Pronouncing In The Field Less Common In Suburbs?

[Jybehofd 85]

I am in a medic program down in the city, and it seems that they pronounce more in the city then in westchester. Granted the call volume is nothing the same. But if the ambulance pulled up with the fly-car for the same job just put it in the northern westchester region we would do cpr and a full code? Why is this? Is it because of the volies? Why won't the medic get online with med control and call it?? I have been on a few jobs where I have asked the medic to call it and they just start working it. Could it be that alot of the medics in the city are just over worked too??

[res6cue 67]

Not sure about Westchester, but here in Rockland EMTs can and do pronounce. I know back in the early 90s when I was still certified and working as a Tech, I personally pronounced my fair share. Back then we were told that Rockland was the only county in NYS to allow EMTs to pronounce, and it had to do with the County Medical Examiner allowing it. Not sure if that still holds true today.

[20y2 43]

Pronouncing in the field only became more popular once Westchester broke off of the Hudson Valley REMAC, HVREMAC protocols stated for the most part that all worked codes were to be transported.

[mikerabbit 2]

Westchester medics are permitted to make pronouncements in the field, it comes down to training, and experience. Some medics will do ot while others wont.

[WAS967 97]

Any EMT can pronounce given the obvious death conditions (decapitation, dependant lividty/livor mortis, rigor mortis, etc).

Our protocols as medics are very specific about situations we can and cannot pronounce. If we pull up on a call and it's, lets say, a V-Fib arrest that becomes asystole, the patient has full ALS [(combi)tube, line, meds], is nontraumatic and not in a public place, the family doesn't object, etc....then we can pronounce if there is no sign or recovery.

My last code we did in a church parking lot. Public place. Protocol says we HAVE to transport.

PD not available becuase they are chasing criminals/too busy to babysit a body. Then you have to transport.

Does it mean you have to work the code in transit? Absolutely not.

I have no problem calling codes in the field. In fact I think a lot of family members feel more comfortable knowing that thier family member "died at home" rather than in an ER. The few people that still believe that not having thier loved one transported to the ER is not doing enough, can be talked down, as 95% of the time it involves hysteria becuase the death was unexpected.

Edited October 25, 2006 by WAS967

[Guest paramedico987]

I make a point of working patients and then "calling it" at nursing homes in my response area. The nursing homes have a propensity to turf their patients to the hospital, but then the statistics of patient outcomes are drastically skewed in favor of the nursing home. Additionally I try to impliment protocol 15 if there's going to be a long carry down involved since we cannot perform CPR and carry prople down the stairs at the same time.

the only thing that's any easier or better about transporting an arrest, in my experiance, is abitlity to restock equipment at the hospital from the already opened code cart...

[Guest alsfirefighter]

I pronounce quite often in the field. But as WAS pointed out there are other factors that must be taken into account. My last arrest there were young grandkids in the house and though it was better to transport. I've had some with so many hysterical family members that the ability to control the scene was non-existant or you could tell that transporting would help the family heal.

I've not pronounced because I know the police agency that I would need to come was very busy or short staffed.

The ability is there but it comes down to the provider on the scene.

[unklecletus 0]

I'm an EMT in Westchester and work with state police alot. I found out that the state police are not allowed to use an emt's word to pronounce. The trooper told me he needed a paramedic to pronounce. It must be some thing new beacuse i'v pronounced before for the state police.

[Guest]

In all honesty....i don't know what everyone is talking about in terms of pronouncing a patient. EMTs in the State of NY are allowed to confirm obvious death given the proper signs (profound and generalized cyanosis, dependent lividity, generalized rigor, decapitation). If you ask me, only Paramedics are allowed to pronounce given that medics can initiate care and if the patient meets certain criteria can case care and confirm (through the use of clinical adjuncts) that the patient is absent of life. Maybe I'm totally wrong...this is just the way I've always looked at it though...

[Guest paramedico987]

I did a little searching to see what the legalities are on this topic...

STATE LAW: From the state attorney general, "Pronouncement is not to be confused with, or construed as certification of death. According to the New York State Attorney General’s office, there is no law or regulation either authorizing a person to pronounce death or prohibiting a person from pronouncing death (Atty. General, 1980)."

So, anybody including the most brillaint medical minds in the world, which can be found at the corner of 3&3 in the vern, can "prounounce" somone dead. This includes EMT's of all levels of training.

With that being said, we have protocols set forth by our various medical oversight commitees which dictate under what circumstances we should make a resuscitative effort or not.

The criteria in Westchester County are the same for ALS & BLS EXCEPT that Paramedics may, if they choose, impliment protocol #15 when working a medical cardiac arrest. Protocol #15 is an online medical control decision to terminate resucitative efforts in the field given a set of circumstances. The time that efforts are stopped is recorded as the "pronouncement time." The legal documentation of death is a "death certificate" which must be filed by an MD/DO.

[Guest alsfirefighter]

WESTCHESTER REGIONAL

EMERGENCY MEDICAL ADVISORY COMMITTEE

POLICY STATEMENT

Supercedes/Updates: New

No. 01-01

Date: 17 December 2001

Re: EMS Guide for Field Pronouncement of Death

Pages: 2

EMS Guide for Field Pronouncement of Death

DEFINITIONS

Pronouncement of Death is the process of recognition and documentation of the physical signs of death. It is the basis of the decision not to engage in resuscitation efforts.

Certification of Death is the legal documentation required at the end of a life. A concise and complete statement of the terminal event and its causes, it is witnessed by the signature of a physician as per NYS Public Health Law.

ASSESSMENT

Patients may be pronounced dead and unable to be resuscitated when pre-hospital providers have found, in addition to apnea and pulselessness, that one or more of following conditions exits:

· Tissue decomposition

· Rigor mortis

· Extreme dependent lividity

· Obvious mortal injury (decapitation, exsanguination, etc.)

· A Valid Do Not Resuscitate (DNR) order

In addition to these conditions, pre-hospital providers should also attempt to determine:

· Confirmation with an AED that “No Shock Advised†or presence of asystole in more than one ECG lead

· Any significant medical history or traumatic event

· Time lapse since patient was last seen alive

As with any patient, EMS can contact Medical Control for consultation if there are questions regarding the patient’s presentation and the decision not to attempt resuscitation.

DOCUMENTATION

As per NYS DOH policy, a PCR for the call must be generated. The disposition code 010 (Other) should be used with the description “obvious death†entered in the disposition box. A PCR for a pre-hospital pronouncement of death should include:

· A description of the body’s physical location and presentation

· Any significant medical history or traumatic events

· Existing physical conditions which precluded performance of resuscitation efforts

· Any EMS contact with Medical Control

· In whose custody the body was left

Since the body will not be transported to a hospital, a copy of the PCR could be left with the law enforcement or medical examiner representative on scene as part of the official record.

REPORTING AND REMOVAL

As per the “Guide to Reporting Deaths to the Medical Examinerâ€[1], all unlawful, violent, unattended, sudden or suspicious deaths, either known or suspected, must be immediately reported to the ME’s office. If a death appears to meet these criteria, EMS should contact local police, if not already on scene, and take care not move the body or disturb the area unnecessarily. The police will notify the ME’s office and preserve any evidence.

For all other deaths, the Medical Examiner still must be notified. The deceased’s attending physician will be contacted by police or the Medical Examiner’s Office regarding the completion of the Death Certificate. Based on all the information provided, the Medical Examiner’s Office will decide to authorize removal or not. If the Medical Examiner’s Office does not authorize the removal, they will assume control of the body from the police.

It is possible that in some special situations the police may order EMS to transport a body to the closest hospital if, in their judgment, expedient removal of the corpse is necessary.

Issued and Authorized by:

Dr. Nicholas DeRobertis, MD, FACEP

Chair, Westchester Regional Emergency Medical Advisory Committee

Attachments:

· Guide to Reporting Deaths to the Medical Examiner – Westchester County 1999

--------------------------------------------------------------------------------

[1] Attachment - Guide to Reporting Deaths to the Medical Examiner, Westchester County, Millard J. Hyland, MD, ME.

[Guest]

cant seem to find anything similar @ the Hudson Valley REMAC website...ill have to give them a call tomorrow...

[Guest]

Outside of "obvious Death".....as not to beat this conversation to death. ALS-wise, patient must be intubated and placement verified. IV access must be established and no less than 2 rounds of meds IV. Defibrilations must be initiated (when applicable). If after 30 minutes there is no change (asystole from start to finish or V-fib to asystole) Medical Control is to be contacted and advised of situation, treatments rendered (dont forget the 5 H's), termination of efforts is either granted or denied.

But also remember, ALS Firefighter made a clear and ground breaking point. Take in your surroundings. Despite the inevitable outcome of your patient (say hi to god for me), you will find yourself in situations where it is best to transport a code rather than field terminate in lue of the overwhelming presence of family. Sometimes we have to look at what's best for the living and not the dead and the fact that my Dunkin Donuts coffee is geting cold in the rig.

[Guest]

I just received an email response from the Hudson Valley REMSCO/REMAC

Mr. XXXXX,

The HVREMAC currently has no such policy or guidance documentation in regard

to field pronouncement for any level provider. It is the position of the

HVREMAC that a Pronouncement of Death requires a Physician or Coroner

examination/assessment. Currently, there exists an ALS protocol which allows the Paramedic level provider to cease resuscitative efforts with medical control approval.

Please refer to your internal agency policies and procedures or your agency

medical director in regard to confirming obvious death.

Please contact me with any questions in this regard.

Respectfully,

Nelson Machado, Jr., NREMT-P

Quality Improvement Coordinator

Hudson Valley Regional EMS Council

[WAS967 97]

profound and generalized cyanosis

Not to nit pick, but the above is NOT an accepted sign of obvious death. Example: you pull a person from the frigid hudson and they look like a smurf. Do you declare them dead? I hope not.

[Guest]

i should have clarified, its a presumptive sign of death not definitive. sorry about that