In the last edition of this column, I outlined the difficult circumstances of a case in which a 2-year-old patient was pronounced dead at the scene of a multi-injury motor vehicle crash. The deceased child was later transported, along with an injured infant, to a trauma center.
After publication of this case, I received a number of insightful comments from readers. I would like to take this opportunity to share those thoughts with you.
Although I have taken the liberty to correct spelling corrections and make other minor editing (identified in bracketed italics), the following comments are basically as I received them. They reflect the controversies inherent in this case as well as some of the many mixed messages experienced by EMS personnel.
I asked my EMS coordinator about transporting the recently dead. She reminded me that the organ harvesters would like to see them. In EMS, we are constantly barraged with conflicting policies and protocols. Add to that the "fog of war" on a messy scene and the possibility that you could lose your house to lawyers just for being there. Add the stress from witnessing the messy ones. Add the ever present personal danger of many calls. One can understand why paid paramedics have a typical career of seven years, and part-time or volunteer paramedics are very difficult to keep. There is nothing worse than an ECRN that makes a stink about a call. The medic or flight nurse on the scene will have very good reasons for not obeying an ECRN with little or no field experience who is representing medical control.
So the two big demoralizing factors in EMS are the fog of battle on the scene and the fog of administration. Much of the fog of administration could be cleaned up with good science and good statistical data.
So, it makes sense to leave bodies for coroners, and several departments have done that hereabouts. Our medics work on those departments and bring that wisdom back to me. But when I mentioned this to our EMS coordinator, we looked in our SOPs (e.g., protocol) and found no support for such an idea. So we will work triple zero traumas, while 20 miles away, they might not. Same EMS system.
I do have personal experience transporting people "pronounced" dead. Dead in three leads for more than five minutes. But we took them in anyway, hoping for the best, I guess.
-- Ray Tomlin
When I read the title of your article, "Why are you transporting dead patients?", I thought that, finally, someone was putting into writing what I've been questioning for years. In reading the article, however, I found that this was not at all the case. Your article presented a topic that I think for most EMS providers would be a "no-brainer." The distinction between the ambulance and the hearse has been pretty well defined since the 1970s. The transport of a dead patient clearly poses a risk to the EMS crew and the public, undesirable legal ramifications and misuse of resources.
The topic that I hoped you had tackled was the transport of cardiac arrest victims. For years, we have seen EMS providers rolling through ED doors with patients that were clearly deceased. Frequently, resuscitation efforts have been ongoing for 30-45 minutes by the time the patient arrives at the ED. At that point, rather than an ED physician, I think it would be more suitable to have a third base coach at the Code Room waving the crew to the morgue. I think that a combination of current factors would make this a popular topic for discussion.
(I agree with the suggestion regarding the transport of cardiac arrest patients and we will tackle that specific subject in a future column. DR)
It is said that, "Asystole is a confirmation of death and not a rhythm to be treated." Why is it then that patients found in asystole, receive CPR and ALS treatment on scene and are then transported when there has been no change from this rhythm. Some EMS systems have developed protocols addressing the termination of resuscitation in these patients, but these protocols are frequently not applied, as we feel obliged to transport the patient to an ED for "definitive care."
Hardly a day goes by when you can log onto the Internet and not find a report of an ambulance collision. Many providers feel that the transport of a cardiac arrest victim constitutes an "emergency," and the lights and siren stay on all the way to the ED doors. Some paramedics may direct their partners to proceed with a "slow code 3" transport, whatever that means. Sorry, but once the lights and siren are turned on, the danger to the crew and public increases exponentially. And how often does this benefit the cardiac arrest patient?
I understand that among our cardiac arrest victims, there are those victims that have a viable rhythm, such as V-fib and V-Tach that require transport to an ED. While all cardiac arrest victims are deserving of aggressive treatment on the scene, I find myself frequently asking, "Why are you transporting dead patients?"
In the case that you presented, the first EMS unit to arrive on scene consisted of a paramedic and an EMT. This crew, with the assistance of one law enforcement officer and one bystander, was presented with five patients. From the description given, the automobile, containing three adults and two children, overturned. The occupants, unrestrained, all were subjected to serious trauma. This situation is the very definition of MCI, as applied to the responders on scene. With CPR already being performed on the 2-year-old female with signs of serious head trauma, the EMS crew should have proceeded on to help the living. Instead the paramedic's heartstrings were successfully tugged, and the paramedic fell victim to tunnel vision. As a result, the more important question in this story should be, "Did the distraction of a trauma victim cause additional harm (or loss of life) to the remaining occupants of the automobile?" While situations such as this certainly suck (to say the least), this is the type of scenario that MCI and Triage classes were designed to address in paramedic and EMT schools. Regardless of which decision is made on scene, it is sure to be a decision that will result in repeated second guessing and psychological trauma for all involved.
-- Tom Murphy, EMT-P, Orlando, FL
What a depressing case you wrote about. You are right on the money about how little some folks in the hospital understand the EMS issues, as somebody chewed the crew's butt for bringing the dead baby in after such a horrible call ... (The nurse) definitely failed the basic humanity test--they were so totally focused on their own administrative issues to the exclusion of anything else, including even an inkling of empathy for the crew, the dead baby, etc. I really can't imagine that happening here. We are too small of a community, and we all know each other on some level, that we all feel the pain of these awful things and really huddle together in cases like this, EMS, nurses, and (some) docs.
I think your recommendations are right on the money. I would also tell the crew that if they think it would be safer for them to leave the scene with the patient, then I would support them in that decision. Here in the hinterlands, we deal with slim and no resources and delayed backup from police. For example, a guy who got shot in the chest in a trailer park was obviously dead. But only the one ambulance (called for "chest pain") and two cops on scene in a seething trailer park with a freaking out family who thought he might still be alive -- the safest thing once they were committed was to grab the patient, make it look good, and haul freight out of there (and the cops ran away too until they got reinforcements) ... We actually called him enroute once they were out of the fracas and dealt with the medical examiner, etc., once they got to the hospital. We do have a protocol for those type of patients so they actually go directly to the morgue.
-- Sabina Braithwaite, MD, NREMTP, Medical Director Albemarle County Fire-Rescue and Piedmont Virginia Community College Paramedic Education Program, Variant View author for JEMS.com
It's easy to say what one would do in retrospect when asked about a specific call, but it's a totally separate matter when you are the responding medic in that time and place. I try very hard not to second guess other medics in such situations. I was not there and can only relate by what I can read. We all know that once a call is done, we often look back and see things that we wish we had done differently, but were either too busy with other things to do or just couldn't for some reason or another. Since the medic was caring for a live patient at the time of scene departure, that was priority on the list. We all learn the art of triage and in that, we learn that the dead stay dead no matter what we do. That deceased body had a chain of custody starting with the responders and ending with the coroner's office that could have easily been tracked. As long as the medic didn't allow it to interfere with care of a viable patient (and it appears it didn't), that particular transport shouldn't matter. It was necessary. The needs of the living outweigh the needs of the dead. I could very well see that scene playing out in my area. Preplanning is the key and too many systems (including my own) do not have such plans in place.
Keep up the great work.
-- Chris Black, NREMT-P, Alabama
And last, but certainly not least, is a note from "down under "
Very well written - and presented article - thanks for sharing it.
Thought you might like an insight into how this case would have been handled in New Zealand Exactly the same!
We do not disturb obviously deceased patients and work with police (who like in the U.S. represent the coroner initially at the scene).
The only patients we would even consider moving would be those whose status is unclear until moved one s that have to be moved to get at other patients who (hopefully) we will be able to do something for Patient s in positions that could cause further accidents (middle of a road we can t block with resources on hand), or could sustain post mortem injuries (i.e. could get run over again).
Unlike in some U.S. states and services, we are trained and authorized to stop or not commence resuscitation attempts (trauma and medical) and do not have to transport all those we are called to.
The only change from this case you described (and we would, like your paramedic, have done everything to unload again and keep our ambulance for the living) would bethe dead baby would not have been unloaded into the hospital. A doctor would have been requested to come out and confirm death (paramedics are not legally able to) in the ambulance and Pt taken to morgue direct (by orderly, on hospital trolley). If ED was too busy, then we would ask permission for the patient be taken direct to the morgue and confirmed later
Why tell you all this? You are not alone!
EMS the world round shares more aspects in common than those that differ.
Are there any differences? Yes. We are half a world away after all!
Our Maori population have strong belief systems regarding spirits and death, and part of their belief affects EMS directly. They believe that any vehicle or equipment used for treatment or transport of any dead person needs to be cleansed and blessed before being used for treating anyone living. The Maori belief is called "Tapu" pronounced as it is written (as is all Maori) "Tar Pooh." It is very similar to the Native Americans belief that spirits can linger and need to be "encouraged" and "honoured" to move on. So we would even more stringently try not to load a dead patient in our vehicles. We also (as a service) have training on the blessings required to "cleanse" our vehicles. In fact, so integral is it to what a Maori is, treatment of the dead and dying has become the norm for non Maori New Zealanders too. So much so that if you visited and asked "why do you guys do that?" we might have to think a bit before we could answer with more scientific vigour than "because!"
P.S. If you see any of the staff involved in this case you wrote about, wish them well from me. We have been there, done that, guys. You did well."
-- David Long, Ambulance Team Leader, Wairarapa Ambulance Service , New Zealand
Thanks to everyone above who took the time to correspond on this challenging case. I truly appreciate your thoughts and hope they bring some insight for our readers who have either faced something like this situation, or will, if they stay in EMS long enough. Please feel free to consider sending your views on this or other cases to my e-mail address.