of such expertise takes this burden off of field providers and allows them to return to service more quickly.
Bringing a patient back into their residence after having been removed to the ambulance may be extremely problematic. Such an action may create undue emotional distress for the patient's family, and may even lead to litigation. Although such an action should be extremely rare, as described in Case #1, it may be considered under specific circumstances.
As prehospital providers more commonly leave patients who fail resuscitative attempts in the field rather than transport them to the hospital, it's incumbent upon EMS leaders and medical directors to develop policies that specify the proper disposition of decedents in the field. These policies must allow prehospital providers to ensure that the decedent is treated with dignity, the concerns of family members are addressed, and the chain of evidence is preserved in cases of violent crime. Direct ambulance transport of the decedent to the coroner's office may be a viable option in certain circumstances. JEMS
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