THE ULTIMATE CONTINGENCY
April 11, 2014
By James Thalman
Jim Page, the father of emergency medical services and the godfather of emergency medical dispatch, died Sept. 4, 2004, from sudden cardiac arrest at age 68. Perhaps it’s fitting that his death matched the “unconscious/not breathing” 9-1-1 call that in his work as a Los Angeles (Calif.) firefighter, and later, as a public safety pioneer, he often described by saying: “The ultimate contingency” has just occurred.
Perhaps it is also fitting in more than one way that the call marking Page’s departure from the planet would be among the most common, easiest to code single-patient pre-hospital response. However, there are exceptions to the usual cut-and-dry course of the so-called obvious death incident. Nearly 25 percent of them involve details that can make the 9-B-1 response in Protocol 9: Cardiac or Respiratory Arrest/Death in the Medical Priority Dispatch System (MPDS) for an obvious death not quite so obvious.
In cases of unconscious/not breathing patients, the caller might initially assess if the patient is “dead.” Although the caller reports this as fact, the EMD must determine if the patient could still be helped through resuscitative efforts. As Adam Johnson, an EMT-P and IAED regional EMD/EMD-Q instructor explains, “The reason we exist is to resuscitate, not to look for reasons not to.”
In some cases, however, the patient’s condition can be determined as obviously beyond help. These clear and unquestionable death incidents are when the caller reports that a traumatic method of death is apparent (e.g., decapitation, incineration, and severe injuries obviously incompatible with life) or when the patient has passed away hours prior to the 9-1-1 call (e.g., cold and stiff in a warm environment, decomposition). Local Medical Control defines the patient conditions that would indicate an unquestionable and therefore “OBVIOUS DEATH” and that would rule out the potential benefit of lifesaving efforts.
Though the protocol clearly outlines each step for the EMD, the research, outcome data, and decisions that go into handling unconscious, not breathing calls are trickier than they may appear. The attitude of both the public and EMS responders regarding resuscitation enters into the decisions as well.
MPDS developer Dr. Jeff Clawson first wrote about the variations in unconscious, not breathing calls in 1995. Dr. Clawson defined a simple line for obvious death in the quarterly newsletter Dispatch1—the predecessor of The Journal of Emergency Dispatch—as follows: “In many of these cases, death has occurred long before, while the possibility of any resuscitative help has clearly passed.”
At the time, EMD was growing into the full-blown member of the emergency medical profession, and both EMS and the public it serves were on an extended honeymoon with electronics and refinements in remote delivery of emergency care. Defibrillators and other devices used to intervene in a health crisis had become so portable, so available in work and public places, and so simple to apply, that the only requirement anyone needed to use an AED was caring enough to step in.
“Many people as well as EMS agency managers believed that paramedics armed with fantastic machines could and should routinely snatch life from the jaws of death,” Dr. Clawson said during a recent luncheon speech. Soon, he noted, the resuscitating of “all comers” became an occupational necessity, and that just as quickly turned into widespread disillusionment when only between 5 and 10 percent of cardiac arrest victims were actually being saved by those interventions.
Physicians and nurses were soon abiding by an almost robotically imposed requirement to resuscitate victims at the scene.
That “never say dead” pledge didn’t fit the reality of field responders who regularly found themselves trying to revive patients who were well beyond rescue at the scene and whose death occurred well before the call for emergency help was made.
The policy was a result of EMS overseers who said paramedics must always at least try to revive the obviously deceased because, if they didn’t, they couldn’t report to the victim’s loved ones that everything possible was done. And that was viewed as tantamount to sending a gilded open invitation to be sued for malpractice.
Trying to revive cardiac arrest victims, no matter what, is a tactic that denies the facts of death and the facts of life, Dr. Clawson said. During his residency in the mid-1970s at Charity Hospital in New Orleans, La., he said, ambulance crews transporting expired patients would describe the job as bringing in a “DOA for any AOD”—a “dead-on-arrival” patient to be certified as such by “any old doctor” who might be available.
As the public’s trust in emergency services and in particular their connection to it through 9-1-1 grew, paramedics were being constantly warned, “If you fail in any way whatsoever to attempt resuscitation of a patient, roving bands of starving plaintiffs’ attorneys will befall your otherwise pleasant day,” Dr. Clawson said.
Fortunately, the claim didn’t turn out to be true in any way whatsoever. “While I wasn’t in daily contact back then with sentinel EMS legal experts like Page, I am not aware of a single lawsuit, successful or otherwise, that has been brought against any EMS agency that followed a medically approved protocol and chose not to resuscitate a person deemed ‘obviously’ dead,” Dr. Clawson said.
The ‘obvious’ fine print
The actual definition of obvious death is basically as clear as callers and the general public might think. However, the conditions indicating obvious death vary from region to region, center to center, and often, doctor to doctor. In the MPDS, the meaning of the term “OBVIOUS DEATH” is established within the policies and practice guidelines outlined by the Local Medical Control and customized for each individual call center.
Prior to any use of the definition or Determinant Codes associated with “OBVIOUS DEATH”, a local medical director/physician must authorize specific conditions that are widely regarded as clearly indicative that the patient has entered a hopeless, nonviable state of being and the certified EMD must be trained and well aware of the locally defined terms. As stated in the definition of OBVIOUS DEATH:
Local Medical Control must define and authorize any of the patient conditions below before this determinant can be used. Situations should be unquestionable and may include:
a – Cold and stiff in a warm environment
b – Decapitation
c – Decomposition
d – Incineration
e – NON-RECENT death
f – Severe injuries obviously incompatible with life
When in doubt, send them out
Dr. Clawson tells the story of a novice dispatcher, a former Hells Angels motorcycle gang member, who asked the defining obvious death question for dispatch: “What do you mean by ‘obvious’?” Given the dispatcher’s personal history, “I was always just a bit careful in answering his questions,” Dr. Clawson said. “After a pause, I said, ‘Well, essentially the “obvious” has to be so obvious that you are willing to bet your job on it.’”
Getting to that point requires asking direct questions. On occasion, these questions might elicit a less than helpful reaction from the caller. Keep in mind that questions can come across as silly and unnecessary to someone who can clearly see the scene, but they are nevertheless essential.
For instance, the first Key Question on Protocol 9: Cardiac or Respiratory Arrest/Death is essential for appropriately assessing the patient’s condition: “(Suspected death) Tell me, please, why does it look like s/he’s dead?” Here, the calltaker’s respectful and serious tone is as important to the interrogation as what is being asked. Even if the caller responds sarcastically, the calltaker will have a clear description of the patient’s condition to determine the best approach. In other words, it doesn’t matter what the caller thinks of the questions; what matters is finding out what the caller knows.
Any description that does not meet the definition of an OBVIOUS DEATH or EXPECTED DEATH situation would elicit a regular cardiac arrest response based on a 9-D-1 Determinant Code, followed by appropriate Post-Dispatch and Pre-Arrival Instructions.
If the patient’s condition matches the local definition for OBVIOUS DEATH, the calltaker should ask Key Question 1a, “Do you think s/he is beyond any help (resuscitation/CPR)?” If the caller expresses any uncertainty, the EMD will send a 9-D-2 response and begin providing instructions for resuscitative efforts.
Key Question 1b, “Are you certain we should not try to resuscitate her/him?” addresses EXPECTED DEATH situations, which may include a patient who has suffered from a terminal illness or who has desired to establish a DNR (Do Not Resuscitate) order—a physician’s order directing medical personnel to not attempt to revive a patient using CPR or other extraordinary means. If the caller is certain that the patient’s wishes were to not be resuscitated (as indicated with a DNR order), the EMD may send 9-Ω-1 only if unquestionable and already defined and authorized by Local Medical Control. However, as Rule 1 directs, if the caller believes the DNR should be ignored or is uncertain if the DNR is valid or in place, an appropriate response and resuscitation attempt should be made.
After completing Key Questions, the EMD initiates an appropriate response and then provides Post-Dispatch Instructions that best address the situation. For either OBVIOUS DEATH or EXPECTED death situations, the instructions similarly reassure the caller “I’m sending someone to assist you” (the calltaker will notify proper authorities) and ask whether the EMD can do anything else for them.
In the case of OBVIOUS DEATH, the EMD also instructs the caller to leave everything as he or she found it, which preserves evidence that may be reviewed in the event of an unexpected death.
For all other cases where resuscitation should be attempted (suspected workable arrest), the EMD provides PDI-c “I’m sending the paramedics (ambulance) to help you now. Stay on the line and I’ll tell you exactly what to do next,” and proceeds to the DLS Links to provide Pre-Arrival Instructions for life-sustaining efforts.
Dr. Clawson points out that while EMS systems dramatically struggle with the “correctness” of precluding “at scene” resuscitation without the approval of a physician, the average American, Canadian, and perhaps especially the European citizen today accepts death as a possibility in any serious emergency case.
To sum up, the obvious death situation provides the trained EMD that chance to first carefully evaluate a situation, determine the true Chief Complaint (non-resuscitable death), and then respond appropriately.
When the case is an actual obvious death, as Dr. Clawson says, “The friend and family become our true patients. The Cardiac or Respiratory Arrest/Death Protocol allows us to treat both the family and the departed loved one with dignity and respect.”
1Dispatch, NAEMD, The National Academy of Emergency Medical Dispatch, Autumn, 1995, Vol. 6, No. 4