[Scan-DC] D.C. FIRE/EMS RUN ON APRIL 2, 2008

[Alan Henney]

Adrian M. Fenty, Mayor     Dennis L. Rubin, Fire Chief
FOR IMMEDIATE RELEASE          CONTACT: PIO 202.673.3331

On Wednesday April 2, 2008, at approximately 1 PM, the District of
Columbia Fire and Emergency Medical Services Department experienced a
delay in locating a patient on a medical response call.  Sadly, this
patient died later that afternoon at Howard University Hospital.
Following completion of an operational review, any appropriate
remedial and/or disciplinary action will be taken as necessary.

“It is the goal of the District of Columbia Government to provide
prompt and efficient care to all persons in need, and we deeply regret
our failure to immediately locate this patient,” said Chief Dennis
Rubin.  “A review of this incident is underway.  Our initial finding
is that the first-arriving Fire/EMS resource made an operational error
that we believe was the primary cause of the delay in locating the
patient.”

The following is a brief summary of events:

• Engine Company 6 and Medic 1 were dispatched to #10 G St., NE at
13:07:36 for a 3rd party 911 call reporting an adult male having a
possible seizure.   Engine 6 was 0.9 miles from that location, and
Medic 1 was 2.73 miles away.

• Engine 6 arrived at what they thought was the location of the call
within 4 minutes and 15 seconds.

• Engine 6 spent a minimum of 1 minute 49 seconds searching the block
for a patient.  They were unable to locate a patient.  Engine 6 called
the Office of Unified Communications by radio requesting clarification
on the address and asking that the 911 caller be called back.  The
Office of Unified Communications (OUC) notified Engine 6 that the
patient was reported to be in front of #10 G St., NE.  The OUC also
called back the original 911 caller and received a voice mail message.

• Upon being informed that there was no answer from the call-back, and
after notifying the OUC that they were unable to locate a patient
after checking the entire unit block (of what they thought was G St.,
NE), Engine 6 placed themselves in service at 13:14:09.

• The Office of Unified Communications received an additional phone
call from the original 911 caller that now suggested the patient was
no longer breathing.  The call-taker initiated pre-arrival CPR
instructions.

• Within two minutes of Engine 6 going in service, the additional
information received by the OUC led to a re-dispatch of Engine 6 and
Medic 1, at 13:16:09.  Engine 6 was still in the general vicinity and
promptly returned to the scene.  Medic 1, which had been placed in
service, had continued their travel towards the area.

• Upon approaching the scene the second time, Engine 6 realized that
they had mistakenly been in the unit block of G Pl., NE during their
initial response, rather than the unit block of G St., NE (one block
away).  They entered the correct block this time, at approximately
13:19:03, and immediately began resuscitation efforts on the patient.
Medic 1 arrived at approximately 13:21:43. Two EMS supervisors
responding to the report of CPR in progress also arrived, at 13:23:38
and 13:24:33.

The total elapsed time from when Fire/EMS was dispatched to when the
first basic life support (BLS) resource reached the patient was
approximately 11 minutes, 27 seconds. The total elapsed time to
arrival of the first advanced life support unit (ALS) was
approximately 14 minutes, 6 seconds.

Upon arrival, Fire/EMS delivered appropriate pre-hospital care.
Despite the aggressive efforts of a team that included a paramedic,
seven emergency medical technicians (EMTs), and two paramedic
supervisors, the patient did not respond to clinical interventions.
The total elapsed time from the placement of the first 911 call to
delivery of the patient to Howard University Hospital was
approximately 34 minutes, 15 seconds. The patient was pronounced dead
at Howard University Hospital and the Office of the Chief Medical
Examiner is performing an autopsy.

The Fire/EMS Department response time goal for critical medical calls
is to deliver an EMT with a defibrillator within 6 minutes 30 seconds
of dispatch, and a paramedic within 8 minutes of dispatch.  The
District is currently meeting these performance targets 91.4% and
89.6% of the time, respectively.  On this call, however, we failed to
meet our performance goal. This incident underscores the need for
modern navigational technology in all emergency response vehicles.
The District is currently in the process of implementing a Mobile Data
Computer (MDC) system in emergency vehicles that will provide
real-time navigational assistance to emergency responders to help
prevent errors such as the one that appears to have occurred on this
call.  These devices are currently being installed in over 1,000
public safety vehicles during Fiscal Year 2008 and 2009 as a
District-wide initiative.  As a result: dispatching, mapping and
routing, navigation, and many other critical functions of emergency
response will be significantly enhanced and improved.

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1923 Vermont Avenue, NW  Washington, DC  20005  Telephone: (202)
673-3331  Fax: (202) 673-3188