DC officials try to improve EMS after girl's death

[May 07, 2010]  WASHINGTON (AP) -- Nannie Lawrence remembers her 2-year-old granddaughter as a playful and precocious toddler, trying on her mother's wigs and changing her own clothes.

Stephanie Stephens died after paramedics refused to take her to the hospital Feb. 10 in the first of two visits to her home after she experienced breathing problems. Her death has prompted a rare criminal investigation and raised questions about ambulance policies in Washington and emergency care for children nationwide.

After the paramedics recommended she be taken into a bathroom to inhale steam from a running shower, Stephanie's family called back hours later and an EMS crew took her to a hospital. The child died from pneumonia the next day.

"All we know is, the baby was gone, and she was the sweetest thing," the 68-year-old Lawrence said.

D.C. Fire and Emergency Medical Services Chief Dennis L. Rubin said an internal review of the case revealed some "abnormalities." He referred the case to the D.C. attorney general, who passed it to police.

"The mere fact that the mother wanted the child transported, it was our obligation to transport the child," said Rubin, who now is reinforcing long-standing policy that a patient has a right to be taken to a hospital.

Following Stephanie's death, Rubin said he is working to drive home that key point: providers never decline transport.

His staff is developing a "patient's bill of rights" to be posted in every ambulance and producing a new training video underscoring that message. In addition, the policy has been expanded to cover instances in which a patient refuses to be transported, including the requirement that responders get an OK from a supervisor and have a witness, such as a police officer, confirm the patient's decision.

Metropolitan Police Department spokesman Lt. Nicholas Breul said detectives are wrapping up a criminal investigation of the senior paramedic who made the decision not to transport Stephanie. Neither that paramedic nor others involved have been identified.

Attorneys representing paramedics and EMS industry groups nationwide said they know of only a handful of cases in which paramedics have been criminally investigated or prosecuted over their care.

State or local licensing authorities typically handle questions relating to performance and decide whether to revoke a medic's license -- a process D.C. Attorney General Peter Nickles said is on hold in Stephanie's case until the police investigation is completed.

Nickles said Stephanie's case was so problematic it merited an investigation into whether there was criminal neglect.

The department had more than 128,000 EMS calls last year and more than 86,000 patient transports. Calls that didn't end in transport were either because the patient refused service or no patient was found, officials said.

Most EMS systems have transport policies similar to Washington's. But in areas where there's heavy 911 use or abuse of the service, experts say, medics might exercise their judgment.

Dr. Nicholas Vasquez, a Phoenix emergency room physician and a spokesman for the American College of Emergency Physicians, said research has shown that when medics are faced with the decision of whether to transport, it's always better that patients be taken to the hospital.

"Every time we study these things, there's a significant enough error rate that they should not be taking on responsibility of making that judgment call at the scene," Vasquez said.

A 2006 study at the Denver Health Medical Center, an urban hospital, found that paramedics correctly predicted which patients needed admission to the hospital in 62 percent of cases.

Torren Colcord, president of National Emergency Medical Services Association, said his union representing EMS personnel favors a national EMS agency to set standards for training and protocol and enforce those rules.

"There's no policymaking body that has teeth in relation to EMS," he said. "They leave it up to local jurisdictions."

Stephanie's death, meanwhile, has put a spotlight on treating children.

Dr. Joseph L. Wright, senior vice president of the Child Health Advocacy Institute at Children's National Medical Center in Washington, said paramedics need to become more comfortable around children, who make up about 15 percent of transports in the District of Columbia.

"We still have a long way to go to really institutionalize quality emergency medical services for children across the country," said Wright, who is working with the agency to provide D.C. medics with more triage observation experience with youngsters.

District fire officials said their refresher training requirements for pediatric care exceed national standards.

The city's latest case comes after other high-profile cases of paramedics declining to take patients to the hospital, including the 2006 death of New York Times reporter David Rosenbaum after he was mugged near his D.C. home. A city report found emergency workers initially believed Rosenbaum was drunk and didn't determine whether he was injured.

D.C. officials set up a task force, and Rosenbaum's family withdrew a lawsuit after giving the city a year to improve EMS operations. Among steps taken were improving EMS training, creating supervisory positions overseeing EMS operations and more EMS battalion chiefs who provide 24-hour staffing.

Rubin said following Stephanie's death, his agency is reviewing two other claims, one from a woman who said she did not receive appropriate care and another person who claims not to have been transported.

Rubin said he knows his department has made some missteps, but he remains optimistic, adding, "We're going to continue to try to get our mistakes down to zero."

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On the Net:

D.C. EMS Task Force Recommendations

National Emergency Medical Services Association:
http://www.nemsausa.org/

[Associated Press; By NAFEESA SYEED]

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