Firefighter May Have Neglected EMS Rules
Wednesday, March 25, 2009; Page B01
Internal D.C. fire department documents show that a paramedic might not have followed procedures in responding to a man complaining of chest pain who did not go to a hospital and died hours later of a heart attack in December.
Edward L. Givens, 39, of Northeast Washington signed a release form refusing further treatment, but family members said the paramedic in charge convinced them that he had acid reflux and just needed an antacid.
Givens said he played basketball, smoked marijuana and ate a hamburger before he felt chest pain and had trouble breathing, said his brother, Anthony Givens, who was at the home during the 911 call. Anthony Givens said he told the paramedic that both his parents had heart attacks, but routine treatment for chest pain was not administered. Instead, according to the documents, the paramedic judged his brother's problem was stomach-related, despite an abnormal result from a cardiac monitor. But EMS personnel are not trained to provide diagnoses, Medical Director James Augustine said in a report.
The choices made in response to that call again raise questions about the medical training of firefighters and whether the city's plan to integrate firefighting and emergency medical services is producing the best care possible. Mayor Adrian M. Fenty (D) promised the city would improve emergency services as part of a settlement with the family of David E. Rosenbaum, a retired New York Times reporter who was assaulted in 2006 but assessed as drunk by responders. He died two days later.
D.C. fire and EMS officials would not discuss the documents, which include an operational review, a two-page medical quality review and an event chronology, referring questions to D.C. Attorney General Peter Nickles. The operational review and the medical review differ in certain conclusions. The operational review raised concerns about the thoroughness of the evaluation; the medical review said that an "adequate patient history was obtained" and that documentation was "acceptable."
Nickles acknowledged that the two reviews might disagree on some operational points but said that the medical review was more informed because it included information from the autopsy. "Given the tragedy that occurred, it would be easy to conclude there could have been more of an effort," but it might not have made a difference, he said.
Fire Chief Dennis L. Rubin has referred the case to the District's inspector general.
Training remains a concern, according to the documents. The paramedic who attended to Givens was a firefighter with paramedic certification. He was taken off the streets for three months and sent to the training academy for remedial instruction. The documents show a three-lead electrocardiogram for Givens produced "some ST-segment elevation," which a top EMS official said "should have generated a higher index of suspicion" of a heart problem.
Last month, the department began mandatory training for paramedics on responding to cardiac patients, including proficiency testing with the 12-lead ECG, which looks at the heart's electrical activity from 12 angles instead of three. Chest pain treatment in the District calls for paramedics to "consider" a 12-lead ECG, along with giving the patient aspirin, oxygen and nitroglycerin. Many jurisdictions make the 12-lead ECG routine.
"The three-lead is not reliable" to detect a heart attack, said Terry Jodrie, a regional medical director for the agency overseeing Maryland's emergency medical services.
The Givens case is instructive because the District is moving toward a system that relies more on firefighters with advanced life support or paramedic certification, phasing out single-role medics.
About four out of every five fire department 911 calls are medical.