When Dead Is Not Dead

The news story that hit the internet last week about the woman who was “pronounced” by the paramedic who was later discovered to be alive is nothing new.  We have seen this type of thing before.  Chances are, if you ask me, probably just about every case of this has hit the media at some level.  If you ask me though this is not an EMS problem.  This is a personal problem driven by the laziness of a provider.

In fact, one article mentions that this exact same medic had an issue a little over a year ago when he flew two patients that probably did not need to be flown, and should not have been flown.  I vaguely remember that story.

The problem with this entire situation though is that what will most likely come out of it will be some policy change either at the state level or medical director level, and some fear within the system that “this might be missed again.”  This is not a systemic issue.  It’s not a state issue.  Its a provider issue.  And more importantly, it is one that should never happen.  The only thing that will prevent instances like this is a thorough assessment by a trained medical professional.

Every field pronouncement protocol should contain a few core components.  For example, obvious signs of death.  Lividity, rigor mortis, and body temperature.  Or some injury that is incompatible with life; a decapitation, or massive evisceration, cranial evacuation.  These are the things that should be obvious to us when we assess a patient, and we do need to assess these patients.  We need to touch them, and inspect them, and make sure that we are making the right call, even if we are on a crime scene.  These things must be done.

The other component that should be part of every field pronouncement protocol is the acquisition of an ECG that shows three leads of asystole for a predetermined amount of time.  The best way for any paramedic to check this is not to get a “quick strip” but instead to do something like a “10-20-30” evaluation of the patient’s ECG.

What I mean by a 10-20-30 evaluation is after placing the patient on the monitor watch their ECG for 10 seconds to make sure that there are no aberrant beats or anything that should not be there.  Once those 10 seconds have passed, start printing the ECG.  Print it for 20 seconds.  Get a good sized strip.  Once you have a 20 second strip in your hands, leave the patient on the monitor for an additional 30 seconds.  Just keep a loose eye on the screen and make sure that you are not missing anything.  Be thorough, it is a minute of your time to make sure that you are making the right call.

The ECG strip is essential in these cases.  I remember, in my old system, there were times that obtaining a strip was actually debated.  Some would say, “well, if you have enough doubt about their status that you have to put them on the monitor, then should you be pronouncing them?”  To me though, it is just being thorough.  Cover your bases.

Finally, make sure your documentation is clear.  Where did you find the patient?  How did you find the patient?  When was the patient last seen?  Do they have any visible injuries?  Be clear and concise.  It will help you down the road if you have to recall the scene, and it will help you make sure that you were thorough and you covered your bases.

Incidents like this one get a lot of publicity.  It is a huge mistake, and frankly, one that should never be made.  We must not lose focus of the root of a problem such as this one.  This is not a case where a person can say, “paramedics cannot do x.”  This is a problem with a single crew, but at the same time it is a lesson that we all can learn from.  Be thorough, be complete, and cover all of your bases on every call, every time.  This will prevent you and your partner from landing in a similar pot of hot water.