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What Rosenbaum Case Investigators Weren't Told

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By Colbert I. King
Saturday, October 14, 2006

There are reasons journalists approach "official" government reports with a healthy dose of skepticism. Case in point? The D.C. inspector general's June final report on the death of New York Times reporter David E. Rosenbaum in January.

Inspector General Charles J. Willoughby told Mayor Anthony A. Williams in a June 15 letter accompanying his report that a team of investigators and inspectors from the Office of the Inspector General "interviewed all D.C. government and Howard University Hospital personnel involved in Mr. Rosenbaum's emergency care and autopsy." Unfortunately, and through no fault of its own, the OIG did not.

Equally important, the information the investigators failed to obtain had a direct bearing on accounts they got from D.C. Fire and Emergency Medical Services (FEMS) workers involved in the Rosenbaum case. The information withheld from the OIG was also not made available to FEMS chief Adrian Thompson, thus causing him to give a positive appraisal of his department's performance when the truth was otherwise.

The Office of the Inspector General did a good job of documenting the failures of D.C. firefighters and emergency medical technicians to properly handle a "John Doe," later identified as Rosenbaum, who was brutally attacked and robbed in Northwest Washington the evening of Jan. 6. The report also detailed failures that continued during his transport to Howard University Hospital and his treatment in the hospital's emergency department.

But the report's portrayal of the role played by Amit Wadhwa, medical director of the D.C. Fire and Emergency Medical Services Department, did not capture all that he did, and did not do, on the night the critically injured Rosenbaum arrived at the hospital.

Wadhwa told the inspector general's team that he was working in the hospital's emergency department and helped another emergency room doctor roll a "John Doe" patient -- Rosenbaum -- onto his side to put a long board beneath him. Wadhwa said he saw only a quarter-size bump on the back of the man's head. He also said he didn't know the patient had been transported to the hospital by FEMS until after he had helped the other doctor.

Wadhwa said he reviewed the Form 151 "run sheet" used by EMTs to document a patient's condition and saw that it was not completed. The incomplete document led him to call the FEMS supervisor on duty, order Ambulance 18 out of service and ask that the crew members write special reports on their handling of the patient.

That's where the inspector general's findings left off. But there is more to the story.

Unknown to the OIG, two emergency medical services supervisors also visited the hospital's emergency department that night in response to an urgent call from Wadhwa.

Capt. Louis L. Carter, a senior EMS supervisor, said Wadhwa called him at about 12:15 a.m. Jan. 7 to say that the crew of Ambulance 18 had given inaccurate information on the condition of a patient they brought to the hospital. Wadhwa told him that the crew described the patient as intoxicated when in fact he had serious, code-one head trauma, according to Carter. Wadhwa, Carter said, took Ambulance 18 out of service and ordered the crew to submit special reports explaining why the patient was not given proper treatment and why the hospital was not notified.

Wadhwa asked that an EMS supervisor report to the hospital's emergency room as soon as possible. Carter dispatched Lt. Roberto Hernandez Jr. to the hospital's emergency department. Carter later joined Wadhwa and Hernandez there.

Hernandez said he arrived at the hospital about 12:30 a.m. and found a "visibly upset" Wadhwa. Hernandez said that after Wadhwa showed him the incomplete run sheet, Wadhwa took him to look at the patient.

Hernandez said Wadhwa pointed to an injury to the back of the patient's head and had him look at the patient's pupils. Hernandez said he observed an unconscious white man approximately 60 years old on a hospital stretcher. The patient had blood on the right side of the back of his head and in his right ear. His pupils were dilated and non-reactive, Hernandez said.

None of that was mentioned to the OIG investigators or FEMS chief Thompson when he reviewed how Rosenbaum was handled. Would it have been important to the inspector general's evaluation of the information provided by other FEMS workers? Inspector General Willoughby thinks so, as he explained in a follow-up letter to city leaders in August after learning about Carter and Hernandez's statements in mid-July, a month after issuing the special report. Not only is he bothered by Wadhwa's misleading statements, Willoughby also doesn't know whom Carter and Hernandez notified in the chain of command regarding their Howard visit and what action, if any, was taken by those notified. What does seem clear, however, is that Thompson was sandbagged by his people, who allowed him to steadfastly defend the actions of firefighters and EMTs when senior officials in the department knew that, as Rosenbaum lay hospitalized following a savage attack, he was also the victim of FEMS incompetence and malfeasance of the first order.

Chief Thompson is on Democratic mayoral nominee Adrian Fenty's chopping block. There is, however, some unfinished business that needs attending to in the upper reaches of FEMS. No one knows that better than Thompson. A wise incoming mayor would let Thompson clean up the place first.

kingc@washpost.com


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