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Dead and Dead-Dead

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After about 15 years away from the Hoosier State, I returned to my paramedical alma mater as an instructor in the education department. I also resumed working the street part time. The hospital ambulance service has one of the most intensive and extensive orientation programs in the firmament of EMS. The good news is that it's comprehensive; the bad news is that it's difficult to recruit part-time medics when they have to take a two-week vacation to attend orientation.

Despite its comprehensiveness, however, I somehow failed to learn one little rule. I don't remember if I just didn't absorb it or if it was one of the service's inevitable unwritten rules. For whatever reason, I was unaware of it -- and I would soon pay the price. This rule was: "Thou shalt not call a code on an intercept."

I was working my regular Saturday day shift on the busiest rig in town. Shortly after I was released from orientation to street duty we were dispatched for a medic intercept with an inbound cardiac arrest from a neighboring county. That county's service hadn't yet gone ALS, so this was a pretty common occurrence. We were to meet them at the county line, about a 20-minute drive from the hospital.

We pulled over at the county line, and they pulled over onto the shoulder a short time later. I had my monitor and drug bag over my shoulder when I opened the side door of their rig. One EMT was in the back; he was alternating between bagging and compressing. He had been doing this for the 20 minutes they had been transporting the patient from the county lockup where he had been found in cardiac arrest. Total down time had to have been at least 45 minutes by the time he got to me.

I took one look at the patient from the door and could see that not only was he dead, he was dead-dead. Dead-dead is the term I use in my classes to describe patients on whom no resuscitation attempt should be made. In other words, it's shorthand for "decapitation, transaction, rigor-mortis or dependent lividity," and this patient exhibited the latter big time. His skin was cold and pasty and he was, shall we say, purple on the bottom.

The EMT explained that they had gotten ventricular fibrillation twice on the monitor during transport. I glanced at their monitor, which looked like a LIFEPAK 350 B.C., one of the early manual AEDs the size of a suitcase with a little 2-inch by 2-inch window that pretended to be a monitor screen. Of course, several things were wrong with this scenario. First, in Indiana, basic and advanced EMTs were not trained or permitted to utilize an ECG monitor. Second, the device was ancient and probably responding to artifact. Third, there was no way this dead-dead guy was fibrillating within the last half hour.

So I got on the cell and asked the emergency department (ED) doc, who also happened to be our medical director, if I could call the code. She said "Yes." Then I asked everyone present if anyone had an objection to terminating the resuscitation -- something I've made a habit of doing since I appreciated it being done years before when I worked in a pediatric trauma center. Nobody indicated they had an objection.

I called the code, and we transported the patient to the hospital per protocol.

Soon thereafter I got a call from our clinical director. "Guy, maybe nobody told you, but we don't call codes on intercepts."

I asked, "Why not?"

"Politics," she answered. She then explained that an irate county EMS director called her after the run. Apparently, one or both EMTs in the truck objected to the termination ex post, and the County Coroner blew an O-ring. "Why," I asked? Well, apparently the coroner was upset because it was unclear on which side of the county line I called the code, resulting in a jurisdictional problem. My suggestion that, in fact, the guy actually died at the jail was not accepted. Nor was my argument that politics was no excuse to put EMS crews and civilians at risk by transporting dead bodies with lights and sirens. Of course, I also understood the importance of inter-service harmony.

Epilogue: About six years later I applied to that same county service to do some PRN (pro re nata) medic work after they went ALS. Initially, I was told by the director (not the same one who had blown a gasket) that I was hired. But weeks passed, and my phone and e-mail messages went unanswered. Eventually I saw the guy at the ambulance bay and he admitted that -- you guessed it -- when he asked around about hiring me, guys from that run six years earlier were still mad about that call. I guess the moral of the story is, well -- draw your own conclusions.

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