3507 - Signal 1, 2, And 3

Question 1

Who shall be responsible for:

1. Maintaining this document.
2. Ensuring this policy and procedures are followed.

Answer 1

The Assistant Chief of Emergency Medical Services or his/her designee

Question 2

Who shall be responsible for:

1. Declaring a Signal 1, 2 or 3 in accordance with the guidelines set forth in this document.
2. Ensuring BLS and/or ALS response is started and continued in accordance with the guidelines set forth in this document.
3. Requesting notification and/or involvement of a Medical Investigator or the Medical Examiner and/or law enforcement as appropriate.
4. Securing the death scene in accordance with Pierce County Patient Care Protocols.
5. Offering the services of the TFD Chaplain to assist the deceased’s family and close friends.
6. Ensuring that an appropriate person accepts custody of the remains of a deceased patient
7. Completing the required EMIR and IRS reports.

Answer 2

The Incident Commander (IC) or his/her designee

Question 3

Who shall be responsible for:

1. Performing ALS assessments in accordance with the guidelines set forth in this document.
2. Following Pierce County Patient Care Protocols, including the American Heart Association Handbook of Emergency Cardiovascular Care, regarding resuscitation and/or base station contact.
3. Declaring a Signal 1, 2 or 3 in accordance with the guidelines set forth in this document.
4. Seeking Medical Investigator or Medical Examiner approval in accordance with the guidelines set forth in this document.
5. Completing the required EMIR and IRS reports.

Answer 3

Captain/Paramedics, Paramedic Supervisors and Firefighter/Paramedics

Question 4

Who shall be responsible for:

1. Providing support to the family and friends of the deceased.
2. Assisting with funeral home arrangements as necessary and appropriate.

Answer 4

The TFD Chaplain

Question 5

Who shall be responsible for:

1. Dispatching resources to possible Signal 1, 2 or 3 in accordance with the EMD cards.
2. Providing CPR instruction over the phone in accordance with the EMD cards.
3. Notifying Law Enforcement, the Medical Examiner’s Office and/or the TFD Chaplain as requested by the Incident Commander.

Answer 5

Fire Communications personnel

Question 6

Who shall be responsible for:

1. Notifying the Incident Commander of the existence and location of a possible Signal 1, 2 or 3 patient found at an emergency incident.
2. Assessing and treating pulseless and apneic patients in accordance with the Pierce County Patient Care Protocols, including the American Heart Association Handbook of Emergency Cardiovascular Care.
3. Being familiar with and able to execute the “Withholding Resuscitation” and “Crime Scene Preservation” sections of the Pierce County Patient Care Protocols.

Answer 6

All TFD operations personnel

Question 7

Obvious death. A death is obvious if are any one of the following signs is clearly present: (6)

Answer 7

rigor mortis, decomposition, decapitation, incineration, lividity, or evisceration of the heart or brain without vital signs.

Question 8

Signal 1.

Answer 8

A death that apparently resulted from smoke inhalation or thermal burns.

Question 9

Signal 2.

Answer 9

A death that is not suspicious and apparently resulted entirely from natural causes, such as known heart disease or diagnosed terminal cancer.

Question 10

Signal 3.

Answer 10

A deceased patient, whose death was sudden and unexpected or apparently resulted partially or entirely from unnatural causes. Examples of Signal 3 include:

1. Sudden death of a person thought to be in good health (e.g., suspected SIDS)
2. Traumatic death from an industrial accident or motor vehicle collision
3. Apparent homicide or suicide

Question 11

A triage system used during mass casualty incidents (MCI) for quick identification and classification of patients into treatment categories._________ is used for patients older than eight years. JumpSTART is used for patients aged eight years and younger.

Answer 11

Simple Triage and Rapid Transport (START or JumpSTART) System.

Question 12

If there is any doubt about whether a death is obvious, and unless valid Do Not Resuscitate (DNR) orders are present, CPR shall be started, an AED shall be employed and ALS response to the scene shall be started or continued.
True or false?

Answer 12

True

Question 13

Once TFD operations personnel start CPR, resuscitation efforts can be stopped only with:

Answer 13

the agreement of appropriate base station.

 a. MAMC for adults 
 b. Mary Bridge for children under 16 years old

Question 14

TFD operations personnel shall contact the appropriate base station physician to confirm all field declarations of a Signal 1, 2 or 3.

 a. \_\_\_\_\_\_\_ for adults 
 b. \_\_\_\_\_\_\_\_\_ for children under 16

Answer 14

a. MAMC

b. Mary Bridge

Question 15

For a confirmed Signal 1 or Signal 3, FCC personnel shall notify:

Answer 15

the Medical Examiner Office and Law Enforcement.

Question 16

For a confirmed Signal 2, FCC personnel shall notify:

Answer 16

the Medical Examiner’s Office only.

Question 17

TFD operations personnel shall be aware that the on duty Medical Investigator or Medical Examiner declines jurisdiction when:
a-d

Answer 17

a. The death is entirely natural and
b. There are no unlawful factors and
c. The deceased has been under the care of a physician and
d. Family or friends are available to choose a funeral home or mortuary.

Question 18

TFD operations personnel shall provide the following information to the on duty Medical Investigator or Medical Examiner upon his/her request:

Answer 18

a. Patient medical history
b. Estimated down time
c. All other medical information, including a copy of the EMIR

Question 19

The Incident Commander shall not order and TFD personnel shall not transport under any circumstances, an obviously dead patient, including suspected SIDS, or a confirmed Signal 1, 2 or 3 without the prior approval of the on duty Medical Investigator or Medical Examiner.
True or false?

Answer 19

True

Question 20

Signal 1, 2 or 3 Confirmation

1. ___ is the agency authorized by the Tacoma Municipal Code to provide emergency medical services to the citizens in its response area.
2. Once the 9-1-1 system is activated, ___ personnel are responsible for confirming all Signal 1, 2 and 3 deaths.
3. Law enforcement personnel do/do NOT have the authority to cancel TFD resources prior to confirmation of Signal 1, 2 or 3 status by TFD personnel.
4. If law enforcement personnel do attempt such cancellations, FCC personnel shall be responsible for:

Answer 20

1. TFD
2. TFD
3. Do NOT
4. advising law enforcement that TFD personnel will continue to the scene to confirm Signal 1, 2 or 3 status as required.

Question 21

Obvious Deaths
1. The TFD Incident Commander or his/her designee shall:
a-h

Answer 21

a. Declare a Signal 1, 2 or 3 in accordance with the guidelines set forth in this policy.
b. Cancel responding ALS resources unless the needs of the incident dictate otherwise.
c. Contact the appropriate base station to confirm a Signal 1, 2 or 3.
d. Request that FCC notify law enforcement and/or Medical Examiner’s office.
e. Secure the death scene in accordance with the steps listed under “Crime Scene Preservation” in the Pierce County Patient Care
Protocols.
f. Assist the deceased’s family and close friends as needed.
g. Ensure proper acceptance of custody of the patient’s remains.
h. Complete the required reports:
i. EMIR
ii. IRS: Dead on Arrival” for an obvious death

Question 22

When Death is not Obvious
1. When death is not obvious and the patient is pulseless and apneic AND if no valid Do Not Resuscitate (DNR) orders are present, the TFD Incident Commander or his/her designee shall ensure that:
a-d
2. If ALS personnel determine upon their arrival that death is obvious, then the procedure for declaring an obvious death as a signal 1, 2 or 3 shall be followed.
3. For patients who are pulseless and apneic but lack any sign of obvious death, TFD ALS personnel shall:
a. Perform an ALS assessment as follows, unless valid DNR orders are present:
i. EKG monitoring of asystole for minimum of:
ii. Patient history that includes-
1-4
b. Determine whether to continue resuscitation efforts or contact the appropriate base station to request orders to stop resuscitation in accordance with Pierce County Patient Care Protocols, including the American Heart Association Handbook of Emergency Cardiovascular Care.
c. After receiving base station orders to stop resuscitation efforts, declare a Signal 1, 2 or 3 in accordance with the guidelines set forth in this document.
d. Complete the required paperwork:
i. EMIR
ii. IRS: “Exam/Assist” only for a death not obvious to the first arriving company

Answer 22

1. a. CPR is started
   b. An AED is employed
   c. ALS response to the scene is started or continued.
   d. An ALS assessment is performed
2. a. i. 60 seconds with views in two nonadjacent leads (e.g., lead I and II)
3. a. ii. 1. Approximate down time
   2. Medical problems
   3. Medications
   4. Whether patient was under the care of a physician

Question 23

1. TFD operations personnel shall stay on the scene until:
2. When the on duty Medical Investigator or Medical Examiner declines jurisdiction, custody can be accepted by any competent adult such as:
3. When the Medical Examiner accepts jurisdiction, a chain of evidence must be established; therefore custody can be accepted only by:
4. TFD operations personnel shall document in the EMIR and the IRS narrative the identity of the person who:
5. TFD personnel shall/shall not accept custody of deceased patient remains.

Answer 23

1. there has been a face-to-face acceptance of the custody of the remains of the deceased patient by an appropriate individual.
2. a. Family member
   b. Close friend
   c. Apartment manager
   d. Facility staff member
   e. Representative of a funeral home or mortuary
3. a. Law enforcement
   b. Medical Investigator or
   c. Medical Examiner
4. accepted custody.
5. Shall NOT

Question 24

PROCEDURE FOR DECLARING AN OBVIOUS DEATH AS SIGNAL 1, 2 OR 3

Incident Commander or his/her designee

Answer 24

1. Declare a Signal 1, 2 or 3
2. Cancel responding ALS resources unless the needs of the incident dictate otherwise
3. Contact base station to confirm the Signal 1, 2 or 3
   a. Before beginning patient report, clearly state that you are calling for an “obvious death.”
   b. Provide patient report to include:
   i. Criteria for obvious death that are present
   ii. Approximate down time
   iii. Patient’s medical history and medications
   iv. Whether patient was under the care of a physician
   v. Whether CPR was performed.
4. Obtain the name of the base station physician and the time he/she pronounces death.
   a. Document that individual’s name on the EMIR.
5. If the base station physician orders transportation, clearly inform him or her that you will accept their direction, but that you have no doubt that the patient is deceased.
6. Once confirmed, request that FCC notify law enforcement and/or the Medical Examiner’s Officer.
7. Secure the death scene.
8. Offer services of TFD Chaplain to deceased’s family and friends.
9. Ensure an appropriate person accepts custody of the deceased’s remains before leaving the scene.
10. Write the EMIR.
    a. Document who accepted custody of patient remains
11. Complete the IRS reports, including “Dead on Arrival” for an obvious death.

Question 25

PROCEDURE FOR DECLARING AN OBVIOUS DEATH AS SIGNAL 1, 2 OR 3

TFD Operations personnel

Answer 25

1. Perform BLS assessment only to the extent necessary to establish the presence of obvious death and to determine Signal 1, 2 or 3.
2. Obtain history to including:
   c. Approximate down time
   d. Medical conditions
   e. Medications
   f. Whether the patient was under a physician’s care.
3. Declare signal 1, 2 or 3, based on BLS assessment.

Question 26

PROCEDURE FOR DECLARING AN OBVIOUS DEATH AS SIGNAL 1, 2 OR 3

Fire Communications Center (FCC) personnel

Answer 26

1. For confirmed Signal 1 and 3 notify the Medical Examiner’s officer and law enforcement.
2. For a confirmed Signal 2, notify the Medical Examiner’s Office only.

Question 27

PROCEDURE FOR OBTAINING ORDERS TO TERMINATE RESUSCITATION EFFORTS
Incident Commander or his/her designee

Answer 27

1. If death is not obvious and no DNR orders are present ensure that:
   a. CPR is started
   b. AED is used
   c. ALS response is started or continued
   d. ALS assessment is performed
2. Notify FCC that the base station confirmed the Signal 1, 2 or 3.
3. Request FCC contact the medical examiner’s office.
4. For a Signal 1 or 3 also request law enforcement.

Question 28

PROCEDURE FOR OBTAINING ORDERS TO TERMINATE RESUSCITATION EFFORTS
ALS personnel

Answer 28

1. Check for pulse, breathing, signs of obvious death.
2. Check for presence of valid Do Not Resuscitate (DNR) orders.
3. If pulseless and apneic, but no signs of obvious death and no valid DNR orders, perform an ALS assessment with patient exam that includes:
   a. EKG monitoring of asystole for a minimum of 60 seconds, including views in two nonadjacent leads (lead I and II for example.)
   b. A short, sample strip of the EKG to attach to the EMIR.
4. Obtain patient history to include:
   a. Approximate down time
   b. Medical problems
   c. Medications
   d. Whether patient was under the care of a physician
5. Determine whether to continue or terminate resuscitation efforts.
6. Contact base station to request orders to terminate resuscitation efforts:
   a. Before beginning report, clearly state that you are calling to request orders to terminate resuscitation efforts.
   b. Provide patient report to include:
   i. Approximate down time
   ii. Patient’s medical history
   iii. Medications
   iv. Whether patient was under the care of a physician
   v. EMS interventions performed.
7. Obtain the name of the base station physician and the time s/he pronounces death.
   a. Document that individual’s name on the EMIR.
8. If the base station physician orders transportation, clearly inform him/her that you will accept his/her direction, but that you have no doubt that the patient is deceased.
9. Declare Signal 1, 2 or 3. 10. Write the EMIR.
   a. Attach a short, sample EKG strip to EMIR.
   b. Document who accepted custody of remains.
10. Complete the IRS report, including “Exam/Assist Only” for death not obvious to first arriving company.

Question 29

PROCEDURE FOR OBTAINING ORDERS TO TERMINATE RESUSCITATION EFFORTS
Fire Communications Center (FCC) personnel

Answer 29

1. For confirmed Signal 1 and 3 notify the Medical Examiner’s officer and law enforcement.
2. For a confirmed Signal 2, notify the Medical Examiner’s Office only.