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 http://www.healthstream.com/crsLib/EMS/accred.htm for a listing of state EMS offices with websites. Most EMS websites will offer downloads of their policies and standing medical orders for paramedics.

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