Members of the Italian Public Assistance (in orange) and members of the Misericordia Assistance Service (in blue), a Catholic association, treat simulated casualties and prepare them for transport to local Italian medical facilities during Exercise “Tuscan Sun.” (Photo by Elena Baladelli.)
By Michael Morse
Chances are good that a fire company will be first on scene for all calls involving a person not breathing, a possible dead-on-arrival, or for somebody unresponsive. Firefighters need to know exactly, without hesitation (and with no chance of mistake) if a person is dead, and be able to justify that determination. It isn’t enough that we have seen dead people, and the patient we were called to help fits the picture. Never is the need for clear, concise communication more important. Family, friends, and especially the deceased deserve to have competent, caring people arrive at their home or wherever it is that the victim takes his last breath. The last thing they need is bewildered expressions on the faces of the people they called for clarity, comfort, and even hope.
Nobody wants to be the person to tell survivors that their loved one is gone. It was, by far, my most dreaded event in a career full of unpleasant moments. People tend to exist in a state of disbelief when somebody dies unexpectedly or even after a long illness; they often await someone else to confirm their fears. We are “the officials” people depend on during moments of crisis. We are the ones who take the last vestiges of hope from them. We are the ones who cannot blow it; there is far too much at stake.
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Most of us have had minimal training on differentiating life vs. death. Textbook answers to obvious questions tend to elude us when confronted by a frantic family, the concerned and cell phone camera wielding public, and a body that we instinctively know is gone forever. The easy choice is to start cardiopulmonary respiration (CPR) after the patient does not respond, is not breathing and you confirm the absence of a pulse, and wait for the ambulance carrying the paramedics. The better choice is to properly assess the patient and determine whether or not to begin resuscitation efforts. It is not easy making the right choice when so much is at stake, but it is absolutely imperative that we do so.
A person is dead when:
- There is no response to tactile stimulation (shake and shout).
- The victim’s pupils do not react to light.
- The victim has no breath sounds (stethoscope required).
- The victim has no heart sounds (stethoscope required).
- Blood has pooled after the heart has stopped beating. The official term is “dependent lividity,” which looks like bruising on the body in the point lowest to where the patient has come to rest. If he died sitting, his legs, feet, and buttocks will be purple, black, and blue. Lying on his back, lividity presents on the back when he is rolled over, and it will hang in the feet and lower legs.
- Rigor mortis begins, first in the small muscles and then to the large muscles. It is prudent to check the mandible and wrists for stiffness.
- Obvious signs of death include decapitation, severe burns, and organ removal, although don’t be tempted to skip steps 1-4 above.
A rapid assessment of the patient, including signs of death, greatly improves your delivery of the bad news to survivors. Instead of doing exactly what they did—checking for breathing and pulses—we, as professionals, need to take our assessment to the next level.
Saying, “I’m very sorry for your loss, there are no pulses, no breathing, dependant lividity is present, and rigor mortis has begun,” lets the person know, without much room for dissent, that the loved one is gone. Sometimes he insists that you start CPR or do “something.” I have learned through experience that, giving in to the family’s wishes against your better judgment does more harm than good and simply prolongs the pain and suffering of the living while disrespecting the remains of the dead. By acting professionally and with compassion and authority, the worst moments of a person’s life need not be spent in a state of confusion, helplessness, and rage.
In the event that there is no lividity, rigor mortis, or obvious signs of death, then by all means proceed with the highest level of training and certification you have. Miracles happen, not every time, but often enough for us to keep things in perspective and do our absolute best to save the lives of the people who depend on us.
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Michael Morse is a former captain with the Providence (RI) Fire Department (PFD), an author, and a popular columnist. He served on PFD’s Engine Co. 2., Engine Co. 9, and Ladder Co. 4 for 10 years prior to becoming an EMT-C on Rescue Co 1 and Captain of Rescue Co. 5.
