Despite all efforts unfortunately some incidents result in the death of a casualty, usually prior to our arrival. LAMRT is typically involved in 4-10 fatal incidents each year with a variety to causes ranging from massive trauma to sudden cardiac arrests.  In these incidents it can fall upon team members to make the decision that the casualty has died and no further attempts should be made to revive the casualty.

The current recommendations for diagnosing death state that: "Death should be verified by a doctor, or other suitably qualified personnel." Therefore as mountain rescuers we cannot diagnose death.  Instead we look to make a reasonable recognition of life as extinct, which can be certified by a doctor or paramedic??? at a later time.  Once life has been recognised as extinct, we can proceed to treat the casualty as if they are deceased.

There is currently no clear universally recognised medical definition of death. For the purposes of MR it can be regarded as 'the simultaneous and irreversible onset of apnoea [no breathing] and unconsciousness in the absence of circulation'.  How we go about establishing that death has occurred depends upon the circumstances.

The relevant procedure to follow for the purposes of recognising life as extinct depends upon which of the following circumstances have occurred:

Injuries unequivocally incompatible with life - where the casualty can be presumed to be dead and no attempt at resuscitation needs to be considered
Circumstances where resuscitation should be considered but not started
Circumstances where resuscitation should be attempted and then stopped
Difficult cases which complicate the recognition of life extinct - hypothermia, lightening, drowning, drug overdose, avalanche???  In these cases resuscitation should be attempted whilst further information is gathered unless injuries incompatible with life are also present.

Safety

Fatal incidents can be messy and take place in dangerous conditions and locations. As is always the case on rescues, the safety of rescuers should be the priority, especially when you consider that unlike most other incidents, there is no time pressure when dealing with the deceased.

Due to the often large amounts of blood, bodily fluid and other matter involved, extreme caution should be taken when handling bodies.  Consider double gloving and wearing arm protectors which can be found in the ???? bag.

 Injuries Incompatible with Life

Some injuries are so severe that you do not even need to consider attempting resuscitation.  These are known as injuries unequivocally incompatible with life.  In the MR setting they typically result from massive trauma following falls from significant heights.  In these instances death is generally readily apparent on approaching the casualty.

Examples would be:

• Massive head and brain destruction
• Major amputation i.e. the whole body below the waist including transection of the lumbar spine.
• Decapitation
• Incineration (burns  over 95% of the body)
• Decomposition and/or putrefaction
• Rigos mortis - stiffness which occurs after death due to the breakdown of enzymes in the muscle fibres (starts around 3 hours after death).
• Hypostasis (livor mortis) - a settling of the blood in the lower portion of the body, causing a purplish red discoloration of the skin. [Livor mortis]
• Frozen solid????
• Massive trauma????
• Exsanguination - massive blood loss????
• Incompressible chest

In these cases as death is obvious do we suggest confirmatory checks??

Resuscitation

In other circumstances the casualty may have suffered less severe or in the case of cardiac arrest no obvious injuries.  In these instances check for breathing, listen and feel the diaphragm for movement for ten seconds.  If there are no signs of breathing resuscitation should be commenced whilst the facts are ascertained? <<alternative wording>> resuscitation should be considered.

Resuscitation does not need to be started if:

It has been over 20 minutes since the collapse/they stopped breathing, no bystander CPR has taken place and the ECG trace shows asystole (see below) for 30 seconds(remember to double check the leads are connected properly).
Sustained CPR and timely evacuation would be impossible

Resuscitation should be started immediately and attempted for ?? minutes if any of the following has occurred:

Witnessed collapse by MR
Bystander CPR has been and is taking place when MR arrive
Any ECG trace other than asystole is present

Other :

You may want to commence resuscitation to reassure family (and possibly yourself) that everything possible has been done.
If appropriate, make full and extensive attempts at reversing any contributing cause of cardiorespiratory arrest e.g. tension pneumothorax.

CPR can then be stopped if:

Practicalities

You are too exhausted to continue
CPR cannot be continued during the evacuation (less of a problem if the AutoPulse is used)
The area becomes unsafe

The casualty has died

CPR for 20 minutes plus sustained asystole (except in the case of hypothermia with no contraindications to starting CPR such as injuries incompatible with life)
Injuries become incompatible with life e.g. prolonged severe bleeding

Confirming Life Extinct

Once the decision has been made to either not undertake or stop resuscitation, death should be confirmed by observing the casualty continuously for a minimum of five minutes to establish the presence of irreversible cardiorespiratory arrest.

Check for:

No attempts at breathing.
Absence of a carotid or femoral pulse (radial pulse is not reliable for this purpose).
Correctly applied ECG shows asystole (flat line) and no cardiac activity at all (see below). You can use FRED or the Propaq for this.
Ideally, check for absence of breath and heart sounds using a stethoscope. However heart & breath sounds can be very quiet and in MR there can be significant amounts of ambient noise which make this difficult.

Asystole (commonly known as flat line) is a lack of cardiac electrical activity.  Contrary to its common name, in individuals whose heart has recently stop pumping, asystole will show as a flat, slightly undulating line, not a completely horizontal line as you see on TV.

[Asystole] Beware - moving the body or doing chest compressions will create electrical activity which will show up on the monitor, this should not be confused with spontaneous cardiac activity.

Difficult Cases

Hypothermia -as the core temperature drops metabolic requirements fall significantly.  Heart rate and respiratory effort decrease along with temperature making signs of life difficult if not impossible to detect in severe cases.  In these circumstances an ECG trace using either the Propaq or FRED should show cardiac electrical activity and the casualty should be treated as alive, but without palpable signs of life.

Additionally due to the significant decrease in metabolic demand which occurs in severe cases of hypothermia, people are able to survive prolonged periods of cardiorespiratory collapse, meaning resuscitation can be successful after long periods without support which would not be survivable in normothermic individuals. Therefore unless there are other injuries incompatible with life or the chest or abdomen have become incompressible, casualty's at risk of hypothermia should be treat as in arrest???, until they have been rewarmed.

Remember - they're not dead until they're warm and dead

Hypoglycaemia - significant falls in blood glucose levels can result in unconsciousness and hypoglycaemic coma. In severe cases heart rate and respiratory effort decrease along with blood glucose levels making signs of life difficult if not impossible to detect.  In these circumstances an ECG trace using either the Propaq or FRED should show cardiac electrical activity and the casualty should be treated with Glucagon on low blood glucose levels have been confirmed.

Drug and alcohol consumption - certain drugs, particular those with sedative effects such as opiods and benzodiazepines can cause very shallow breathing with a weak slow pulse.  In extreme cases breathing and a pulse can be undetectable, making them appear dead.  However an ECG trace using either FRED or the Propaq should show some cardiac activity (probably sinus bradycardia).

Drowning -If no other injuries are present, water temperature & duration of submersion/immersion???? are the most important factors influencing the decision to stop resuscitation.  Professor Mike Tipton has given the following general advice to SAR teams when considering resuscitation.

Survival becomes extremely unlikely if:

If the water temperature is greater than 6°C and the casualty has been submerged for more than 30 minutes. or
If the water temperature is 6°C or below and the casualty has been submerged for greater than 90 minutes.

Lightening strike -

Actions Following Recognition of Life Extinct

Actions to be taken after death has occurred:

Record asystole for 30 seconds.  If using the Propaq take a snapshot, if using FRED take a picture if possible.
Do not move the deceased or disturb the scene.
Secure and protect the scene. Limit the number of people entering the area.
Inform the base, ask them to inform the police and attain permission to move the deceased.
Record the time, location and name of assessors.
Photograph the deceased including the face and any distinguishing marks. In trauma be sure to photograph the hands and footwear including the sole.
Photograph the scene. In falls try to photograph where they fell from and initially impacted.

Remember - Team radio's are not secure.  If possible avoid broadcasting details over the radio.  The airwave radio's carried by the team leaders are secure and can be used to transmit details.

Once permission to move the deceased has been granted by the police.

Move the deceased into a body bag.
Place any personal effect into tamper proof evidence bags and seal them. If any objects are to large to fit in an evidence bag they should be placed in the body bag with the deceased.
If in a heavily trafficked public location attempt to clean the scene e.g. put soil over obvious patches of blood.
Ask for a minute of radio silence then read the words of remembrance.

Insert a copy of the words of remembrance here

Remove the deceased from the hill to Ada's nook for collection by Dignity????

Once back at base.

The assessors will need to provide a statement for the police
Photographs (and possibly the phone or camera used to take them) will have to be passed to the police

Witnesses, Friend's and Family of the Deceased

Once the casualty has been diagnosed as deceased, their friends, family and any witnesses become the focus of our assistance.  The sudden death of someone they care about can be immensely shocking and upsetting.

Ask them not to call people, the police have specially trained officer's who will inform the relatives and offer them support.

Assign a person to escort them off the hill, this can be very slow and emotionally demanding.  Everyone reacts differently

Arrange for the police to meet up with the party at the road.

Bring them back to the base to give their statements???

Advise about contacting their GP????

Rescuers

Making the decision that someone has died and dealing with the deceased can be among the hardest things we encounter in MR.  The scene of a fatal incident can also be extremely graphic and it is difficult for people outside MR to understand the effect this can have.

Your team mates do understand what it's like and it's normal for them to pepper you with messages asking how you're doing and offering support, especially if it's your first fatal incident or you made the diagnosis of death.

Whilst everyone has their own coping mechanism and it's advisable not to go over the events repeatedly in the first twenty four hours (because it builds up neural pathways), you are encouraged not to suffer in silence. Talk to friends or call a team mate they will have been through the same thing and know how you're feeling.

TRiM

Diagnosis of Death By Les Gordon