Dead Reckoning: EMS, Death, and Resource Management

“Unresponsive to stimulus; without breathing or heart beat” – that is a common description used by EMS (emergency medical services) staff in reporting the status of someone believed to be already dead. However, it may still be appropriate to transport that patient by ambulance to a hospital or other healthcare facility because, under some conditions, rapid transport, combined with the medical care provided by EMS responders, may give the patient a chance to survive. In most of the United States an EMS crew can usually determine that a patient is beyond help. However, and despite appearances, that person is sometimes transported as a living patient, and still receiving care.

There is another, larger, pool of patients who share the same general description but are not viable and therefore are not transported by ambulance. Included in this pool are patients whom EMS starts to treat, but without improvement, and care is then officially terminated.

Laws related to death and dying are generally enacted at the state level, as are the regulations governing EMS care. In the United States, the forensic investigations of death are under the jurisdiction of medical examiners and coroners. A medical examiner, or ME, is a physician, typically a forensic pathologist; a coroner is usually an elected layman.

All states have enacted statutes requiring that certain types of deaths – including all deaths outside of a hospital or hospice setting – be reported to the ME or coroner within the local jurisdiction. This requirement gives those officials the opportunity to determine whether the remains of the deceased can be released to a funeral home or must be taken under their own jurisdiction. In the majority of cases the remains are removed from the scene, by either the ME’s or coroner’s staff – or by the funeral home staff – after the jurisdictional decision has been made.

A Short List of Mandatory Prerequisites

In many states, the transportation of human remains in an ambulance, regardless of how recently death might have occurred, is prohibited except under very limited circumstances. Decisions in this area, though, are considered separately from those governing the transportation of patients, described earlier, who are without a heartbeat or breathing but are still receiving care. The circumstances under which a dead body can be transported often include situations in which the deceased is in public view. New York City’s EMS procedures, for example, permit the removal of a patient who has a presumptive diagnosis of death only when the removal is requested by police, the remains are in public view, and the removal also has been approved by the shift supervisor – even then, the removal can be carried out only by an EMT unit.

The decision to transport a presumably dead body is an important issue for EMS staff, because the ambulance carrying the remains not only is lost from the system for the duration of the transfer but also may have to be decontaminated afterward. From an EMS system-management perspective the result is a loss of productivity and for that reason such transport is approved only for reasons that serve the greater community. Another factor to be considered is that paramedic units are not and should not be used for transport duties because such units are not only few in number but also require more equipment and training.

Even a large-scale loss of life at a disaster does not necessarily justify the use of ambulances for removal of the dead. In many large-scale mass-casualty events, of course, many remains or partial remains will have to be moved if only to facilitate the still ongoing rescue work or for other life-saving tasks. In these situations, though, the location and position of the remains should be documented – as fully and as accurately as possible – by trained death investigators, through photographs, site maps, and even GPS (global positioning system) units, to ensure that future investigators will have a clear picture of the accident scene – and of the remains of the victims as they were immediately after death.