Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

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WKYT Investigates: Can paramedics declare someone dead?

 
Friday, I wrote about a patient apparently pronounced dead a bit hastily.[1] Today, the news has more information.
 

What is death?

Clinical death means that the heart has stopped. When we attempt to resuscitate a patient, it is because the person appears to be only clinically dead.

What about pronouncing death?
 

However, a question has been raised: Can a paramedic declare someone to be dead?

“Paramedics are trained very thoroughly in determination of death, and there are certain procedures that we go through,” answered Poynter.[2]

 

Mike Poynter is the Executive Director of the Kentucky Board of Emergency Medical Services (KBEMS).

Paramedics can declare death in Kentucky. They may have to make medical command contact, but that is not stated in the story.
 

This leader (Poynter) also has experience as a paramedic and says sometimes the call goes deeper than what the rules say.[2]

 

Deeper?

But EMS is about the superficial (if it isn’t specifically stated in the protocol, it is wrong) and (there is one best answer).
 

Is this rhythm asystole?
 


 

Some people would argue that the ECG strip above is asystole.
 

Looking at just one lead might miss a rhythm that is there, because sometimes the electrical axis of the heart is perpendicular to the lead being looked at, which would make the rhythm invisible on the monitor. Looking at any other lead, especially one of the other limb leads (I, II, III) should make any such rhythm visible on the monitor.
 

Above is lead V2, cut from a 12 lead and pasted end to end to give a longer strip.

A 12 lead ECG is not necessary to get two different leads.

Running 12 leads to document death would suggest either a very bizarre patient or a lack of competence.
 

“It’s stated that you should determine two different leads with an EKG, unless there are signs of trauma,” he continued.[1]

 

Here is lead V2, from above, in the context of V1 and V3.

Perspective is important.
 


 

V1 and V3 are being recorded from the same heart at the same time as V2, but they look completely different.

Below is the full 12 lead ECG with V2 highlighted. The leads are expected to show more of a continuum from V1 to V6, so there may be a problem with the placement of the lead, but this is a lead hooked up to a patient with an easy to recognize rhythm in 11 of the leads and almost nothing showing on one lead. This is not common, but it is reasonable to check another lead, even if it is not required.
 


Image credit. Click on images to make them larger.
 

Did the paramedic hook the patient up to the monitor?

We do not know, but the description of the assessment by the husband suggests otherwise. The husband was probably distraught at the time and may not have noticed a full assessment, because of the stress of the situation. Eyewitness accounts of stressful situations are notorious for unbelievable inaccuracies, except unbiased information shows that we should believe that the eyewitness truly was wildly inaccurate.
 

Few kinds of evidence are as compelling, or as damning, as eyewitness testimony: A human being, frequently a victim, takes the stand, looks at the defendant, and says, “He did it.” Eyewitness testimony is a staple element of criminal cases. In 1999, eyewitness identifications led to 75,000 prosecutions in the United States.1 Unfortunately, juries’ acceptance of faulty eyewitness identifications is also a leading cause-possibly the leading cause-of wrongful convictions.2 [3]

 

The documentation should solve that problem. Even if the paper printout is lost, the monitor should retain a long history of time stamped ECGs. This should not be a choice of whom to believe.

While I usually mock the cliche, If it isn’t documented, it wasn’t done, this is one case where that is true. Waveform capnography for endotracheal tube confirmation is another.

If the medic documents that rigor mortis was present, then his assessment is going to be very difficult to explain. While rigor mortis does wear off, it is an irreversible muscle breakdown that occurs after death. I don’t know of any documented cases of breathing returning after rigor mortis.

Could it have been the agonal breathing of a dead body? That would be much more likely, if the patient were pronounced dead upon arrival at the ED, but that was not the case.
 

According to Lincoln County Deputy Coroner Tony Floro, the breathing was faint but Tygart was still unresponsive. The victim was rushed to nearby Ephraim McDowell Hospital and was then flown to UK hospital, where she died the next day.[4]

 

EMS arrived on scene at 10:06. The coroner arrived about half an hour later. She was treated at the local hospital, then flown to a university hospital. A lot of people would have to have to not notice/ignore obvious death for a long time – or she was not really dead. It is possible for even doctors to ignore reality. I have seen doctors push repeated doses of succinylcholine to try to relax the jaw for the intubation. This was the jaw of a child in rigor mortis. They stopped after about an hour. Maybe they ran out of succinylcholine, or maybe they finally accepted reality.

EMS -> ED -> Flight crew -> ED over more than half a day, with no recognition of death? They should be able to provide ECG strips from the second ambulance and the hospitals.
 

See also –

She’s Not Quite Dead Yet – 4/25/2014

Details on the Recent Patient Prematurely Pronounced Dead – 5/05/2014

Footnotes:

[1] She’s Not Quite Dead Yet
Fri, 25 Apr 2014
Rogue Medic
Article

[2] WKYT Investigates: Can paramedics declare someone dead?
Updated: Thu 11:54 PM, Apr 24, 2014
By: Tim Johnston
WKYT
Article
 

Still he was able to answer questions about procedures and requirements and he said since 1998, paramedics have been trained in the procedures about declaring a person to be dead.[2]

 

[3] Beyond Admissibility: A Practical Look at the Use of Eyewitness Expert Testimony in the Federal Courts
JL Overbeck
NYUL Rev., 2005
HeinOnline
Abstract

Free Full Text in PDF Download format from nyulawreview.org

[4] Lincoln Co. paramedic pronounces woman dead, later found breathing
Updated: Thu 6:28 PM, Apr 24, 2014
By: Tim Johnston
WKYT
Article

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