Friday, September 14, 2012

Informing Families in a Murder Case

This week's medical question comes from South Carolina mystery writer Ellis Vidler. 

"My question is, how would the victim’s family be told of the death in these circumstances? The victim died on the way to the hospital, maybe 30 minutes to an hour after being stabbed and left for dead. The police or paramedics found his ID in his wallet and located his brother, who was called to the hospital. When the brother gets there, I have him directed to a waiting room. Then, almost immediately, the police detective and the doctor come in to inform him of the death. Which one is likely to give him the news and what would they say? Also, the only ID so far is from the victim’s wallet. Would the detective ask him to identify the victim? I’m not sure how the police and medical staff would deal with this."

I sent Ellis the following answer.

If the police were present when the paramedics originally arrived to care for the victim, the police might have already searched the victim for his wallet. If the paramedics got there first, they wouldn't have searched for a wallet, but they could have found it if it was in a piece of clothing they needed to remove in order to get to the wound. 

The police would be the ones to notify the brother. The brother would be directed to the waiting room by the ER registrar, who would then notify the charge nurse of the brother's presence. The charge nurse would notify the doctor and the police, and then either the charge nurse or the nurse assigned to the victim would come out to meet the brother and take him to a private area, usually a small room off the waiting room, used for the express purpose of informing families of the death or critical condition of their loved one. The doctor and the detective would then go to that room. 

The doctor would be the one who told the brother of the victim's death. He would first introduce himself and the police officer, then he'd verbally verify the relationship of the victim to the person with whom he's speaking. If it is the brother, he'll say so. If it isn't the brother, the presence of a policeman would most probably compel the man to state his true relationship -- friend, business partner, etc. -- to the doctor. If he isn't the brother, the conversation with the doctor would end there due to privacy laws concerning the rights to personal information. The police office would then ask any questions he might have for the man.

If the man is the brother, the doctor would then say how sorry he was to have to inform the man that, despite all efforts by the paramedics, his brother died before arriving in the ER. The doctor would explain the victim's injuries and how critical his condition was when help first arrived. He would reiterate the fact that everything possible was done to save the victim, but how his injuries were so severe that he was unable to survive them. He would then tell the brother that the police officer is investigating the victim's death and that he, the doctor, will leave the officer and the brother alone so that they can talk. He would then add that the brother should tell the staff when he is ready to see the victim and a nurse will take the brother to the victim's room in the ER.

 At this point, your detective would ask the brother some questions to verify his relationship to the victim. If the ID from the wallet is a picture ID, he can ask the brother to verify the identity that way. If the ID doesn't include a picture, he can tell the brother the circumstances under which the victim was found and ask the brother to visually identify the victim as the person listed on the ID. The cop would then accompany the brother into the ER and a nurse would take both men to the cubicle where the body rests on a cart. After identification, the victim would be kept in the ER until the medical examiner's -- or coroner's -- van arrived to collect the body. 

Now even if the patient died in the ambulance, the paramedics would continue resuscitation efforts until they reached the hospital and an ER doctor decided further efforts were useless. The victim's clothes would be bagged if any were removed by the paramedics or ER staff, and they would be sent with the body or given to the police per individual system policy. The ER doctor would not sign a death certificate as that's the province of the ME or coroner, but he would pronounce death and give the time of death as the time he pronounced the victim. This time would be relaid to the ME or coroner's office via telephone by the nurse assigned to the patient. The biological time of death used in any court case would be decided by the coroner or ME, who would rely on the paramedic report, the ER doc's pronounced time of death, and the autopsy report to ascertain the time. In this particular case, the ME or coroner would probably use the ER doc's pronounced time of death as the official record time.

Outside of that initial meeting, the doctor would have no further contact with the brother unless the brother had specific questions concerning the wound and demanded to speak with the doctor. The nurse assigned to the victim would answer any other hospital related questions voiced by the brother, and the detective would be able to tell him about release of the body for burial.


Friday, September 7, 2012

The Writer's ER: Paramedics and Death Scenes

Mystery writers often create scenes where the protagonist finds someone dead in a house, office, restaurant, or some other setting far from immediate medical help. Sometimes the scene progresses to where the protagonist calls 911 for help. Other times the writer ends the chapter with that scene and jumps ahead to a new chapter where police -- and sometimes paramedics -- are already on the scene. The writer usually concentrates on the activities of the police, and if he does mention the paramedics, it's only to say that, at some point in the story, they cart away the body.

The reason so many writers avoid describing paramedic activity is this: most of them simply don't know what paramedics do when called to a death scene. They rarely see paramedics in action on TV shows, and medical mystery novels like those of Tess Gerritsen or Robin Cook generally incorporate doctors, rather than other medical personnel, as sleuths.

Rather than make a mistake, writers often prefer to skip over the role of paramedics and concentrate instead on better known or easily researched police procedures. Including the actions of the paramedics, though, can sometimes make for a more gut-wrenching scene. It can also tell the protagonist something about the victim that he/she might otherwise never be able to learn -- the victim had an unusual tattoo on his chest or was wearing a patch that delivered medication for a certain disorder that could be relevant to the case.

So what would paramedics do in a mystery novel when a 911 call takes them to a death scene?

First of all, on arrival, paramedics would size up the scene using the information given them by the 911 dispatcher. If they arrive before the police, is it safe for them to enter the area where the victim was found? Did the story's protagonist tell the dispatcher he found a dead body in his office when he arrived for work? Did he mention anything out of the usual, like a gun on the floor near the body? If the paramedics are told of no unusual circumstances surrounding the death and feel the scene is safe, they would approach the victim as if this was not a crime scene. Of course, this means if the victim was poisoned, the paramedics might inadvertently destroy some evidence -- they might move a coffee cup found overturned on the floor next to the victim, or push office furniture out of the way to get to the victim. Doing those things could initially confuse the police investigation and given the story's protagonist a chance to do some snooping.

Now if paramedics arrived at an obvious crime scene due to trauma -- the victim has a knife sticking in his chest or a bullet hole in his forehead -- and they got there before the police, things would go much differently. All paramedics are taught to protect a crime scene, meaning it is imperative they do not contaminate or destroy any possible evidence (bloody footprints, etc.) while ascertaining the condition of the victim. In this case, one paramedic would carefully approach the victim to check for any signs of life.

If found, both paramedics would proceed to give life support via CPR and emergency treatment of wounds while avoiding any unnecessary contact with objects around them. If they had to cut through the victim's clothing, they would avoid areas with bullet holes or other tears and stains. If they applied dressings to wounds, they'd make sure they removed only the wrappings when they left and didn't accidentally pick up any items that could be considered evidence. They would apply dressings to, but not clean the blood from, any bullet wounds present. In stabbing cases, they would not remove the weapon from the victim. If transporting a GSW victim, they'd check for any possible evidence left in their ambulance after transport, such as expended bullets that had tangled in the victim's clothing and dislodged during transport. If their patient had been assaulted and was a victim of asphyxiation, they'd avoid cutting or untying knots in the material used to strangle the person unless absolutely necessary to open the airway and restore breathing.

If no signs of life were present in the victim, the paramedics would back off from the scene until the arrival of the police. While waiting, they would contact their base hospital and report in. Depending on the condition of the body and their system's policies, they may or may not refer to the victim as a "Triple Zero."

So what are signs of life? When can paramedics legally withhold resuscitation efforts? Basically, signs of life include cardiac electrical activity as recognized on a portable heart monitor, a palpable heartbeat (pulse), and active respiratory effort (breathing). Some Emergency Medical Services (EMS) systems, though, expand that definition to include other factors.

The Region XI Chicago EMS system defines "signs of life" as "any respiration, a palpable pulse, a pupillary response, or spontaneous movement". Paramedics working under the Chicago EMS system could withhold resuscitation  from any trauma victim 16 years or older where there is a "trauma-related lethal mechanism of injury" -- be it a car accident or a gunshot wound -- and the victim is asystolic (no cardiac electrical activity), EXCEPT in the cases or drowning, strangulation, lightning strikes or electrocution, situations involving hypothermia, victims with visible pregnancy, or where medical conditions are the likely cause of cardiac arrest (as when someone has a heart attack and goes into cardiac arrest while driving, then crashes his car into a tree).

The Region XI Chicago EMS system's policies and procedures do not include reference to the term "Triple Zero", but they do mirror other area systems' definition of this term when describing other reasons paramedics can withhold resuscitation. Illinois' Region VII EMS groups six EMS state systems consisting of 16 hospitals, 115 fire departments and ambulance services, and almost 5000 EMS providers. Region VII EMA uses the term "Triple Zero" to indicate a victim who is pulseless, non-breathing, and exhibits at least one long-term indication of death. Those indications are: profound dependent lividity; rigor mortis without profound hypothermia; decapitation; decomposition; mummification or dehydration; and putrefaction. Region XI Chicago EMS, while not using the term "Triple Zero", lists those same six circumstances as reasons for withholding resuscitation, but also includes the above mentioned trauma-related circumstances plus incineration and presence of a frozen state of being. Region IX EMS includes some of both the other two region criteria when they call "Triple Zero" a condition "incompatible with life". They also include thoracic.abdominal transection and massive cranial/cerebral destruction as reasons to withhold resuscitation.

Including paramedics in a death scene can benefit a writer in many ways. But because here in the U.S. the Emergency Medical Services program is divided into 300 designated regions, writers are advised to check out the policies of their local region.

Writers can go to for a listing of state EMS offices with websites. Most EMS websites will offer downloads of their policies and standing medical orders for paramedics.