Massachusetts FAIL

[fiznat]

This article is pretty slanted towards the grieving family, I must say. It isn't written like news, but rather a drama. Seems to me that articles of this type are trying to provoke an emotional response rather than provide information. With that in mind, maybe we should consider that all of the facts here may not have been accurately represented.

I don't see how the quality of a QA/QI program could have prevented or caught this incident. Short of having a QA/QI representative on the scene of every call, there is no way that this would have been identified, except through the means that it was. Taking RSI away from this service on those grounds is a knee-jerk reaction that I'm not sure was warranted.

Did these medics do the wrong thing? Probably, but I think it would be prudent of us to realize that this is the ultimate in Monday-morning quarterbacking. The fact of the matter is we weren't there, and the only information we have is that which was provided by this clearly dramatized "news" article.

[chbare]

Not much doubt that the medics did things wrong; however, equating the walking with the patient's death is a stretch and quite dramatic IMHO. Massive anterior wall MI's tend to have high rates of morbidity and mortality. While the situation may have been handled incorrectly, the drama and blame game stuff is a bit over the top to be balanced reporting..

Take care,

chbare.

[CBEMT]

*My own reply copied from the other thread*

That's REALLY disappointing. UMass/WEMS has a reputation as a top-notch agency, albeit overworked like most urban providers- they could probably stand to put a couple of more trucks on the road. They staff 4 double paramedic trucks in the city, with one dedicated unit providing EMS to the neighboring town of Shrewsbury by contract. I'm told many of their paramedics got their education at the Quinsigamond Community College degree program, and supposedly QC grads are the only paramedic students allowed to do their ride time with WEMS.

I had no idea things had gotten so bad that OEMS had yanked their RSI project waiver. The only thing this can serve to do is bolster WFD's claim that they should be allowed to run WEMS into the ground. They tried to "offer" to run a few BLS trucks to "help out," but were denied by the city. Leading up to the 2007 contract the city studied all the options and came to the conclusion that it didn't make any sense to start a fire-based EMS program when they got UMass for free.

Addendum: I contribute part of this problem to the MA OEMS rule that all patients, regardless of the complaint, cannot "be allowed to ambulate or otherwise exert themselves." CHF? Stairchair. Possible STEMI? Stairchair. 1cm finger lac? Stairchair.

Do that for long enough in any system, much less a system of 37,000 calls a year, and I'm pretty sure you'll do anything to NOT do it eventually. Do THAT for long enough, and you're going to walk somebody you should have carried.

What will save the medics asses, I think, is that there seems to have been a (possibly significant) time lapse between onset and when the patien allowed 911 to be called. Throw in lifestyle, etc, and you could make the argument that carrying this patient would not have saved him. Whether it works or not is up to the jury.

Even if it does, it ain't going to save them from OEMS, that's for sure.

Edited April 28, 2009 by CBEMT

[RatPack]

Save them from what? They were already fired.

Did they get fired for falsifying a run report, lying or allowing this guy to walk?

If its was for their run report, in my area thats grounds for losing your ticket.

If it was for lying, that also may be grounds.

If it was for walking this guy then their admiting blame and the city will take it on the chin.

[singeroi]

very interesting...

simulation assurance vie

[Dustdevil]

The drama continues:

http://www.telegram.com/article/20090719/NEWS/907190373

July 19, 2009

EMT censures spur state action

By Thomas Caywood

The Sunday Telegram

WORCESTER, Mass. — In late April, Richard J. Markiewicz read a front-page Telegram & Gazette article about the death of Charles F. Rondeau, a 48-year-old city man who died of a heart attack in the hospital shortly after being walked down three flights of stairs by UMass Memorial EMS paramedics.

Mr. Markiewicz, who maintains that he, too, was made to walk down a flight of stairs by UMass Memorial paramedics while complaining of severe chest pains, in September 2007, said he was astonished to read a hospital official's characterization of Mr. Rondeau's case as an "isolated incident."

"I saw the article, and I was just completely flabbergasted," Mr. Markiewicz said in an interview. "I felt guilty that I hadn't called the state before. I thought, 'Oh God, am I responsible?' That's when I made the decision: 'I'm calling now.'"

Mr. Markiewicz's complaint to the state Department of Public Health was one of two lodged against UMass Memorial EMS in the days following publication of the April 26 article about Mr. Rondeau's death and the resulting state investigation.

Both complaints alleged that UMass Memorial EMS paramedics, as in Mr. Rondeau's case, had required gravely ill patients to exert themselves by walking down stairs — a violation of the state treatment protocols. Ambulances are equipped with a special device called a stair chair to carry patients when necessary.

The other complaint was lodged in early May by a city woman who, a state investigator determined, in May 2008 was made to walk down a flight of 10 stairs to an ambulance while suffering from what turned out to be a heart attack.

"It did appear that there was a pattern," said Abdullah Rehayem, director of DPH's Office of Emergency Medical Services, which regulates ambulance services in Massachusetts.

After the four-month state investigation into Mr. Rondeau's death, which determined the two paramedics involved attempted to cover up their actions, the DPH issued a stinging Notice of Serious Deficiency to UMass Memorial EMS. The action criticized the unit for serious, widespread and persistent problems that extended well beyond what happened in that particular case.

Then came the additional complaints, raising concerns that cardiac patients were being forced to exert themselves in at least several instances.

Hospital officials stress that such complaints represent a minute fraction of the roughly 30,000 calls the ambulance service's 75 paramedics and EMTs field during a year on average.

Even so, the hospital has moved aggressively and spent freely over the last three months to address the problems raised by the state investigations, Mr. Rehayem said.

More training, technology

"UMass has administered training programs to EMTs, and they have invested a lot of money into electronic collection of EMS data through a laptop technology. That will allow them to do more monitoring," Mr. Rehayem said.

In an effort to improve supervision of paramedics, the ambulance service also has created six field supervisor positions, a new level of management immediately over paramedics. UMass Memorial also has ordered five new ambulances, among other steps, officials said.

Dr. Walter Ettinger, president of UMass Memorial Medical Center, declined to discuss what, if any, disciplinary steps had been taken to address the problems cited in the state reports.

"We've done a number of things to improve what was already a good quality of care and to ensure that we're best serving our community," Dr. Ettinger said.

He pointed to the new, roughly $500,000 electronic medical records system for paramedics as a key improvement. The system allows them to quickly enter information from their calls into an electronic database.

Dr. Ettinger said the electronic system should enhance the quality of care because it allows supervisory medical staff to quickly gather and review data on calls dealing with a certain type of medical complaint, such as chest pains, or calls fielded by a particular paramedic.

In addition to the new equipment and new supervisors, UMass Memorial EMS required all of its paramedics to be re-trained on procedures for ensuring that the highest quality of care is provided, Dr. Ettinger said.

The DPH's Mr. Rehayem said his office is satisfied with the corrective action taken by the ambulance service.

In the case of the city woman who suffered a heart attack in May 2008, William E. Humphrey of Worcester, the lead paramedic on the call, told the state investigator that he ruled out using the stair chair because the woman was too large and heavy. The woman is not identified by name in the state investigation report.

Mr. Humphrey said he determined that supporting the woman on both sides as she walked down the stairs was the best means of getting her to the ambulance safely. The woman had to be resuscitated in the ambulance and again shortly after arriving at the hospital.

The paramedic told an investigator that the woman later called him to thank him for saving her life — the first time in his career that had happened.

Cardiac patients exerted

The state investigation faulted Mr. Humphrey and fellow paramedic Deanne Feeney of Hubbardston, both of whom were issued letters of reprimand by the state in July 2005 after another call, for walking a cardiac patient and for failing to bring their cardiac monitor and defibrillator into the home to begin treatment immediately.

The two paramedics will be issued letters of clinical deficiency as a result of the latest investigation. The letters will be placed in their EMT certification files for six months.

For his part, Mr. Markiewicz, who was out of town last week, had said earlier in a telephone interview that he's relieved to learn UMass Memorial EMS has taken steps to improve the care it provides.

The paramedics who came to his house shortly before midnight in September 2007 - Mark F. Wilson of Leicester and Christopher P. Cavan of Oxford - told the state investigator that Mr. Markiewicz was highly agitated and initially refused to go to the hospital.

Mr. Cavan told the investigator that the patient never complained of chest pain, according to the investigation report. Mr. Wilson said the patient complained of "chest tightness," but not of chest pain, according to the report.

When the patient agreed to go to the hospital, he hopped up and strode down the stairs to the ambulance without warning, according to the account of the two paramedics. They said they just followed him down the stairs for fear of discouraging him from seeking treatment at a hospital.

"That's complete baloney. It's completely untrue," Mr. Markiewicz said.

He said he knew something was seriously wrong when he called 911 because of the severe pain in his chest, but that the EMTs tried to convince him otherwise.

"They told me I was hyperventilating and that's what was causing the problem, and that I should just sit down and calm down," Mr. Markiewicz said. He maintained that he thought he had no choice but to walk down the stairs because he just wanted to get to the hospital.

"I was in so much pain. I questioned why I had to do that. They said, 'You're OK.' They said, `There will be one of us in front of you and one of us behind you.' At that point, I just wanted to get to the hospital," Mr. Markiewicz said.

"They never did any tests or anything in the house," he added. "At one point, finally, this guy started doing some of the tests in the ambulance, and I could tell by looking at his face that there was something wrong."

Letter of deficiency

Efforts to contact Mr. Cavan and Mr. Wilson at home and through UMass Memorial were unsuccessful. A letter of clinical deficiency, essentially a written reprimand, will be placed in their files for one year, according to the state report.

The report indicates Mr. Wilson has a "previous compliance history with the Department." The report doesn't elaborate.

The state report concluded that the paramedics violated the state treatment protocol for acute coronary symptoms, but the investigator said she was unable to determine if there were any other violations because of conflicting information provided by the patient and the EMTs.

Mr. Markiewicz had suffered a heart attack the night he was stricken, according to the investigation report.

Mr. Markiewicz said he called Stephen Haynes, chief of the ambulance service, in December and left a voice mail saying that he wanted to discuss his concerns. He said his call was never returned.

The Rondeau family earlier had told state investigators that Mr. Haynes also didn't return their telephone calls or take their complaint seriously. Feeling that their concerns had been blown off, one of Mr. Rondeau's daughters complained to DPH, triggering the initial investigation.

Mr. Markiewicz said he had called Mr. Haynes a few more times, but eventually let the matter drop as he focused on recovering from his heart attack, and then getting back to work.

Dr. Ettinger said that while the medical center has a "robust process" for handling patient complaints, all staff and managers in the ambulance service have been re-trained in what's expected of them when presented with a patient complaint.

The ambulance service has logged 10 complaints over the last two years, he said, but that number only reflects the complaints that were taken seriously and properly entered into the system, as all patient complaints should have been.

"We are doing everything in our power to make sure that happens. We are really taking that seriously," Dr. Ettinger said. "We have re-educated and gone back to all of our EMS staff and mangers and said, 'If you get any kind of a call with a complaint, we have a protocol for taking that down and following up on it.'"

Edited July 22, 2009 by Dustdevil

[cosgrojo]

The drama continues:

http://www.telegram.com/article/20090719/NEWS/907190373

July 19, 2009

EMT censures spur state action

By Thomas Caywood

The Sunday Telegram

WORCESTER, Mass. — In late April, Richard J. Markiewicz read a front-page Telegram & Gazette article about the death of Charles F. Rondeau, a 48-year-old city man who died of a heart attack in the hospital shortly after being walked down three flights of stairs by UMass Memorial EMS paramedics.

Mr. Markiewicz, who maintains that he, too, was made to walk down a flight of stairs by UMass Memorial paramedics while complaining of severe chest pains, in September 2007, said he was astonished to read a hospital official's characterization of Mr. Rondeau's case as an "isolated incident."

"I saw the article, and I was just completely flabbergasted," Mr. Markiewicz said in an interview. "I felt guilty that I hadn't called the state before. I thought, 'Oh God, am I responsible?' That's when I made the decision: 'I'm calling now.'"

Mr. Markiewicz's complaint to the state Department of Public Health was one of two lodged against UMass Memorial EMS in the days following publication of the April 26 article about Mr. Rondeau's death and the resulting state investigation.

Both complaints alleged that UMass Memorial EMS paramedics, as in Mr. Rondeau's case, had required gravely ill patients to exert themselves by walking down stairs — a violation of the state treatment protocols. Ambulances are equipped with a special device called a stair chair to carry patients when necessary.

The other complaint was lodged in early May by a city woman who, a state investigator determined, in May 2008 was made to walk down a flight of 10 stairs to an ambulance while suffering from what turned out to be a heart attack.

"It did appear that there was a pattern," said Abdullah Rehayem, director of DPH's Office of Emergency Medical Services, which regulates ambulance services in Massachusetts.

After the four-month state investigation into Mr. Rondeau's death, which determined the two paramedics involved attempted to cover up their actions, the DPH issued a stinging Notice of Serious Deficiency to UMass Memorial EMS. The action criticized the unit for serious, widespread and persistent problems that extended well beyond what happened in that particular case.

Then came the additional complaints, raising concerns that cardiac patients were being forced to exert themselves in at least several instances.

Hospital officials stress that such complaints represent a minute fraction of the roughly 30,000 calls the ambulance service's 75 paramedics and EMTs field during a year on average.

Even so, the hospital has moved aggressively and spent freely over the last three months to address the problems raised by the state investigations, Mr. Rehayem said.

More training, technology

"UMass has administered training programs to EMTs, and they have invested a lot of money into electronic collection of EMS data through a laptop technology. That will allow them to do more monitoring," Mr. Rehayem said.

In an effort to improve supervision of paramedics, the ambulance service also has created six field supervisor positions, a new level of management immediately over paramedics. UMass Memorial also has ordered five new ambulances, among other steps, officials said.

Dr. Walter Ettinger, president of UMass Memorial Medical Center, declined to discuss what, if any, disciplinary steps had been taken to address the problems cited in the state reports.

"We've done a number of things to improve what was already a good quality of care and to ensure that we're best serving our community," Dr. Ettinger said.

He pointed to the new, roughly $500,000 electronic medical records system for paramedics as a key improvement. The system allows them to quickly enter information from their calls into an electronic database.

Dr. Ettinger said the electronic system should enhance the quality of care because it allows supervisory medical staff to quickly gather and review data on calls dealing with a certain type of medical complaint, such as chest pains, or calls fielded by a particular paramedic.

In addition to the new equipment and new supervisors, UMass Memorial EMS required all of its paramedics to be re-trained on procedures for ensuring that the highest quality of care is provided, Dr. Ettinger said.

The DPH's Mr. Rehayem said his office is satisfied with the corrective action taken by the ambulance service.

In the case of the city woman who suffered a heart attack in May 2008, William E. Humphrey of Worcester, the lead paramedic on the call, told the state investigator that he ruled out using the stair chair because the woman was too large and heavy. The woman is not identified by name in the state investigation report.

Mr. Humphrey said he determined that supporting the woman on both sides as she walked down the stairs was the best means of getting her to the ambulance safely. The woman had to be resuscitated in the ambulance and again shortly after arriving at the hospital.

The paramedic told an investigator that the woman later called him to thank him for saving her life — the first time in his career that had happened.

Cardiac patients exerted

The state investigation faulted Mr. Humphrey and fellow paramedic Deanne Feeney of Hubbardston, both of whom were issued letters of reprimand by the state in July 2005 after another call, for walking a cardiac patient and for failing to bring their cardiac monitor and defibrillator into the home to begin treatment immediately.

The two paramedics will be issued letters of clinical deficiency as a result of the latest investigation. The letters will be placed in their EMT certification files for six months.

For his part, Mr. Markiewicz, who was out of town last week, had said earlier in a telephone interview that he's relieved to learn UMass Memorial EMS has taken steps to improve the care it provides.

The paramedics who came to his house shortly before midnight in September 2007 - Mark F. Wilson of Leicester and Christopher P. Cavan of Oxford - told the state investigator that Mr. Markiewicz was highly agitated and initially refused to go to the hospital.

Mr. Cavan told the investigator that the patient never complained of chest pain, according to the investigation report. Mr. Wilson said the patient complained of "chest tightness," but not of chest pain, according to the report.

When the patient agreed to go to the hospital, he hopped up and strode down the stairs to the ambulance without warning, according to the account of the two paramedics. They said they just followed him down the stairs for fear of discouraging him from seeking treatment at a hospital.

"That's complete baloney. It's completely untrue," Mr. Markiewicz said.

He said he knew something was seriously wrong when he called 911 because of the severe pain in his chest, but that the EMTs tried to convince him otherwise.

"They told me I was hyperventilating and that's what was causing the problem, and that I should just sit down and calm down," Mr. Markiewicz said. He maintained that he thought he had no choice but to walk down the stairs because he just wanted to get to the hospital.

"I was in so much pain. I questioned why I had to do that. They said, 'You're OK.' They said, `There will be one of us in front of you and one of us behind you.' At that point, I just wanted to get to the hospital," Mr. Markiewicz said.

"They never did any tests or anything in the house," he added. "At one point, finally, this guy started doing some of the tests in the ambulance, and I could tell by looking at his face that there was something wrong."

Letter of deficiency

Efforts to contact Mr. Cavan and Mr. Wilson at home and through UMass Memorial were unsuccessful. A letter of clinical deficiency, essentially a written reprimand, will be placed in their files for one year, according to the state report.

The report indicates Mr. Wilson has a "previous compliance history with the Department." The report doesn't elaborate.

The state report concluded that the paramedics violated the state treatment protocol for acute coronary symptoms, but the investigator said she was unable to determine if there were any other violations because of conflicting information provided by the patient and the EMTs.

Mr. Markiewicz had suffered a heart attack the night he was stricken, according to the investigation report.

Mr. Markiewicz said he called Stephen Haynes, chief of the ambulance service, in December and left a voice mail saying that he wanted to discuss his concerns. He said his call was never returned.

The Rondeau family earlier had told state investigators that Mr. Haynes also didn't return their telephone calls or take their complaint seriously. Feeling that their concerns had been blown off, one of Mr. Rondeau's daughters complained to DPH, triggering the initial investigation.

Mr. Markiewicz said he had called Mr. Haynes a few more times, but eventually let the matter drop as he focused on recovering from his heart attack, and then getting back to work.

Dr. Ettinger said that while the medical center has a "robust process" for handling patient complaints, all staff and managers in the ambulance service have been re-trained in what's expected of them when presented with a patient complaint.

The ambulance service has logged 10 complaints over the last two years, he said, but that number only reflects the complaints that were taken seriously and properly entered into the system, as all patient complaints should have been.

"We are doing everything in our power to make sure that happens. We are really taking that seriously," Dr. Ettinger said. "We have re-educated and gone back to all of our EMS staff and mangers and said, 'If you get any kind of a call with a complaint, we have a protocol for taking that down and following up on it.'"

Well... haven't pissed anyone off in a while... how about this...

Further evidence that a 2 paramedic system leaves patients with sub-standard BLS care (i.e. lazy paramedics that are not accustomed to carrying people).

*DISCLAIMER* I am not saying all paramedics are lazy... but having worked in the Mass system of 2 medics for 911 trucks... and having worked in NH and Maine where a medic can be a medic regardless of their partner... I find that the 2 medic system breeds laziness that far too often leads to poor patient outcomes. So all the Medics on the city can now clamor about how you have never shirked your responsibility as a medic, and would never do as these medics have done... but it does not negate the fact that it is happening, and at a high frequency in this 2 medic system. *END OF DISCLAIMER*

At least if two basics were there, they would not hesitate to carry the poor people down the stairs. This is why I prefer systems with BLS first response and ALS intercept trucks. ALS gets to do ALS, BLS gets to do BLS. As my father always said... stick to what your good at. He also used to tell me, "Son, there are no stupid questions... just stupid people." Don't know why he said that to me all the time...

[Mateo_1387]

Well... haven't pissed anyone off in a while... how about this...

Further evidence that a 2 paramedic system leaves patients with sub-standard BLS care (i.e. lazy paramedics that are not accustomed to carrying people).

*DISCLAIMER* I am not saying all paramedics are lazy... but having worked in the Mass system of 2 medics for 911 trucks... and having worked in NH and Maine where a medic can be a medic regardless of their partner... I find that the 2 medic system breeds laziness that far too often leads to poor patient outcomes. So all the Medics on the city can now clamor about how you have never shirked your responsibility as a medic, and would never do as these medics have done... but it does not negate the fact that it is happening, and at a high frequency in this 2 medic system. *END OF DISCLAIMER*

At least if two basics were there, they would not hesitate to carry the poor people down the stairs. This is why I prefer systems with BLS first response and ALS intercept trucks. ALS gets to do ALS, BLS gets to do BLS. As my father always said... stick to what your good at. He also used to tell me, "Son, there are no stupid questions... just stupid people." Don't know why he said that to me all the time...

I believe I know.

It is funny how in this double medic system the 'Basics' know what they are doing, but not the Paramedics. Do I sense some animosity?

[letmesleep]

I'm not real sure how it is that having 2 medics on the truck causes poor outcomes for pts, or why it is that EMTs would be the only ones that would carry a pt to the truck. Unfortunately these types of stories exist and continue to happen all the time in this field. Irregardless of what the ranks, titles, licensures are it happens all the time with the one continuing factor being laziness, period.

I also agree with the statements that we don't have both sides of the story, but how much more info do we need? following an investigation it was found that, and the medics admitted too, FALSIFYING their report, this leads me to believe that we know what happened, and this pt was not carried by choice, anything else woulda/ shoulda/ coulda been documented. I doubt seriously that the walk caused this pt's death, based on stats related to this type of STEMI, however it still comes down to 1 thing..........LAZY!

[cosgrojo]

Mateo -

I never said basics knew what they were doing and medics did not. I certainly implied that basics are more accustomed to, and do a better job lifting and carrying people down stairs. If you would like to think that I am silly enough to equate lifting with EMS skill and ability... then that is your prerogative. It doesn't make it true, but whatever tickles your chain young man.

I have no animosity toward paramedics... in fact have a tremendous amount of respect for the good ones. I do, however, have animosity towards laziness, and my comments were to point out my observations about the 2 medic system... not medics in general. There are just as many lazy basics out there... but their laziness tends to be toward assessments and patient care, and less toward lifting and moving patients.

It appears, dear sweet Meat-ee-o, that you are perhaps a little sensitive about your role as a paramedic. You obviously have some deep-rooted fear and hesitance toward your place in the EMS paradigm (probably suffer from a bit of Napoleon complex as well). I can not help you over come your emotional and psychological burdens... but I hope that your reading comprehension is not a skill that makes your para-medicine skills appear wanting.

BTW minus 5 for not being funny. I set myself up for any number of doozies with my last line... and that's all you come with? Goodness me Mateo.

Letmesleep - All credibility on your post was unserruptitiously negated with the use of the term "irregardless." You were making some good points... but they can no longer be taken seriously. Banish that term from your repertoire, and then we will be able to move forward amicably.

But to answer your question, I believe any good EMS system requires balance. If you have two evenly trained individuals working together all the time, who are focusing on the same things and working the same treatment modalities in their heads, things get overlooked and complacency sets in. I believe however that when you have two people who have different specialties working toward the same goal, less gets overlooked, and both sides get a chance to keep divergent skills fresh and in practice, or learn new skills that one didn't know at the outset. Having only basics in a system would be even more disastrous than having 2 medics... I recognize that. All I have been trying to point out is that a good system should have a balance of licensure and skills. Only working with people in your own level can cause serious gaps in knowledge and skills, and keep you further away from mastering your craft. And these gaps can and do lead to poor patient outcomes.