What Went Wrong

Saturday, June 17, 2006

On Jan. 6, David E. Rosenbaum drank some wine before and during dinner in his Northwest Washington home, then went out for a stroll shortly after 9 p.m.

Minutes later, he was struck on the head with a metal pipe and robbed. A neighbor found him on the sidewalk, unable to speak or get up. According to a report released yesterday by the office of the D.C. inspector general, Rosenbaum, 63, then became a victim of shoddy work by the city's police and fire departments and by medical personnel at Howard University Hospital. He died at the hospital Jan. 8.

Some of the failings:

· Even though all D.C. firefighters are required to be certified emergency medical technicians, the firefighter in charge of Engine 20, which arrived at the scene first, did not have EMT training. The firefighter, a 24-year veteran, said he had repeatedly asked for such training, but he "just fell through the cracks." The report said he was not "in any way qualified to oversee" other firefighters on an injured-person call.

· The other firefighters on Engine 20, who are trained as EMTs, failed to do "a complete assessment of [Rosenbaum], and not one of the patient's vital signs were recorded at the scene." Because one of the firefighter/EMTs "perceived an odor of alcohol coming from the patient," the crew assumed Rosenbaum was drunk and had passed out.

· The driver of Ambulance 18, dispatched to the scene from Providence Hospital in Northeast Washington, got lost on the way, delaying its arrival by six minutes.

· The most highly trained EMT on the ambulance did not take charge at the scene and did not help her partner assess Rosenbaum. The ambulance crew also believed he was merely intoxicated. Although a test called a "Glasgow coma scale" was performed on Rosenbaum and the results suggested he had suffered a brain injury, the findings "were disregarded, and not brought to the attention" of personnel in the Howard emergency room.

· Although the closest hospital was Sibley Memorial, Rosenbaum, wrongly classified as "a low priority," was taken to Howard instead, for "personal reasons" related to a member of the ambulance crew. The report does not specify the reasons but said the decision "delayed the emergency hospital care that would have been available minutes earlier" at Sibley.

· Medical personnel at Howard failed to "perform basic assessments" of Rosenbaum when he arrived. Rosenbaum "was incorrectly diagnosed as intoxicated, but employees did not follow triage policy on treating an intoxicated patient," such as checking his vital signs every 15 minutes. As a result, he remained on a gurney in a hallway in the emergency room for more than an hour before anyone noticed his severe head wound.

· Believing Rosenbaum was drunk, D.C. police "failed to secure the scene" of the mugging and did not "collect evidence, interview all potential witnesses, canvass the neighborhood, conduct other preliminary investigative activities, or properly document the incident." That caused delays in identifying Rosenbaum, whose wallet had been stolen, and in finding the two men now charged with killing him.

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