Man Prematurely Declared Dead

[firemn23 8]

Questions haunt town where man North Carolina was prematurely declared dead

By ALLEN G. BREED

Associated Press Writer

INGLESIDE, N.C. (AP) -- Larry Green stepped out of the darkness so suddenly that the car that hit him didn't even leave skid marks. The impact sent his shoes, socks and the unopened beer in his hand flying.

Green came to rest on U.S. 401 alongside a trash-strewn ditch, where he was examined by paramedics and declared dead.

Over the next 2 1/2 hours, the bloody body with a gaping head wound was zipped into a black vinyl bag, taken to the morgue and slid into a stainless-steel refrigerated drawer.

There was just one problem: Green was alive.

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Two weeks after that shocking discovery, the 29-year-old Green clings to life in a hospital intensive care unit, paralyzed.

Anguished family members have listened in horror as officials described the many missed signs and miscues that led to the error. They and others in this rural tobacco community northeast of Raleigh are left to wonder how something like this could have happened - and whether it has happened before.

"Something ain't right with that," said T.J. Henderson, a high school classmate of Green's. "I thought they were supposed to try to give mouth to mouth or the shock at least till they got to the emergency room. That's where I thought you were pronounced dead at, not on the scene. ... Not on the street."

On the chilly night of Jan. 24, Green and a pair of friends showed up at the Ingleside Grocery about 8:45 p.m. to pick up a few tall-boy cans of Natural Ice to take back to his trailer down the road. Green never made it.

According to reports from state troopers and the Franklin County attorney's office, 36-year-old Tamuel Jackson did not have time to stop her car before it slammed into Green as he tried to cross the highway in front of his trailer.

Randy Kearney, an off-duty paramedic, was on the scene at 8:54 p.m. and found no pulse or sign of breathing. Blood had formed a foot-wide corona around Green's skull.

When county paramedics Paul Kilmer and Katherine Lamell arrived moments later, Kearney told them Green was dead, but asked Kilmer to double-check. Kilmer replied that his determination was "good enough for me," according to Kearney and two firefighters. Kilmer told officials he could not remember saying that, but doesn't deny it.

By the time paramedic Pamela Hayes arrived at 9 p.m., Green was covered by a white sheet.

Although the law does not require the medical examiner to go to accident scenes, Dr. J. B. Perdue showed up half an hour later and began examining the body, lifting and twisting Green's broken right leg, rolling him over and inserting a gloved finger into the gash in Green's head.

"That's more than I need to see!" Lamell shouted.

When Perdue opened Green's jacket, several firefighters holding a tarp to shield the body from onlookers noticed what appeared to be an in-and-out movement in Green's chest and abdomen.

"Doc, is he breathing?" the firefighters heard Kearney ask. Perdue told Kearney that it was just air escaping or moving around inside the body.

Paramedics put Green in a body bag and drove him to the morgue in nearby Louisburg. There, Perdue examined the body a second time. He took a blood sample, lifted Green's eyelids and sniffed around the man's mouth for alcohol.

Hayes, who had accompanied the body, thought she noticed twitching in Green's right eyelid. She asked Perdue if he was sure Green was really dead. Perdue responded that the twitching was a spasm, "like a frog leg jumping in a frying pan."

"I don't feel good about this," Hayes told colleagues, according to the county attorney's report. She asked Perdue again if he was sure Green was dead. He reassured her. The body bag was zipped back up, and Green was placed in the portable morgue unit, where the temperature is kept a few degrees above freezing.

Green probably would have remained in the stainless-steel container had state Trooper Tyrone Hunt not arrived around 11:20 p.m. and asked Perdue to help him determine the direction from which Green had been struck.

This time, Perdue observed slight movement. He could not find a pulse in Green's neck, thigh or wrist, even with a stethoscope. Perdue summoned paramedics and an electrocardiogram, which was able to pick up a faint heart rhythm.

Family members who have kept vigil at Green's bedside say his eyes flutter at times and he shows signs he recognizes those around him. It is unclear whether his paralysis is from the accident, or the handling of his body afterward.

Within days, Kearney, Kilmer, Hayes and Lamell were all suspended with pay. The state's Office of Emergency Medical Services suspended Kearney's and Kilmer's credentials, citing "a lack of competence to practice with a reasonable degree of skill and safety."

Kearney and Kilmer were fired; Hayes and Lamell were ordered to undergo remedial training before coming back to work. Kearney declined an Associated Press request for comment, and the others did not respond to messages.

Dr. John Butts, the state's chief medical examiner, said that Perdue did everything the law required of him and that there are no plans to censure the 34-year veteran.

"He went because he was informed that a man was dead as a result of violence or trauma," Butts said. "He did not come with a doctor's bag and a stethoscope. He came with a pencil and paper to get information."

Perdue told the AP: "I am not in any shape form or fashion responsible for pronouncement of death. ... Obviously, I'm in sympathy with the family. My heart goes out to them, and my prayers are that this person recovers."

The family has retained an attorney.

Elaine Hicks, who lives two trailers over from Green's, said she thinks people should focus on the miracle of Green's survival. In fact, she asked, who's to say the paramedics weren't right, and that Green did not come back from the dead?

"It could have been the Almighty," the 57-year-old woman said. "He has the last say so."

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[Guest WolfEMT]

When Perdue opened Green's jacket, several firefighters holding a tarp to shield the body from onlookers noticed what appeared to be an in-and-out movement in Green's chest and abdomen.

If there were any doubt, and from the way this makes it seem, there was, they should have worked him under the assumption that the in-and-out movement was breathing and Green was, in fact, alive.

[WAS967 97]

Yeah. I think a few things were missed in this case. I would have to wonder if any attempt was made at listening for heart sounds. And there was no mention of a monitor being applied and getting a three lead 6 second strip of Asystole. At least then they'd have something to back up thier documentation in cases like this.

[calhobs 110]

You know i been doing this a long time now, and i find this funny, no not funny i shold say disgusting. Yes some of the medics if not all got what they desvered. But the Doctor who had it pointied out to him what 3 or 4 times that there maybe life and he discards that info. AND NOTHING HAPPENS TO HIM. wow. ](*,) and for his boss to say he arrived on scene with a pencil and paper not a doctors bad is a little scary. 8-[ From what i remeber (its been a while since i saw an ME on a scene) but didnt they carry doctors bags just to make sure or at least show up hours later to be on the safe side? it just amazes me how this happend

[Guest alsfirefighter]

There are several points of this case that are glaring, on an overall EMS level and some points that can be pointed out here in Westchester.

First is again how we are inadequate in public education. The fire service has this problem also. People generally do not understand nor know what we do or why we do it. "That's where I thought you were pronounced dead at, not on the scene, not on the street." Perhaps if we took more time for those to understand all that we can do these types of quotes will be less frequent.

Secondly, this again reflects how easily a mistake can be made when making pronouncements. I was glad and still appreciate the fact that we can make pronouncements in the field, which shows the level of respect we are gaining as providers in the county and speeds up those calls which working the arrest is not warranted or you have worked the arrest within the scope of the termination protocol. However, you must make certain you do everything you can to ensure clinical death has occurred. Along with the EDP discussion, the pronouncement and termination is something that was not adequately discussed, given direction or training to Paramedics who now also have to be able to effectively deal with patients family members. I use as many clinical signs to ensure the patient has expired and a full work up is not warranted before finally making a decision. Pulseless, apneic, no heart sounds, pupils, running a strip, looking for lividity, rigor and color and temperature all have to come into play. You are the only person whom can protect yourself in that situation. Be cautious of the not so routine incidents where its not easy to determine like hangings, crime scenes where the PD is overly protective (partly rightly) of the scene, cold temps etc.

[Guest WolfEMT]

That is extremely well-said, alsfirefighter, and hits the nail right on the head. Just a note for everyone else, as alsfirefighter pointed out, be cautious for the not-so-routine calls, such as cold temps; a person may be cold, but is not clinically dead until they are warm and dead.

[roeems87 0]

Not that I feel what happened was right, but for the time being, let me play devil's advocate...

Firstly, take a look at the description of the patient. The man was thrown an extreme distance from a car with a clearly fatal MOI. The body had obvious signs of death (which according to what is taught only includes "obvious and massive trauma"--which I would say gaping hole and a facture of the skull, never mind the blood, and obvious other fractures and deformities would include), and no appreciable pulse or breathing in any of the three pulse check spots. Let's be serious. Obviously the arriving medics should have checked the body for themselves, but when it is the concurrance of 3 medics looking at the body that it would seem so obvious, and the first found no signs of life, wouldn't you agree with the decision made.

Moreover, hind sight is 20/20. How many times has anyone had a firefighter second guess whatever EMS is doing...right or wrong? How many other times could you hear someone say, "are you sure he's dead?" when a medic makes a pronouncement. This only furthers the point about the public becoming more educated about the scope of practice within EMS.

Obviously there could have been more done to check this guy out, but also take the post-trauma/hospital stay/quality of life arguement. Is it reasonable to continue to try to resusitate someone in PEA after 45 minutes of CPR, defibrillation, and drugs? The quality of life post-incident is obviously taken into consideration where you decide to draw the line. Based on the description of this incident, and the patient, come on now...

You have to assume that this was such an extreme case when this accident ocurred under the auspices of 4 paramedics, whatever other EMS trained people on scene, and a doctor.

I don't think the arguements I present here are unfair... Please feel free to comment, disagree, yell, whatever you need to do, I just thought I would provide another side of the story, even if just for arguement's sake...

[WAS967 97]

That is extremely well-said, alsfirefighter, and hits the nail right on the head. Just a note for everyone else, as alsfirefighter pointed out, be cautious for the not-so-routine calls, such as cold temps; a person may be cold, but is not clinically dead until they are warm and dead.

Dr. McGurty brought up an interesting case at the call audit at HVHC tonight. A man fell through the ice over near Roa Hook Road near the oil tanks. Guy was in full arrest on arrival (this was about 10 years ago) and core temp was in the low 70s (yikes). They had the Tumper on the guy and admitted him (yes, i said admitted) to the ICU with the Thumper going all night long. Basically it took all night for his temp to return to normal levels and was in the end declared dead. I thought this was interesting in the fact that they had the guy being "worked" all night long until his temp returned to normal.

[Guest WolfEMT]

Low 70's is a bit of an extreme case, but let's just say you have a vic who fell through the ice in the Hudson River. The vic can't tread water and eventually falls under to a moderate depth. It takes responding units 15 minutes to get there and set up, then another 10 to dive and get the body. So at this point, the vic has been under for a total of 25 minutes and his or her body temp is probably less than the 98.6 degrees necessary to sustain life. In that case, the vic is probably in a "suspended" state and I would definitely work the vic until his or her body temp returned to normal, then wait for medics to make the pronouncement, if necessary.

[mikeinet 37]

I was taught that if you come across a pt that's so cold as in the above case, they need to be brought back to a std body temperature before they can be declared dead... as you know body functions can cease in order to allow the heart and necessary bodily functions to continue. does seem kind of weird, but hey... you never know. always side on the side of the patient.

[Guest alsfirefighter]

Both cases are similiar between WAS's case and Wolf's.

One thing there is no "wait" for a medic to make a pronouncement. The patient in Wolf's scenario needs to be immediately transported, a medic could not possibly pronounce that patient in the field, we have no method of measuring body core temperature. 98.6 isn't the magic number, that is just the average normal adult body temperature. Hypothermia is defined as a body core temp below 95 degrees F. You lose your shivering mechanism around 90 deg. F. Again the problem is EMS providers do not carry anything to measure body core temp, you must transport this patient as gingerly as possible if you follow the textbooks and a heart rhythem is present or you put them into V fib easily. All immersion hypothermic patients must be transported for aggressive rewarming and resuscitation that we cannot provide.

I actually recently had a case where a elderly gentleman has passed on and had not been seen or contacted in several days. His house was very chilly as the furnace was not operating and the emergency switch was off. He was extremely cold, but he did show several other signs of extended death, including rigor, dependant lividity, his eyes were completely dried out and had foaming of the mouth. I pronounced him and left him with PD for further investigation. The ME concluded he had sufferred a heart attack while sleeping and not from hypothermia. Yes he was cold, but clinical experience and judgment played into the situation. However, again, any hypothermic immerision victim must be transported barring other obvious indicators that the person has been in the water for an extended period of time. Ie, missing flesh/organs from fish/animals feeding, vicitm is frozen solid, bloating and the distinguishing color that comes with being in that state and the Hudson for an extended period of time.

Excellent discussion!