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How Not to Save a Life

Here are excerpts from the June 2006 inspector general’s report about the emergency medical treatment of David Rosenbaum, who was struck on the head during a robbery attempt near his Northwest DC home.

Discovery of “Man Down”

At approximately 9:20 pm on January 6, 2006, a resident of Gramercy Street, NW (Neighbor 1), observed an unknown man lying on the sidewalk directly in front of his house. According to Neighbor 1, he approached the man, who was lying face up on the ground, and saw that he appeared to be ill or injured. He was unable to rise. When Neighbor 1 spoke to the man, he responded with groans. Neighbor 1 called to his wife, Neighbor 2, and told her to dial 911 for assistance. Neighbor 2 relayed the 911 call taker’s questions about the man to her husband. She then relayed her husband’s answers to the 911 call taker. After ending the call, Neighbor 2 went outside to see if she could help the man. According to Neighbor 2, the man was “dressed nicely and not unkempt.” Stereo headphones were lying next to him, and as he kept raising his left arm, she noticed that he was wearing a watch and a wedding band.

Engine 20 Arrives

On January 6, 2006, at 9:30 pm, Communications dispatched Battalion 4, Engine 20, headquartered at 1617 U Street, NW, to the Gramercy Street 911 call. According to interviews and the Event Chronology, Engine 20, a BLS (basic life support) vehicle, arrived on the scene at 9:35 pm.

Four firefighters responded to the Gramercy Street 911 call: FF, FF/EMT 1, FF/EMT 2, and FF/EMT 3. A review of FEMS personnel records showed that three of the four, FF/EMT 1, FF/EMT 2, and FF/EMT 3 had current EMT certifications. FF/EMT 2 was an EMT-Advanced. FF, who was the officer in charge that evening, had never been trained or certified as an EMT.

Firefighter Interviews

FF has been a firefighter at Engine Company 20 for 24 years. When he was hired, EMT training was not required. After such training became a requirement, FF still never received training. According to FF, he “just fell through the cracks.” FF informed his supervisor about his lack of training but was never put into a class. The last time FF tried to get into a class was 6 years ago. FF’s CPR certification expired 2 years ago, and he does not have first aid training.

On January 6, FF’s immediate supervisor was sick, and he was designated as the “acting officer in charge,” supervising the activities of the crew assigned to Engine Company 20. FF was assigned to this supervisory position even though he was not trained, certified, or in any way qualified to oversee the firefighter/EMTs’ care and treatment of ill or injured persons.

Residents’ Observations

Neighbors 1 and 2 told the OIG [Office of Inspector General] team that while the arrival time of the fire truck was good, they believed the ambulance took too long to get there. When the firefighter/EMTs arrived, Neighbor 2 asked them if they would be able to help and “kept trying to talk to them,” but they did not pay any attention to her. Neighbor 1 heard the firefighters say that “9 out of 10 times it’s alcohol related.” Neighbors 1 and 2 did not smell alcohol on the patient’s breath.

According to Neighbor 2, the firefighter/EMTs did not appear to know what they were doing.

EMT Interviews

EMT 1 remembered that on January 6, they were at Providence Hospital around 9:30 p.m. when the Gramercy Street call came in. EMT 1 was outside smoking and believes that she answered the call.

When asked if she protested going to Gramercy Street, EMT 1 denied protesting. The OIG team then played the tape, on which EMT 1 is heard questioning why Ambulance 18 was being sent to Gramercy Street. On the tape, the dispatcher tells EMT 1, “The lead [dispatcher] says you are to go to this call. If another unit closer becomes available, it will be sent there.” The OIG team then asked EMT 1 if it is usual for an EMT to question Dispatch about being sent on a particular call, as EMT 1 had done on the tape. EMT 1 replied, “That’s my right. I can question anything. They ain’t always right.”

FF/EMT 1 and FF/EMT 3 helped the Ambulance 18 crew load the stretcher with the patient onto the ambulance, and care of the patient was transferred to the EMTs. The patient was not placed on a backboard and did not have a neck collar. Engine 20 returned to the firehouse after clearing trash from the scene.

Ambulance 18 did not take a direct route from Providence Hospital to the Gramercy Street incident. In addition, for personal reasons, the EMTs did not take the patient to the nearest hospital. As a result of that decision, it took twice as long for Ambulance 18 to reach Howard than it would have taken to get to Sibley Hospital.

Howard University Hospital

Nurses did not properly triage and assess Mr. Rosenbaum. The triage nurse did not perform basic assessments and did not communicate an abnormal temperature reading. The patient was incorrectly diagnosed as intoxicated, but employees did not follow triage policy on treating an intoxicated patient. Howard’s Patient Care Standards—including monitoring airway and breathing, assessing for trauma, conducting routine lab tests, and monitoring vital signs every 15 minutes—were not followed.

Mr. Rosenbaum’s head injury was discovered at Howard in the early morning hours of January 7 and reported to MPD. MPD subsequently linked Mr. Rosenbaum’s injuries, his missing wallet, and the unusual credit card activity, and initiated an assault and robbery investigation.

Despite surgery and other medical interventions to save him, Mr. Rosenbaum died on January 8, 2006.

Issues and Findings

These multiple individual failures during the Rosenbaum emergency suggest alarming levels of complacency and indifference which, if systemic, could undermine the effective, efficient, and high quality delivery of emergency services to District residents and visitors.

Footnote: According to Toby Halliday, David Rosenbaum’s son-in-law, the family consulted neurologists who told them Rosenbaum had a survivable injury “if he had been treated properly and promptly.”

This article is from the February 2009 issue of The Washingtonian. For more articles from the issue, click here 

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