BLS - Patients with Vital Signs Absent (Transportation) Standard

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1. All patients will be assumed to be viable and will be treated as living persons. Patients will be provided with the care and transportation required unless they are pronounced dead or are obviously dead as defined in this standard.


2. No person except a qualified medical practitioner has the authority to pronounce a person dead. This may be requested by paramedics acting upon the direction of a base hospital physician when local procedures on pronouncing death have been established.


Procedure

In instances of sudden or unexpected absence of a patient’s vital signs, the paramedic is obliged to:


1. Assume life. A decision based upon subtle physical factors such as skin temperature, skin colour, etc. is inappropriate.


2. Initiate life support measures, i.e. SAED, CPR, in accordance with the ALS - Patient Care Standards unless the provisions of Policy 4.6 - Interfacility Do Not Resuscitate Orders apply [obsolete - see the new DNR Standards, or reference the local BLS - DNR Standard].


3. Initiate transport of the patient to a medical facility as quickly as possible.


4. Document the detailed findings of the history taking, patient assessment and any patient care efforts (including the results of such efforts) on the Ambulance Call Report (ACR). Report the information to the receiving facility medical personnel.


5. In cases of suspected foul play, every effort should be made to leave the scene undisturbed and to preserve as much evidence as possible for the police. This obligation is second only to ensuring that the appropriate assessment, treatment and transport of the patient occurs.


Criteria for Presuming Death

1. Legal Death
Legal death exists only when a physician (including a base hospital physician acting through a paramedic) has pronounced death.


2. Obvious Death
a) Obvious Death - No Physician Present
Upon completion of a thorough physical assessment and history taking, the paramedic may "presume" death has occurred if gross signs of death are obvious, i.e. by reason of decapitation, transection, visible decomposition, putrefaction or otherwise.
b) Obvious Death - "Otherwise"
Upon completion of a thorough physical assessment and history taking, the paramedic may presume that death has occurred only in circumstances where the patient exhibits:
i) absence of vital signs, and
ii) “obvious” signs of death, i.e. grossly charred body; open head or torso wounds with gross outpouring of cranial or visceral contents; gross rigor mortis.



Presumption of death is based upon knowledge, skills and training in patient assessment and care. Should there be any doubt that death has occurred, every effort must be made to resuscitate the patient.



Notes


1. Gross rigor mortis is defined as one or more of the following findings in a patient with absent vital signs:
  • limbs and/or body stiff;
  • coldness and/or posturing of limbs, body;
  • lividity (liven mortis);
  • complete or partial corneal opacification associated with any of the above.

2. Severe hypothermia
a) Severe hypothermia should be assumed if the history of the incident and scene observations suggest severe hypothermia and the patient is cold and/or postured, stiff and unresponsive and pulse and respirations are slow or absent.
This also includes severe hypothermia secondary to near-drowning (immersion/submersion) unless other signs of "obvious death" are present concurrently.
Some drug overdoses and poisonings may result in a patient being VSA in association with hypothermia, e.g. barbiturates, alcohol, insulin, opiates, phenothiazines, sedative hypnotics, benzodiazepines.
b) Check pulse and, if available, utilize a cardiac monitor, for 45 seconds. If the patient is pulseless/asystolic, initiate appropriate SAED protocols in accordance with the ALS - Patient Care Standards.
c) If pulse is palpable during the 45 second interval, initiate ventilation without chest compressions. Use humidified oxygen, warmed if possible, and transport as soon as possible.
d) If transport time is prolonged (i.e. greater than 30 minutes) it may not be practicable to continue resuscitation on all severely hypothermic patients especially if the patient remains pulseless, apneic and the chest remains stiff and immobile despite repeated manual ventilatory efforts. Contact will be made with a base hospital physician, if available, to request termination of resuscitation efforts.

3. Victims of high voltage electric shock or lightning strike may appear dead, with fixed, dilated pupils and stiffening from muscle contractions. Unless other signs of rigor mortis or obvious death are present, initiate appropriate SAED protocols in accordance with the ALS Patient Care Standards.


4. In cases when death appears obvious in infants or children, or other situations where family members of the deceased are unable to deal with the situation, i.e. they are unable to accept that death has occurred, initiation of patient care and transport is recommended. Use compassion and judgement to balance the parent’s or family’s need for action with the requirements of this standard.


5. In cases where death appears obvious and CPR is being performed by citizens or other first responders, the paramedic may advise the citizens or first responders to discontinue CPR. The paramedic will follow the procedures described under Patient Presumed Dead.


Patient Presumed Dead

When the criteria for presuming death has been met, each paramedic will ensure that the deceased is treated with respect and dignity; be conscious of the family and try to respect their wishes.


1. In Cases of Unexpected Death
a) If there is any evidence that this is an unexpected death, advise the ambulance communications officer and request that the police and coroner be notified.
b) Remain at the scene (unless directed otherwise by a ambulance communications officer) until either the police or the coroner arrive and accept responsibility for the deceased.


2. In Cases of Expected Death
a) If from the evidence collected regarding the deceased, the paramedic determines this to be an expected death (e.g. patient had terminal illness and death was expected), the paramedic will request that the family have the family or attending physician notified of the death and request the family or attending physician’s presence at the scene to pronounce death.
i) Should the family be unable to comply, the paramedic will notify dispatch to request the family or attending physician’s presence.
ii) If the family or attending physician cannot be contacted and there is a locally designated base hospital with a field pronouncement of death procedure, the base hospital physician should be contacted.
iii) If the family or attending physician cannot be contacted and a base hospital physician is not available, the crew will notify dispatch to request the attendance of the coroner.
b) If there is an apparently responsible family member or friend willing to assume responsibility for the deceased until the family physician, attending physician or coroner arrives, the paramedic may depart the scene as soon as documentation is completed.


3. In All Cases of Death
a) Document the detailed findings of the history taking, patient assessment and any patient care efforts (including the results of such efforts) on the ACR.
b) In accordance with Regulation 257/00 as made under the Ontario Ambulance Act, "legally" or "obviously dead" persons must not be transported by ambulance, except from a public place where no body removal service is readily available. In such circumstances a coroner or a police officer acting on a coroner’s order may authorize transportation of a deceased person by ambulance to the nearest hospital or morgue when an alternative ambulance is readily available to respond to emergency calls as determined by the local CACC/ACS.

Notes


"Public place" means any place, building or public conveyance to which the public habitually resorts or to which the general public are admitted free or upon payment, but does not include a hospital, nursing home or any other health facility, or any home or other facility for children or for the aged, or any facility for persons with mental or physical handicaps, or any private residence or boarding house.

Where a body is in a location where it is visible to the public and when the ambulance communications officer gives approval and indicates that another ambulance is available, a paramedic may transport the body to the closest available hospital or morgue





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