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Old 03-11-2011, 10:39 PM   #1
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Priority 4 patients (DOA) and your agency?

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........

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Old 03-11-2011, 10:44 PM   #2
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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

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Old 03-11-2011, 10:47 PM   #3
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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.
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Old 03-12-2011, 11:25 AM   #4
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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....

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Old 03-12-2011, 07:39 PM   #5
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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).
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Old 03-12-2011, 07:58 PM   #6
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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.
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Old 03-13-2011, 05:46 AM   #7
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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.
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Old 03-13-2011, 06:09 AM   #8
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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.
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Old 03-13-2011, 12:15 PM   #9
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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.
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Old 03-13-2011, 11:24 PM   #10
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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.
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