Darkness and the Dawn

A tragedy gives rise to positive changes in D.C. EMS

   It started with a mugging.

   On January 6, 2006, a resident of the District of Columbia's Gramercy Street NW found an unknown man lying on the sidewalk, unable to speak. A call to 9-1-1 brought police and fire/EMS. The arriving EMTs, focusing on the patient's vomiting and an odor of alcohol, did not recognize the seriousness of the man's condition or the underlying cause of his altered mental status, and did not request advanced life support or an expedited transport response. The patient was ultimately taken, after some delays, to Howard University Hospital, where it took another four hours for a neurological evaluation.

   Two days later, the man died of head injuries sustained in the assault. He was New York Times journalist David Rosenbaum, and the resulting story went national.

   In response, Mayor Anthony Williams had his inspector general review the chain of events that preceded Rosenbaum's death. The report came five months later and had fault for a range of players, including the Howard ED staff, district police and the district's fire and EMS department. Multiple personnel from agencies involved that night failed to follow their protocols, the IG concluded, suggesting "alarming levels of complacency and indifference" and even an "impaired work ethic."

   Bad stuff--but this is where a bad story turns good. In response to the findings, district leaders took swift action. In March 2007, new Mayor Adrian Fenty announced a settlement that included the creation of a task force on EMS to investigate the response and make recommendations for D.C. Fire & EMS. If, in a year, Rosenbaum's survivors were happy with the progress the department was making in implementing the task force's recommendations, they agreed not to sue.

   As 2008 came and went, they didn't. The department had made good progress in instituting the improvements the task force sought. That progress continues today, and continues to yield benefit.

   "I think it's an example of a leadership commitment that demonstrates that change and improvement are both possible and practical," says Rafael Sa'adah, the service's assistant fire chief for emergency medical services. "The commitment from our mayor and Chief [Dennis] Rubin was rock solid. And beyond just a policy commitment, the mayor committed resources to make these changes a reality."

   The task force made six major recommendations for the department:

  • Transition to a fully integrated all-hazards agency;
  • Elevate and strengthen the EMS mission;
  • Improve care through enhanced training and education, performance evaluation and quality assurance, and employee qualifications and discipline;
  • Revise deployment and staffing procedures;
  • Reduce misuse of EMS and delays in patient transfers;
  • Strengthen Department of Health oversight of EMS.

   Within each of these recommendations were individual action items. As it worked toward these changes, the department reported its progress on each on its website, allowing anyone interested to track its efforts.

   "I think the fact that the public can monitor our progress is hugely important," says Sa'adah. "We're very proud of our progress and have tried to be very open about the areas where we haven't completed the goals we set forth and the reasons why."

   That's all available at http://fems.dc.gov. Some of the changes chronicled there have been profound.

Mission Quest

   By the time Sa'adah updated attendees of the Pinnacle EMS Leadership & Management Conference on the department's progress last July, D.C. Fire & EMS had completed 39 of the task force's 50 total action items, including all related to elevating the EMS mission. Eight, overall, were still in progress; only three had passed with deadlines unmet.

   Elevating the EMS mission had several components: A panel to ferret out practices suggesting a lower priority to EMS. A medical director at the AFC (assistant fire chief) level. An AFC for EMS, reporting directly to the chief. Additional EMS battalion chief and captain positions to ensure better 24/7 supervision and career options.

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