Pronouncing death outside the hospital

[cassica]

Hi, I can't find the answer to my Q so I thought I would post it here.

This afternoon, I was waiting for the subway. The train was stopped at the station and tons of people were waiting to get on. I could see people exiting only one cart...being super nosey, I went over and found out there was a cardiac arrest going on. So I went to help three other nurses who were already 15 min into CPR. We had no defibrillator and no airway. anyways, after 20 min, the paramedics showed up, pushed us aside, starting bagging him and defibbed x 1. another 10 minutes later, they had an IV in and started epi etc... This went on for another 15 minutes and the man was obviously dead. he had been asystolic for about 30 minutes or so.

 

There were hundreds of people witnessing this and I don't understand why they kept doing CPR. The nurse told me the EMS could not stop CPR until a coroner showed up to pronounce the death and that we could not pronounce him dead as MDs and nurses...is that true?

[webshy]

Hi, I can't find the answer to my Q so I thought I would post it here.

This afternoon, I was waiting for the subway. The train was stopped at the station and tons of people were waiting to get on. I could see people exiting only one cart...being super nosey, I went over and found out there was a cardiac arrest going on. So I went to help three other nurses who were already 15 min into CPR. We had no defibrillator and no airway. anyways, after 20 min, the paramedics showed up, pushed us aside, starting bagging him and defibbed x 1. another 10 minutes later, they had an IV in and started epi etc... This went on for another 15 minutes and the man was obviously dead. he had been asystolic for about 30 minutes or so.

 

There were hundreds of people witnessing this and I don't understand why they kept doing CPR. The nurse told me the EMS could not stop CPR until a coroner showed up to pronounce the death and that we could not pronounce him dead as MDs and nurses...is that true?

 

The information that the nurses gave you is false. Advanced Care Paramedics have the ability to do everything for a medical cardiac arrest patient that can be done in the emergency department. When further efforts are futile, they can patch to a Base Hospital Physician (ie: contact a physician at their delegating facility, either by phone or by radio patch) to pronounce death. At that time, all resuscitation efforts are stopped. However, a death certificate still has to be completed. That is done by a physician who attends the scene (likely the coroner; however, possibly the family physician depending upon the situation) or by the coroner after an autopsy (which would be ordered by the attending coroner).

 

Why do 30 minutes of rescusitation? By the way you described the procedures, it sounds like the patient was not asystolic for the entire time (or he/she would not have been defibrillated twice). In a dynamic arrest in the pre-hospital environment, the chance of obtaining a return of spontaneous circulation (ROSC) is actually quite high in Toronto (where I'm assuming you were, because you said subway - please pardon my ignorance if I am incorrect) - about 7%. To ensure that a potentially viable patient is not pronounced and to ensure that the family has the assurance of that, an arrest is typically worked for about 20 to 30 minutes.

 

One other question - are you sure the nurses were doing CPR for 15 minutes prior to your arrival, which was prior to paramedic arrival? Response times for cardiac arrest calls are much faster than that. However, my experience is that people always think that paramedics take longer than they do, because time seems to slow down in an emergency.

 

Elaine

[cassica]

Elaine, thanks for the reply.

You are right, the arrest was in Toronto. I think it took a while for paramedics to get there because it took a long time to actually call EMS from underground +/- time going very SLOWLY during a stressful situation. Either way, I didn't get to the scene until 10-15min into it from what I recall the nurses saying.

So in regards to the 20-30 min of resuscitation before pronouncing a patient, does this start when paramedics get there or when "lay people" start CPR?

 

Also, do you know if a doctor who was at the scene can actually pronounce the person after the base hospital physician has been notified...and do you know how long it takes for a coroner to come to the scene?

 

thanks so much for your knowledge!

[blinknoodle]

I am surprised the TTC doesn't have AEDs!

 

(sorry I can't meaningfully contribute)

[noncestvrai]

I'm not surprised I don't remember how to operate an AED, let alone my ACLS courses...

 

(sorry for also no contributing to the thread).

 

noncestvrai

[leviathan]

Hi cassica,

 

Same applies here in BC, so I think the nurse was mistaken. After 30 mins of CPR without ROSC, we can consult an emerg. physician for approval to discontinue resuscitation. That's even without ALS care present.

[doc2B]

I just wanted to add that I too am surprised they don't have AEDs readily available.

 

To noncestvrai, the AEDs they have in public areas are specifically designed for use by anyone. You don't actually have to REMEMBER anything. There are pictures that show you where to place the electrodes and once you turn it on the AED tells you what to do, literally. In a computerized voice it will tell you when to push buttons, when to stand clear, when to shock when to do CPR, and it will count down for you for the CPR. They have them in malls, airplanes and many other places so they should have them on buses and subways too.

 

We teach the use of AEDs to Standard First-Aiders now (a weekend first aid course).

[webshy]

Hi cassica,

 

Same applies here in BC, so I think the nurse was mistaken. After 30 mins of CPR without ROSC, we can consult an emerg. physician for approval to discontinue resuscitation. That's even without ALS care present.

 

Hi Lev,

 

What do you do for the 30 minutes if you don't have ALS? Do you start transport, and pronounce enroute? If so, do you have difficulty having hospitals accept a pronounced patient (a problem we often have, as there are no rooms available in the ED for patients, and obviously having a pronounced patient in off-load delay in the hallway isn't appropriate), or do you transport directly to the Coroner's office? In odd situations, we've transported a patient to a funeral home - but that certainly isn't the norm.

 

Also - in the cities, do you have mandatory ALS for cardiac arrests?

 

Elaine

[leviathan]

Hi Lev,

 

What do you do for the 30 minutes if you don't have ALS? Do you start transport, and pronounce enroute?

I've personally never seen it in practice, so I'm still not sure of the specifics. If we get 3 no-shocks on the AED, we call the EP for orders to transport. While en route, if you have been doing CPR for 30 minutes and had persistent "no shock" messages from the AED, you can then pronounce if you call back for permission.

 

If so, do you have difficulty having hospitals accept a pronounced patient (a problem we often have, as there are no rooms available in the ED for patients, and obviously having a pronounced patient in off-load delay in the hallway isn't appropriate), or do you transport directly to the Coroner's office? In odd situations, we've transported a patient to a funeral home - but that certainly isn't the norm.

I wish I could comment on this, too, but I've yet to do an arrest call where we pronounced on scene. A friend of mine who works up in rural B.C. pronounced on scene one time where they had a long response time, and fire had already been on scene for 30+ minutes with their own AED unit. He said the coroner showed up to the scene to take care of the body after they pronounced.

 

Also - in the cities, do you have mandatory ALS for cardiac arrests?

ALS will always be dispatched along with BLS to a cardiac arrest call. If all ALS are tied up at the time, then there are circumstances where only a PCP crew would manage the arrest. I've only ever done codes with ALS on scene, and we actually transported to hospital for all of them. It probably had to do with the fact that they were all less than 5 minutes to the hospital. One of them was literally across the street...I figure he must have been trying to get himself to the hospital but didn't quite make it.

[donna2011]

Hi, I also have a question regarding pronouncing death outside the hospital. If a person residing in a LTC was pronounced dead in the ambulance enroute to the emergency. Where would EMS take the body? To the emergency or back to the facility?

[MSc-microbiology]

My understanding, in NS anyway, is that ANY unexpected or accidental death must go to the medical examiner who will complete the death certificat following investigation and determination of cause of death. Further that in NS "coroners" have been phased out and "medical examiners" now take on the responsibilities.

[A-Stark]

I'm still not really clear on when a death is "unexpected" (a ICU patient whose care was withdrawn was an ME case). Maybe it's as any kind of eventual sequela of an accident?

 

I do know that ME cases mean less paperwork...

[Davjw]

All TTC stations have AED.

 

http://www.ttc.ca/News/2011/July/NR_Heart_defibrillators_are_now_available_at_all_TTC_station.jsp