When One Life Ends: Death and EMS

Michael James Azevedo, Jr., EMT-B; Chief Carmel Fire and Rescue

I offer greetings to my friends in Emergency Medical Services. I would like to dedicate this article to my mother, Marie E. Azevedo. She passed away on January 3, 2009 at Penobscot Bay Medical Center at the age of 61. I received a call from the doctor at PBMC on Friday January 2, explaining that Mom was not doing well, and the doctor was looking for direction on further medical care. My brother and I, along with my uncle and father, discussed the situation, and, after meeting with the doctor, made a decision to let nature take its course, and not to perform extraordinary measures. I received a call on January 3 at 0400 from her nurse telling me that her vital signs were not stable. I drove to the hospital where my brother and father met me in the ICU. I held her hand for three hours and she died at 0710.

In the last month, I have thought more about death than at any other time in my life. My mother had been battling life’s circumstances for better than five years, and death was the end result. I knew this, knew that it was a possibility, but never anticipated that it would be this quick. It has caused me to reflect on my life, the situations that I have been in, and the decisions I have made. The first of many correct decisions was when I decided to become an EMT, a decision supported and funded by my mother back in the spring of 1990. I have always wanted to help other people, and this was something that she supported.

I have been totally amazed at the number of people who have been supportive of my family during this time. My own crew members who took time to attend the funeral, sent food for the reception, and the many cards I have received. I thank them for their support and help. It is with the support of my wife and children that I return to the fire station, to continue doing what I have done for years, and that is to help others.

And it is thanks to Mom for the topic for this month’s training column on death and dying. As EMT’s, we spend most of our training trying to help and to save lives. In the basic EMT class, we mention death as a possibility, but we are so busy learning life-saving skills, that we never learn how to handle death, much less prepare for it. I would like to share some of the things that I have learned over the years, topped off with what I have learned in the last month.

First, and foremost, death is okay. Death is expected and we will all die someday. Not to be morbid, but sometimes when the accident happens, death will already have occurred by the time the EMS crews arrive. There is nothing we could have done, even if we had been there as it happened. So what are some of the things that should be covered in a class about death?

What do you say to the family?

Sometimes it is best to say nothing at all. This is the time to be most respectful of the family and the patient. Say that you are sorry for their loss, and ask if there is anything you can do to help. (Please make sure that you have confirmed that there is no further chance for resuscitation.) When possible, place your ambulance in service, and stay for a while with the family. At least stay until law enforcement arrives. People do understand that you may have to leave.

Hospice care

Hospice care is a program which supports people who have made a decision to die at home. Many people choose to die in the comfort of their own home. Hospice care will help take care of all the arrangements, and this includes taking care of the person after death. The ambulance is generally not needed, but can be called when someone in the family does not understand how hospice works.

Squad chiefs could contact a local hospice agency and have someone come to a meeting and talk with service members. It really helps to know something about it before you are talking with a family involved in a death.

Funeral home involvement

I would never have thought about visiting a funeral home. However my experience has shown me that they can be a wealth of information. In my mom’s case, they took care of all the funeral arrangements, took care of the obituary (after my father wrote it), and they have provided information on grieving. They have been very helpful and understanding during this entire event.

Clergy involvement

I remember some time ago sitting at a scene, watching another EMT talking with a grandfather who had just found Grandmother dead in her room. The man asked the EMT how to handle the grief. The response from the EMT was this: “pray.” I know that this is how I handle many situations. Death makes people think about God and Church. Many churches have pastors, grief teams and other members who are very willing to help during these trying times. If you have a church in your town, the church membership may provide you additional assistance with dealing with death. Ask your local clergy to consider speaking at a training session.

Most police and fire departments have a chaplain, either on staff or on call. Many families do not go to church today, but the police and fire chaplains can help during these times. All you have to do is ask.

Police involvement

I learned the hard way what an “attended death” meant. “Attended” does not mean that someone watched the person die. An attended death is where a doctor is aware of the patient’s condition, and will sign a death certificate. An “unattended death” does not have a physician who is aware of the situation. Any time there is a death, it is considered a crime scene until proven otherwise. As EMS providers, it is necessary to understand that we can help a crime investigation by doing only our job, and not destroying evidence. Ask for a member of your local police department, sheriff’s office, or Maine State Police to speak to your service about crime scene preservation.

Grief sharing

It is important that EMT’s understand grief. People react in different ways under pressure, and this includes when someone dies. People will do things that you would never expect. They say things that are not meant and these comments may be directed at the rescuers. Remember your personal safety, but you can help just by listening to the people. I remember going into a house in Carmel after a grandfather had passed away. My partner had grown up in town and the grandmother recognized him. While my partner was outside, the grandmother started telling me about how my partner had grown up and spent time with her kids. I listened for about 20 minutes as she re-lived old times. I was amazed at how she was reacting, but as we waited for police and the funeral home, I felt like I was part of the family.

CISD

Crisis Intervention can be a very important service for ambulance crew members. Knowing how to contact the CISD team can help a service deal with not only serious calls and deaths, but also issues that will affect members' lives for a long time to come. I have been involved in one myself, and know of several services that have used the team. Contact can be made through the local EMS office. A member of the CISD team may be able to come to a meeting and explain how the process works. It is better to know ahead of time how the process will go, and, if possible, this will make it more comfortable for you.

DNR

This is an opportunity to review the Maine EMS Do Not Resuscitate Program. More information can be obtained through your local EMS office. The orange form and bracelet make it easy to find out what the patient’s wishes are. You may also honor a note from a doctor, as long as it is signed in the last six months. If you cannot locate a DNR order in a quick fashion, you need to take necessary measures to save the patient’s life. Explain to the family what and why you are doing things. You may contact Medical Control if you need help dealing with the family.

Cardiopulmonary resuscitation

Code drills are always a good way to practice very important skills. It is important that EMT’s are comfortable with CPR skills, the location and use of their equipment, and be able to do this under trying conditions. An upset family, a patient in a snow bank or in the dark is where these activities may take place. I remember one morning doing CPR in a small bedroom in the dark. I remember very vividly hearing the ambulance pull into the driveway and three of my crew members walking through the door with equipment. The gentleman died, but I know we did everything we could.

I have always tried to find the good in every situation. My mother always did. I will find it a challenge with her gone. Every Friday I would call and talk with her. I even tried calling her the Friday after she died. I was calling to see if she was coming to the funeral. She never did answer the phone, but she was there. I hope that through her death and the ideas I have listed above, you will be able to train your ambulance crews to handle death a little easier.

Until next time, thank you for the people you train and the lives that are saved as a result.