D.C. Medic Suspended in Applicant Death

[PVFD233 68]

D.C. Medic Suspended in Applicant Death

Courtesy of The Washington Times

D.C. fire officials have restricted the duties of the paramedic responsible for examining a recruit candidate who died Monday after a physical agility test at the department's training academy in Southwest.

Eric Allen, 23, of Temple Hills, died early Monday after complaining of trouble breathing when he completed a stair-climbing exercise in the facility"s hose tower building at about 10 a.m. Sunday.

Fire officials said he was examined by a paramedic on the scene and transported to Greater Southeast Community Hospital. He later was flown to Washington Hospital Center, where he died.

Fire officials yesterday confirmed they have placed the paramedic on no-patient-contact status as they investigate whether she appropriately assessed Mr. Allen's condition. Sources have identified the paramedic as a 20-year emergency medical services employee who has worked as a paramedic in the department for more than 10 years.

"That's standard anytime there's an event like that," said Battalion Chief Kenneth Crosswhite, a fire department spokesman. "We just want to make sure everything was done correctly."

Chief Crosswhite said an investigation was a standard procedure after an incident, but sources close to the investigation told The Washington Times of several irregularities in the patient care.

The sources said Mr. Allen had a heart rate between 150 and 200 beats per minute and had complained of shortness of breath, which should have made him a critical call.

But the sources said that after examining Mr. Allen, the paramedic ordered him transported to Greater Southeast in a basic life-support ambulance staffed by two lesser-trained emergency medical technicians. The patient was given a Priority 3 status, the department's lowest priority transport code.

Chief Crosswhite confirmed that Mr. Allen was classified as a Priority 3 patient and that he was transported to Greater Southeast in a basic life-support ambulance. He would not comment on whether the procedures were appropriate for the patient, saying that would be determined in the course of the investigation.

No cause of death has been determined.

The investigation is being conducted by the fire department's medical director, Dr. Michael Williams, and several senior staff members. Officials said there was no time line for completing the investigation.

Chief Crosswhite said fire officials have suspended the paramedic pending the outcome of the investigation of the department's Physical Agility Test. The series of physical tests determine if candidates are qualified to become recruits.

Officials said Mr. Allen had been through a medical evaluation Sunday morning before beginning the test.

Kenneth Lyons, head of the American Federation of Government Employees Local 3721, which represents the city's civilian emergency medical workers, said fire officials had met with the paramedic and told her that her actions did not contribute to the firefighter candidate's death.

Chief Crosswhite called Mr. Lyons' statements "almost criminal."

"It's impossible to say that," he said. "We don't know all the facts yet." Republished with permission of The Washington Times.

The sources said Mr. Allen had a heart rate between 150 and 200 beats per minute and had complained of shortness of breath, which should have made him a critical call.

But the sources said that after examining Mr. Allen, the paramedic ordered him transported to Greater Southeast in a basic life-support ambulance staffed by two lesser-trained emergency medical technicians. The patient was given a Priority 3 status, the department's lowest priority transport code.

HR of 150-200 and BLS??!!!

[Guest alsfirefighter]

HR of 150-200 and BLS??!!!

OK...I'll bite...what makes a HR of 150-200 automatically an ALS job?

[Oswegowind 17]

A nervous EMT...

[Guest alsfirefighter]

LOL Oswego...you said it not me.

I guess that's why I get some of the looks in certain areas (mostly when you get "intercept" jobs with crews you don't know) when I BLS a call. I guess I never found in the protocol book where it says if BLS thinks it should be ALS you must start with Protocol #1: Routine Medical Care.

All joking aside...I'm still trying to figure out why DC would say that with tachycardia and SOB it is a critical call. Are they chef's using a cookbook or Paramedics acting as clinicians?

I'm still going to watch for some good posts and for someone to tell me why with a HR of 150-200 that this call should automatically be ALS. Or why some question that it went BLS.

[Goose 188]

Seeing as the guy was running up and down stairs, a heart rate of 150 - 200 doesn't seem to be out of the norm. It seems that much of what this individual was experience could have hinged on his physical condition. I don't know of any ALS intervention that could have brought down his heart rate or alleviate his SOB if this was all from running up and down the stairs. It could very well turn out that this person had a previously unknown cardiac or other condition that was exacerbated and led to the death of this individual. Hopefully, a speedy resolution is at hand.

[20y2 43]

OK...I'll bite...what makes a HR of 150-200 automatically an ALS job?

Inadequately trained EMTs. The guy has a legitimate reason for being tachycardic and short of breath, but at the end of the day we all have to make spur of the moment decisions that may come back to kick us in the butt.

[Oswegowind 17]

So I am not held to my 1 liner...

As previously stated, after running up and down those stairs, a heart rate will obviously be elevated and any normal person may have some shortness of breath. This is where diagnostic tools and common sense come into place. Sit him down, cool him down, throw him on the monitor, pulse ox, listen to breath sounds, check his skin...or in plain emtlish (play on words) do a proper patient assessment. If 5-10 minutes go by and the vitals don't change and the patient is still complaining then maybe they really need a little help. As well age and physical fitness come in on the assessment and will help any trained professional do their job. On the other note, there may have been nothing they could do for him, we still don't know why he died, it could have been a pulmonary embolism or something that shook off and caused it...until we know the autopsy it is a mystery.

As for suspending a paramedic that assessed a patient that later died is ridiculous. We are human beings and have the ability to make mistakes, hence to err (not air) is human. How many times have we picked up a patient having heart problems or in cardiac arrest and later learn they saw the cardiologist within the past 4 days (sometimes even the same day) and they die. Should they suspend the doctor? Should they revoke his license? Or should we realize that nature takes its course? Should we consider that there is really a time when it is your time? These are philosophical questions that require an immense amount of thought, but they are worth pondering...

[Guest alsfirefighter]

OK. I have to admit that I was partly trying to make reference to my original quote of

HR of 150-200 and BLS??!!!

It the ??!!! at the end that sparked my interest and a topic that has spurned me from the beginning of my career as a medic.

To put it simply and I"m glad a few of you stepped up, just because the patients HR was 150-200 doesn't automatically warrant ALS intervention. As some of you already mentioned, I thought to myself, when was this HR documented, we know the press isn't accurate particulary if comes to dramatic effect. Secondly, even with the SOB it still doesn't make it an ALS job. What were his lung sounds? What was his overall condition and impression upon arrival and throughout assessment and several sets of vital signs that may give more light into the problem.

There are several reasons why someone could have a HR this high and SOB. Anxiety attack, extreme physical exertion, etc. The HR means squat without any other info. If he was in the 170's to 200 for the duration of getting him assessed and into the bus, and he is genuinly SOB that isn't improving with breathing exercises for hyperventilation, you could start to lean towards adenosine if its sinus.

The final question I have just based on the info given...perhaps the press or the department isn't giving the whole story but it could sound to me that he went into actue atrial fibrillation and somehow developed a complication from that. I think there is more to the story then just what is being reported. I'm thinking some sort of arrythmia presented itself and the provider may not have hooked him up to the monitor and such.

Fact is we are no different then any other medical provider. We make decisions and sometimes we get it wrong. Fortunately I've only had that happen a handful of times and none were negative outcomes for my patients. You'd be hard pressed to find an experienced medic who hasn't BLS'd a chest pain to have the person having an MI. Feces happens, its tough, I hate it but I take the time to learn from it. Even Dr's send patients home who bite the big one once they get there. There is a difference between making a sound decision on the sound information you have versus negligence and deriliction of duty.

[Goose 188]

Very interesting response ALS, chock full of a lot of good insight as well. If his HR didn't come down would the adenosine slowed the rate down? I looked up adenosine and it mentioned that it could be used to try and chemically cardiovert or temporarily slow down the HR in the case of A-Fib.

From a BLS perspective, if this guys vitals did not come down to within normal ranges in a reasonable amount of time i think i would have made the call for ALS and upgraded to a code 3 response to the hospital.

Now, from an ALS perspective, what would be the proper action? Should this guy have been thrown on the monitor along with a full set of vitals ? Maybe a vegal maneuver? Prior to turning over full patient care to a BLS crew?

Likewise, i can recall having a patient with A-Fib (if i recall properly) sometime ago when i went to go take his pulse on scene it was all over the place...so someone must have felt something...no?

Edited October 20, 2007 by Goose

[ckroll 101]

OK...I'll bite...what makes a HR of 150-200 automatically an ALS job?

It wouldn't think it is automatically ridden in, but if an adult has a HR consistently over 150 with symptoms, then an ALS evaluation is in order if an ER is not around the corner. There is much we do not know about the call, like everything except the outcome... 150 is a whole lot different than 200, how long was the rate elevated, does the pulse match the heart rate, was there dehydration, heat exhaustion, or pharmaceutical complications. As we all know, 160 bpm is about where the heart exceeds maximum output. Beyond that the asystolic phase is insufficient for the heart to perfuse itself adequately. Failure to return to acceptable levels in 5 minutes would be a significant indicator. Under any circumstances, a young male with an elevated heart rate should always be checked for undiagnosed WPW.

Not having been there, it is not mine to judge if the care was adequate. Lots of calls fall into the gray zone where we either look for reasons to ride it in or to send it BLS. I am betting if she had it to do over, she'd ride it in.

[Guest]

Without being on scene, I can't say that how the patient was presenting...however...what happened to old fashioned professional courtesy? Would it really be a big deal to throw the monitor on, pop a line and draw some blood to expedite his visit at the ER? Maybe it would not have made a difference but at least you could tell the family that he received the highest level of care from his peers. This is a potential MOS that would have been working side by side with EMS.

Edited October 20, 2007 by x710

[ckroll 101]

OK, we know more about this call than we think we do. The pt went via BLS ambulance to a community hospital [ website says 450 beds, full service] and was air lifted to a medical center. 'where he died.' Distances around DC are not large. One can assume the full service community hospital saw something it didn't like and couldn't treat and that the patient was stable enough for air transport to definitive care. Last I checked, any community hospital is better equipped than a paramedic and staffed by MD's as well. It appears the patient had contact with a BLS crew, a community hospital, a flight crew and a medical center between the time the paramedic evaluated him and his ultimate demise.

We know nothing about how long the patient was with any of them. That he lasted as long as an air flight to definitive care says that the list of people who had a chance to change an outcome is exceedingly long.

[JetPhoto 626]

Monday morning quarterback time......

[20y2 43]

Without being on scene, I can't say that how the patient was presenting...however...what happened to old fashioned professional courtesy? Would it really be a big deal to throw the monitor on, pop a line and draw some blood to expedite his visit at the ER? Maybe it would not have made a difference but at least you could tell the family that he received the highest level of care from his peers. This is a potential MOS that would have been working side by side with EMS.

We don't perform invasive medical procedures just so that we can say to a family that he received the highes level of care. We do it because the patient needs it. If this was a healthy 20 year old with no previous medical history, no medications, with generalized shortness of breath and no other presenting problems, I would send im off BLS.

[firemoose827 324]

Without being on scene, I can't say that how the patient was presenting...however...what happened to old fashioned professional courtesy? Would it really be a big deal to throw the monitor on, pop a line and draw some blood to expedite his visit at the ER? Maybe it would not have made a difference but at least you could tell the family that he received the highest level of care from his peers. This is a potential MOS that would have been working side by side with EMS.

Thats my beef too x710....quality patient care. We have plenty of medics in their expensive fly cars drive to a lot of calls and just say "BLS it in...Ill follow you." And all of a sudden medics, who are technically STILL EMT's, have this terrible attitude. The "Stop being paranoid and leave me alone" or the bogus "Do your assesment and your pt care and youll be fine"...

Guys, Im not trying to start a fight here, just pointing out that the whole point of patient care is to give the best care we can. Is a guy with a heart rate of 200 getting the adequate volume of blood pumped to his systems to adequately perfuse them? I would think that the heart isnt filling enough to adequately perfuse at 200 bpm, it wouldnt have enough time to completely fill up in between beats. I have been an EMT for 10 years, and a Critical Care Tech for three and Im tired of the ALS Vs. BLS argument...we are here for the patient to give them the best we can.

We lost a brother....a PARAMEDIC was on scene and sent him BLS to the hospital...would it have hurt the medic to ride on the rig, put him on monitor, and try a few vagal techniques like asking him to "Bear down" as if he was taking a dump? In this case it wasnt the "paranoid EMT" who called for ALS, it was the medic who downgraded the call that ended up in the death of a firefighter. Where did the whole EMT Vs. Paramedic thing come from? A few cocky members? ANyone else agree? Or am I the only one brave enough to discuss it?

[ny10570 745]

ckroll hit it all ready. The pt died at least 14 hours after being assesed by the medic. In that time the patient was seen by the staff to two hospitals and the flight crew. I'm led to believe that the medics inaction did not cause his death. Until the actual cause of death is released no one can know if earlier treatment could have made a difference. Any interventions the medic could have performed could have been performed at any stop along the way. If the medic had missed anything in the EKG it should have been picked up in the first ER. SOP in every hospital I'm familiar with has someone with his complaints getting an EKG as soon as he hits the door.

If there is nothing in the medics bag of tricks that can help the patient why waste the resource. If the medic sent the guy off to the ER lights and siren then there would be something to look at. He went cold. Having that medic ride along with him would not have changed the outcome.

Edited October 20, 2007 by ny10570

[Guest alsfirefighter]

Monday morning quarterback time

Actually none of the posts started on Monday. I'm sorry Jet that you don't feel you can learn from this thread, particulary when there is only about 1 or 2 posts that even mention what the medic mentioned in that article did.

I'm not sure if your in the EMS realm...and if you are what level and for how long...but in the medical world, everything is about Monday Morning Quarterbacking. That is what call audits are for, CME's, etc. The higher up the medical food chain you go, the more critical they become. And when anyone else thinks its Monday Morning QBing...you perhaps might want to find another field, you have to learn from mistakes in this field.

Jonesy, Goose and CKroll...excellent posts and I'm going to reply to a few of your comments in general for discussion with all.

Is a guy with a heart rate of 200 getting the adequate volume of blood pumped to his systems to adequately perfuse them?

Give me a set of vitals and allow me to assess the patient and I will tell you.

it wouldnt have enough time to completely fill up in between beats.

Sorry, but I disagree with this statement. If this was true we would have people dropping like rocks in combat and on fire scenes alone. It certainly isn't optimal, but there are other mechanisms for your body to compensate. I'd love to get into the textbook stuff, but I just don't have the time.

Where did the whole EMT Vs. Paramedic thing come from?

It came from a few members who apparantly cannot tell the tone of a joke, particulary between 2 friends whom have worked together. LOL. Some of you need to relax.

I looked up adenosine and it mentioned that it could be used to try and chemically cardiovert or temporarily slow down the HR in the case of A-Fib.

In the pre-hospital setting Adenosine is used for the chemical treatment of Supraventricular Tachycardia...or as most medics know it...the longest 6 seconds of their career. If you diagnosed it as SVT and you give adenosine often the rate will slow...allow you to get a look at it better and then return. You can go from there to either repeat the adenosine at a higher dose...or move on to a more appropriate treatment. As you pointed out, A-fib is usually associated with an irregular pulse and it should reflect the same on the EKG as long as its not so fast you cannot tell. Cardizem is the medication of choice for uncontrolled atrial fibrillation.

Now, from an ALS perspective, what would be the proper action? Should this guy have been thrown on the monitor along with a full set of vitals ?

Along with a full set of vitals? Every patient should get a full set of vitals on any borderline call that a medic is going to BLS. If the patients pulse rate was irregular, didn't start to slow after resting and as both myself and CKroll pointed out...depending on the actual rate...again 150 compared to 200 is a big difference, then yes I (note I said I) would run a 12 lead.

From a BLS perspective, if this guys vitals did not come down to within normal ranges in a reasonable amount of time i think i would have made the call for ALS and upgraded to a code 3 response to the hospital.

Goose, just wondering what your thought for upgrading to "code 3" would be? It isn't a true emergency in my book...just interested in your thought. There are an extremely limited amount of jobs I transport "code 3" and as many crews are learning...cardiac arrest is even off that list. I still get a few ask me "Do you want lights and sirens?" or when I ask them to turn them off "Oh, I'm sorry I didn't know if you wanted me to or not." I always give the same reply..."If I want them I'll ask for them, otherwise its always Code 1."

we are here for the patient to give them the best we can.

Absolutely, I've never interacted with anyone on the EMS boards here who didn't seem to share the same sentiment. However, saline has never cured anything and often the best care a patient gets has nothing to do with actual hands on medicine...its interaction and compassion.

Edited October 21, 2007 by alsfirefighter

[Goose 188]

ALS, i threw in "along with a full set of vitals" just to cover all my bases. Now, as far as upgrading to a Code 3, i as you, transport 99.9% of my patients Code 1. From where i sit as a BLS provider, if this individual's vital signs and breathing difficulties didn't alleviate themselves via natural pathways, it is clear that this patient needs to get either an ALS intervention or definitive care immediately. There is little i can do other than support his ABCs and prepare for possible total system failure - so for me supporting those ABCs and getting him to most appropriate definitive care is my biggest concern.

[calhobs 110]

Just reading the article lets look at some basic information, hr between 150-200. SOunds like there quoting two or three different times vitals were taken. I am guessing here that 200 was at the first set, let say 150 around the second or third set of vitals, if this is the case looks like to me the pt is starting to stablize why not give it to BLS. I would like to think any Medic out there would ride the call in if the vitals were reversed such as first set 150 then second set 200.

[ckroll 101]

ALS, i threw in "along with a full set of vitals" just to cover all my bases. Now, as far as upgrading to a Code 3, i as you, transport 99.9% of my patients Code 1. From where i sit as a BLS provider, if this individual's vital signs and breathing difficulties didn't alleviate themselves via natural pathways, it is clear that this patient needs to get either an ALS intervention or definitive care immediately. There is little i can do other than support his ABCs and prepare for possible total system failure - so for me supporting those ABCs and getting him to most appropriate definitive care is my biggest concern.

Lights and sirens are useless. All they do is increase the level of anxiety for patient and crew and encourage drivers, [ambulance and public] to do rash things. Save for unsecured airways and major trauma, it should no longer be an emergency once a medic is there. What an EMT at any level has to bring to a patient is a mindful assessment, the relief that comes from thinking that the emergency is controlled and on its way to resolution, and patient advocacy.

Not even the best of us can make good decisions without good information. Consistently asking oneself, is there something here I can work with? [and by this I mean, something to improve outcome, not for show], and actively looking for treatable problems means that at the end of the list, if all the answers are 'no.' , then the transport decision will likely be a good one. I love 12 leads and do them on anything reasonable that doesn't move faster than I do. You might be amazed by how many elderly patients who 'can't shake this flu' have ST depression in multiple leads. I had a 50 year old writhing in pain and bawling for his mommy. Classic panic attack [ as was pointed out to me by 3 people in the ER, not particularly kindly, might add.], --accompanied by a 6 pack of tombstone T's. How the patient presents and how we present the patient can be a 20 minute difference in time to the ER evaluation. We underestimate how much a hospital, especially when it is busy, will rely on the paramedic or EMTs initial assessment. Make it a good one.

A friend put a large name on his small fishing boat. I asked why and he said ' Two boats call for help, the " Put, Put 2" and the "Glomar Challenger"... where do you think the Coast Guard is going first?' 'Not doing well.' sent in BLS or 'Not doing well with EKG changes.' sent in ALS. Where do you think the ER is going first? If we aren't advocating for the patient we're bringing in, at least initially, the ER isn't going to either.

EMTs and paramedics can't fix much...but we can try to find it and point it out to someone who can. That's good assessment and good advocacy.

[firemoose827 324]

It came from a few members who apparantly cannot tell the tone of a joke, particulary between 2 friends whom have worked together. LOL. Some of you need to relax.

I will have to apologise here gang. When I first read the post I got frustrated because of whats going on here in our county with our medics. I have since re-read the post and now see it to be harmless bs between friends.

We are just having problems with our medics not doing anything at all...just running to scenes only to follow behind, EVERY TIME, and never do anything...including diabetics and MI patients. Just frustrating.

Also, ALS, I thought that way back when when I got my EMT-CC training ( a Loooooong time ago!) they told us that people in tachycardic rythms were unable to perfuse adequately? And yes, I too have no patience to try and remember the textbook stuff!! I just remember there being some sort of formula for blood volume, and the heart failing to re-fill adequately enough when beating too fast.

[helicopper 1,050]

I'm glad CKroll beat me to the punch... Lights and sirens going TO the hospital do little but inflate the drivers sense of self-importance and increase the patient's anxiety. Slow and steady is the way I want to get to the hospital and that is NOT going to be the case if the driver is vaulting from intersection to intersection with lights and siren going. Face facts - lights and siren save VERY VERY little time!

This case is another prime example of emotions getting in the way of professionalism. We can't just "do ALS" because it is a fellow ____ (insert service here). The medic will be taken to task if he/she provides ALS when it is not medically indicated. That's emotion and circumventing protocol because of emotional involvement is a recipe for cutting corners, getting hurt, and making the whole situation worse.

Some valuable information has been posted here - the medic is being taken to task because of the death 14 hours two hosptials, one flight crew and who knows how many assessments later. If he made it 14 hours, ALS intervention probably wasn't going to make a difference.

Jonesy, if you have medics in your system that aren't pulling their weight and doing their job then report them to your agency chief and/or medical director. Document their conduct as it gives all medics a bad name! If I need ALS intervention, I don't want the medic "following the ambulance" - that's a lot of nonsense!

I feel for the medic in this situation and hope that the investigation expeditously proves that he did nothing contrary to protocol or accepted procedure and he is able to get back on the street as soon as possible.

If anyone hears what the actual cause of death was, please post it so we can all get the real story!

[Guest paramedico987]

I guess I never found in the protocol book where it says if BLS thinks it should be ALS you must start with Protocol #1: Routine Medical Care.

LMFAO!!

Edited October 24, 2007 by paramedico987

[Guest paramedico987]

FIRSTLY

My heartfelt condolences and prayers to the family and friends of this young man who like all of us just wanted to help people in their time of need, and died tragically young.

SECONDLY

I wasn't there and I will always give anybody in any of the emergency service sectors the benefit of the doubt. We have incomplete information from a source who's best intrest is the biggest shock value. This was a 20 year veteran EMS worker we're talking about here. For all we know the patient didn't even want to go to the hospital and he was convinced by the medic in question to "go get checked out, just in case."

To play devil's advocate a bit here though, I can't imagine that they would suspend someone, as many of you have said, just because of a bad outcome for the patient; I think we're missing a big piece of the puzzle here.

IMHO a hep lock probably wouldn't have been a bad idea, but unless he was in SVT/VT/etc. the outcome would have been the same.

[ny10570 745]

patient care restriction isn't that out of the ordinary. Close to 6 months ago two EMT's at my station were restricted for several months and after everything was said and done they learned that their restriction was an over reaction and it was a paper work failure that had kept them off the road for so long. I've personally been restricted for an incident that first wasn't a patient care issue and secondly wasn't my fault, but until the details get sorted out a knee jerk reaction from the wrong supervisor can have some serious looking affects.