We get dispatched for a report of a man unresponsive in a locked car, covered with blood. Priority One.
My partner and I speculate as we head out lights and sirens toward the address in the neighboring town, a street lined with cheap hotels, where many marginal people rent by the week.
We both think it will be a murder victim, someone shot awhile ago and only now discovered. We both doubt the victim will be fresh.
A few minutes later we get an update. Slow down to a two. It is a suicide.
We slow down as we hit off the lights and sirens. This will be a simple presumption. Put the electrodes on, run off the asystole, call the time.
It takes us another six or seven minutes to get there.
The address is not a motel, but a restaurant parking lot.
There are a half dozen police cars at least. Yellow crime scene tape blocks off the parking lot. A photographer is taking photos by a car with an open door.
Something doesn't seem quite right. Given the location of the car. How did he go so long unnoticed? Maybe the car has tinted windows? Maybe people just aren't observant?
We have to drive up on the grass to get around the police tape. I get out, and take the monitor out of the side door. I approach the car. From the rear I can see a man slumped back in the seat.
Give us a minute to finish taking pictures, an officer says, holding up his hand. I am standing back. I am hearing some conversation, scattered bits about getting the names of patrons who were witnesses.
Did this just happen? I ask.
I don't get an answer, but I get a look.
I might have to work this guy, I say. If he's dead dead, I am not going to work him, but the state says if he's fresh, he "may" need to be worked. I give "may" a certain emphasis, as if "may" to the state means work him, but too me, it means maybe, just maybe there is some gray that I can find refuge in.
The cop says nothing.
I am still standing back. I'm looking around at all the cops, the cameras, the people in the restaurant.
I know what the state guidelines say -- they say you have to work someone in arrest unless they have rigor mortis with dependent lividity, incineration, decapitation, decomposition or body transection. We all used to think there was a line in there about "injury incompatible with life," but it isn't in there. The state knows there are problems with the guidelines, and the state medical committee is actively rewritting it. I know because I have been involved in working on the draft. I am hopeful we will get the line "injuries incompatible with life" put back in where it belongs.
The committee wants to require medics to call medical control to presume. I have been against this because what happens when the doctor tells you to work the person who you have not been working, who no one has been working because he is dead. I have been a big advocate of letting the medic use his judgement following a reasonable protocol. Dead is dead.
They finally let me have access. The man has a gun in his curled left hand. His head is back against the headrest. His mouth is closed. There is a hole in the back of his head -- not exactly what I would call gaping. He is pulseless and apneic. He is not cold.
Look there's some brain, my partner says.
There is some, but not what you would call chunks, more like flecks. Like a very minor case of brain dandruff.
I hook up the monitor and attach it. The officer is watching my eyes. I look back at him.
I think he is thinking don't you even think about working this guy.
I am thinking this strip better be flat line. The last thing I want to see is a rhythm, even a agonal one.
I can picture the scene, me yanking the body out of the car, all ten of the cops, going what the f... Spectators passing out. And all hell breaking loose.
The monitor shows flat line.
I run a long, long strip, then detach the monitor leads. I write my name down a piece of paper along with the date, time and my paramedic licence number. I give it to the investigating officer. I walk back to the truck.
A supervisor has arrived and I explain the situation -- how I feel somewhat jammed up, but I am willing to take responsibility for my decision. She thinks I should call medical control just to get it on record. What if he says I have to work it? I say. The guy is dead. He's not coming back. He's been dead for at least twenty minutes.
They won't make you work it, she says. You need to cover yourself.
I call, hoping I don't get a moonlighter. I explain the situation. We were slowed down, delayed access, bullet through head, brain matter, asystole.
I'm think this is going to be something now if all of a sudden I have to go back, and say sorry the doctor wants me to work him.
Fortunately, the doctor grants his concurrence with my decision, but from his tone it sounds like he is thinking "Why are you even bothering me with this?"
It all leaves me slightly uneasy.
***
Twice before I have been slowed down to a not breathing, told it would be a presumption, only to find the patient did not quite meet the standard. They were dead -- no doubt -- dead and not coming back, but not dead enough if you follow the protocol.
Picture the scene, officers offering the family condolences, the family calling relatives to tell them that granny has passed on. And the medics come in with their monitor only, then suddenly they go throw granny on the ground and start doing CPR and yelling for their gear.
And what does the family think after they've talked to the lawyer. The police did nothing. They slowed the ambulance down. Maybe granny would have lived.
And what would happen to the officers -- these guys who have my back, who save my butt when a psych wants to kick my ass, who help with lifts when my partners lack the neccessary strength, who put their backs on the line to save mine, guys I am friends with, guys who like me are trying to do the best they can for themselves and their loved ones. What happens to them if I start working the patient who we all know is dead?
The news is granny was dead.
Sometimes its a matter of interpretation.
I guess I have to fall on the side of doing the right thing for my own conscience.
Dead is Dead.
***
Later in the week I talk to police officer who runs a volunteer EMS service. I tell him about the call and ask for his perspective.
He is sympathetic to my decision making. The guy was dead, and had I worked him, I would have jammed up a lot of people, with no change in the result. We talk about how on one hand the state has protocols for EMS that suggest patients need to be worked regardless of fatal injury and on the other hand the average police department has no idea such protocols exist so they go on taping up obvious death scenes as crime scenes, and medics are slowed down on the way to presume bodies that may not quite meet the state standard. They wait outside the yellow tape while the photos are taken, then are given access to call the time. There was obviously no cross communication in the development of the EMS protocols.
***
(Another example is the state regulation that requires a police officer to ride in the back of the ambulance if the patient is handcuffed. The police departments all have policies that allow the officer to follow in their cruiser. Now the reason for the regulation is in case the person becomes suddenly ill, maybe stops breathing and needs to be unhandcuffed, what do you do if you don't have the handcuff keys readily available (i.e. in your immediate hands rather than in the car following)? Answer -- you are screwed. The patient is screwed.
Now sometimes the cop will ride in the back, but most of the time, they follow. You can be a hard head and insist that they ride in the back, but then that jams them up, they need to get another officer to the scene when they may already be holding police calls. Sometimes they'll just tell you no -- this is how its going to go down. I try not to argue with people wearing guns -- unless I think it is really important. They are just not aware of the regulation. I doubt they were consulted when the regulation was written.
What do you do? You may only be a few blocks from the hospital. Why be a stickler when the only reason you are going to the hospital is because the patient needs a few stitches? They are fully healthy and alert. Why be an obstructionist?
They will tell you one thing in a class, but then there is the reality of the street.
I try to use common sense on a case by case basis. Sometimes I ask the officer to ride in back if I think there might be a problem with the patient being cuffed. If I don't think there will be a problem, I go with the flow.
You need regulations, but you also need common sense.
I will note that I raised this issue at a regional MAC meeting many years ago -- just pointing out that it was a problem medics faced -- being asked to violate the regs in the due course of the daily job. A letter suppossedly went out to police departments for a third time, but nothing changed.)
***
Some would say the only way to do this job is to be black and white on everything. Others would say flexibility and common sense must rule. I am in the latter camp. Of course there is responsibility to be accepted whenever the issue is gray.
But I will accept that responsibility.
That's what being a paramedic is about.
In my opinion.
***
An interesting sidelight of our conversation is the officer mentions he has recently been on a call where he and other officers arrived to find a person in (nontraumatic)cardiac arrest -- not breathing, no pulse. They put on a defibrillator -- no shock advised -- they started CPR. A paramedic arrived. Put the patient on the monitor. The patient was asystole. The paramedic told them to stop CPR. She said she was calling the patient dead. The officer left, leaving another officer on scene. He later heard from the other officer that a second paramedic showed up, and after CPR had been interrupted for ten minutes, for some reason the second medic convinced the first medic that they needed to work the patient. So they ended up transporting the patient to the hospital, doing CPR -- all after a ten minute interruption(*see note below).
Now I wasn't there so maybe I have some of the facts wrong. It sounds like the first medic failed to follow the protocols that require you to do 20 minutes of ALS rescusitation on medical asystole patients before calling the patient dead. Did she not know the protocols? Was she lazy? Or were there other factors that I don't know about that led her to say stop? Maybe there was some rigor in the jaw? I have been on calls where the cops were doing CPR, but the patient had early riggor so I stopped. Dead is dead. But what happened when the second medic showed up? Why did they start working the patient again, and not just working for 20 minutes on scene and then presuming dead, but working and transporting? I guess you would have had to have been there.
What does it all mean? There are many decisions to be made. Everyone has their lines of demarcation. Some are inside mine. Some are outside.
I have argued against having medics have to call the physician to get permission to presume. I want to be able to decide for myself, but when I hear of people not working people who I would have worked, then I think maybe it is neccessary.
There are no doubt medics who might say I should have worked the guy in the car? Could they be right? I don't think so, but who am I then to judge someone else? Dead is dead. Or is it? There are people who are dead, who I will work only because there are too freshly dead for me to say they are dead even though I know they are dead. I don't like to walk a razor's edge.
Bottom line is the State Medical Committee is working on rewriting the state guidelines and not only do they need to be rewritten, but each medic needs to know what is in them and how much leeway they have in interpreting them. Good guidelines would allow common sense to prevail, and the best person to use common sense is the medic on scene who can take in all the information. But what if people don't have common sense? That is a whole other problem, and a very scary one.
***
A number of years ago there was a call in the city where a veteran paramedic had called a suicide gunshot to the head dead when a new medic showed up and insisted on working the patient, which caused quite a bit of friction and led to the hospital issueing a policy that stated all medics on scene must agree with the desicion to cease or not start resucitation. I loosely used that instance as a basis for the first chapter of a novel I have been writing. (Note: In real life the patient did not live.)
The chapter is excerpted here:
Mortal Men: Chapter One
