A Death and Multiple Failures

Monday, June 19, 2006

ON JAN. 11 the District's fire chief issued a statement that we now know to have been wildly at variance with the facts. "Our operational review indicates that appropriate measures were taken and EMS providers met all standards of care as outlined in our protocols," Fire and Emergency Medical Services Chief Adrian H. Thompson said of the emergency response to the assault on David E. Rosenbaum.

The truth, as established by the D.C. inspector general's investigation, released on Friday, is that the response of the Fire and Emergency Services Department (FEMS) to Mr. Rosenbaum, a New York Times reporter who was robbed and beaten, was marked by failures to follow established protocols at just about every turn. Failures ranged from incomplete patient assessments and poor communication between emergency responders to inadequate evaluation and documentation of the incident. Said the inspector general: "The result, significant and unnecessary delays in identifying and treating Mr. Rosenbaum's injuries, hindered recognition that a crime had been committed."

The significance of the probe extends beyond this case. As the report observed, the multiple failures discovered by investigators "have generated concerns . . . about the systemic nature of problems related to the delivery of basic emergency medical services citywide." In other words, what happened to Mr. Rosenbaum could happen anywhere in the District. The department is infected with "an impaired work ethic that must be addressed before it becomes pervasive," the inspector general declared.

Let's take a closer look at findings about the system defended by the chief:

· The firefighter in a supervisory position over the personnel who first responded to the scene never received EMT training as required, did not have first-aid training and his CPR certification expired two years ago.

· Technicians delivered oxygen to the patient contrary to FEMS protocol and accepted medical practice and disregarded an indication of possible head or spinal cord injury. An inadequate assessment was performed after blood was found.

· Indications of a criminal attack were not followed up, and the first responders made inconsistent, confusing and contradictory statements.

The police department, the inspector general reported, failed to search the "man down" for identification, did not conduct a preliminary investigation, made no connection between his condition and a possible crime, and failed to file a report on the incident.

Howard University Hospital employees failed to perform basic assessments that could have revealed the serious nature of Mr. Rosenbaum's problems, choosing instead to treat him as a drunk and "just let him sleep," the inspector general reported. He was also documented inaccurately in the emergency room ("awake and alert"), and the attending doctor's recollection of her actions could not be supported and were contrary to Howard's own written documentation.

On Friday, Mayor Anthony A. Williams told this page, "Clearly Chief Thompson's initial assessment is not correct." Asked if he still retains full confidence in the chief, the mayor said "[the inspector general's] report gives me no confidence in the initial investigation that was done." The mayor expressed concern about the systemic questions raised by the investigation and declared that "people will be held accountable," and not just low-level workers. Thus far, the firing of a technician involved in the lousy response and the disciplining of two supervisors by the fire chief, as well as the reported "corrective action" taken against two police officers, represent an anemic reaction given the breadth and magnitude of the failures cited by the inspector general. "It's incumbent upon me to take action," Mr. Williams said. Residents will be watching to see if the mayor's actions match his words.

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