- The Washington Times - Friday, April 24, 2009

Scores of the District’s paramedics failed to meet the minimum national standard on written exams testing or mishandled basic life-saving procedures during videotaped assessments, according to interviews, videos and documents obtained by The Washington Times.

One of the nation’s premier emergency medical professionals, who reviewed the materials at The Times’ request, said the deficiencies identified during a sweeping assessment of the city’s paramedics posed a safety crisis for the nation’s capital.

“Based on what I saw on those videos, there is no question in my mind,” said Paul Werfel, director of New York’s Stony Brook University’s paramedic program and a clinical assistant professor of health sciences. “To be perfectly honest, I think there’s a real threat here. The safety of the people of the District of Columbia is at risk. It’s a clear and present danger to them.”

He said many of the paramedics displayed a lack of familiarity with the equipment they were using and had difficulty performing basic paramedic tasks, such as intubating a patient. He said that one paramedic put a bag valve mask that assists patients with breathing difficulties on the mannequin upside down, others mismanaged the patients’ airways, and others administered medications to cardiac arrest victims when the situation called for electric shocks. Many of the paramedics used obsolete techniques to determine the condition of the patient.

The city has about 250 paramedics, and about 175 have been put through the assessment program at a training center in Maryland. The Times obtained test scores for at least 95 of the paramedics. Only three scored in a range to get a passing grade under the national standards for entry-level paramedics.

City officials originally threatened an investigation or legal action to stop The Times from publishing the materials, saying exposing the scores would hurt the city’s efforts at improving its oft-criticized paramedic service. But after a further review, D.C. Attorney General Peter J. Nickles said too many people had access to the information to pursue any leak probe or legal action.

Fire and EMS Chief Dennis L. Rubin and Mayor Adrian M. Fenty issued a two-page statement this week addressing the city’s efforts to assess its paramedic force and make improvements.

The statement hailed the department’s “historic effort to improve the level of clinically competent, professional and compassionate patient care through enhanced training, education, performance evaluation and quality assurance.” It said the testing, performed from March to June 2008 by the Maryland Fire Rescue Institute (MFRI), led to the creation of improved clinical protocols. It also said that “several areas for systemic training have been identified,” although it did not name them.

The statement issued Wednesday warned that examining the tests “without a thorough understanding of the testing environment and process could lead to misinterpretation of the results” and suggested that the “attacks” by unnamed people were an attempt to thwart the agency’s reforms.

“Transformational change of this nature is very threatening to special interest groups and individuals that want to maintain the status quo,” the release said. “These persons will continue their attempts to destroy public trust in an effort to undermine the District’s EMS improvements.”

The written test, taken by about 175 of the city’s 250 advanced life-support providers, is equivalent to the National Registry of Emergency Medical Technicians test for paramedics — an entry-level examination required for national certification in 38 states and the District.

The same 175 paramedics were videotaped during a practical skills assessment in which they were required to deal with a cardiac arrest on a high-tech mannequin. Both tests were administered at MFRI, a nationally known training facility affiliated with the University of Maryland in College Park.

The Times obtained about 90 of the videotaped assessments and 95 of the written test scores. On the 95 written tests, only three paramedics scored 70 percent or above; a passing grade for an entry-level paramedic on the national registry exam is 75. Twenty-three paramedics scored between 60 percent and 70 percent, and more than two-thirds scored below 60 percent.

The lowest score The Times reviewed, below 40 percent, belonged to a field training officer, the documents stated.

More than 75 of the 10-minute videos were submitted by The Times to multiple local and nationally recognized paramedic instructors and quality-assurance specialists, who said they observed egregious health care violations.

“The performances I saw on these particular tapes I would not accept from people graduating a paramedic course, much less people with years of experience,” said Mr. Werfel, a founding member of the board of directors of the National EMS Educators’ Association. “Almost all of them exhibited extremely poor technique,” Mr. Werfel said. “Based on the videos I saw, I wouldn’t be able to sleep at night if I was responsible for putting these people on the streets.”

‘Outstanding’ performances?

Mr. Werfel cited one test in which a paramedic failed to notice for more than 30 seconds that his patient had gone into cardiac arrest. The test, unbeknownst to Mr. Werfel, was taken by one of the District’s senior emergency medical services administrators.

The department’s medical director, Dr. James J. Augustine, who has served in the position since August, reviewed the same test with a Times reporter last month and termed it “perfect,” later describing it as a “textbook” response.

But Geoffrey T. Miller, associate director for the research and curriculum development division of prehospital and emergency health care at the University of Miami, said he would also have ordered remediation for the senior EMS administrator — whose identity he was unaware of when he viewed the test. He viewed the video last month in Baltimore while attending a national conference of the Journal of Emergency Medical Services.

“It may be textbook for them,” Mr. Miller said after he was told of Dr. Augustine’s conclusion. “I think you would find some medical directors around here who would have a different opinion.”

The problems revealed in the tests cut across the divisions normally associated with the fire department, which provides EMS through uniformed firefighters trained as paramedics and by single-role paramedics who have a different union, a different pay scale and different retirement fund from the uniformed fire service.

Four videotapes were selected for evaluation by The Times as a broad-based look at paramedics functioning at different levels within the agency. They included the senior EMS administrator’s test, an EMS field training officer’s test and a longtime single-role EMS provider’s test.

The fourth test was that of a firefighter-paramedic whose skills were called into question in December after he responded to an incident in Northeast involving Edward L. Givens. Family members say that hours before Mr. Givens died, a paramedic responding to a medical call at his house told Mr. Givens he was likely suffering from acid reflux.

“Based upon viewing the videotape, I would have serious concerns about him performing any medical practice,” said Graydon Lord, a licensed paramedic and former fire and EMS chief in Cherokee County, Ga. “I would recommend that the medical director make his determination as to whether this provider can safely practice medicine in the pre-hospital care environment,” added Mr. Lord, who serves as director of EMS policy for the National EMS Preparedness Initiative.

Three regional paramedic quality-assurance instructors with knowledge of the District’s protocols viewed all the videos obtained by The Times and discussed the results but asked not to be identified because their work brings them into contact with the D.C. fire department. The three agreed that while there are some competent paramedics on the job, the vast majority seemed deficient in their skills, with one terming more than half of the advanced life support providers “unsafe.”

First asked in December about the results of the tests, Dr. Augustine — who previously served as Chief Rubin’s medical director when the two worked in Atlanta — told The Times that he had reviewed 91 of the test videos and the paramedics had performed well.

“Less than a handful had an issue at all. A handful had small issues,” Dr. Augustine said. “I found their performances to be outstanding.”

During an interview last month, Dr. Augustine said only eight of the 175 paramedics who took the tests were found to have had any problems. He said some of the problems could be attributed to the fact that the paramedics were working alone in the simulation instead of in teams. But in most cases, the District deploys its paramedics on fire engines or on ambulances paired with lesser-trained emergency medical technicians.

Dr. Augustine also said the lab environment and the use of patient simulators were new to D.C. paramedics.

Steven T. Edwards, director of MFRI, where the testing took place, agreed that the mannequin used in the testing was “relatively new technology.” Dr. Augustine also said the paramedics found it difficult because the assessment required them to verbalize their actions during each of 10 critical interventions. But Mr. Edwards said that was not the case, pointing out that the mannequin records the paramedic’s interventions so they can react as they would at the scene of an emergency.

“The paramedic doesn’t stand up and say, ‘I’m going to administer epinephrine now’ or something like that,” he said.

Lowered expectations

The Times first reported details of the testing plan in February 2008 — days after the family of journalist David E. Rosenbaum dropped a lawsuit it had filed against the city, saying they were satisfied with the District’s progress in reforming its emergency medical services. Mr. Rosenbaum was beaten and robbed in his neighborhood in January 2006 and died two days later. An investigation found that a neglectful, botched emergency response contributed to Mr. Rosenbaum’s death.

After that incident, Mr. Fenty pledged in August 2006 as a candidate for the Democratic nomination for mayor to remove emergency medical services from the administration of the fire department.

“In this city, having a fire department and having EMS under it just has left EMS out of the priority line,” Mr. Fenty told The Times in 2006. Mr. Fenty said at the time that as a council member representing Ward 4, he co-sponsored legislation in 2005 to separate the agencies. He pointed out the Department of Motor Vehicles and the Child and Family Services Agency succeeded only after they were spun off from other city agencies.

But as mayor, he backtracked on the pledge. The city set up a task force as part of the settlement with the Rosenbaum family to examine ways to improve the city’s Fire and Emergency Medical Services Department. EMS was left under the fire department, but the task force recommended improvements to training and oversight.

An assessment of all the agency’s paramedics, however, was not among the recommendations.

Dr. Michael D. Williams, the department’s previous medical director who resigned in August, told The Times in February 2008 that he had expected the tests to reveal that some paramedics would need to be retrained, others would need to be reassigned to work as emergency medical technicians who have fewer responsibilities than paramedics, and that some would need to be fired.

“I expect there will be people that fail this process and that I will be saying, ‘You’re really not out there functioning as a paramedic, so we’re going to pull you out’ — which is going to make the operations chief nuts, but my obligation sort of trumps his on this one,” Dr. Williams told The Times. “I’ve really got to make sure that we don’t let someone out there that really isn’t functioning at that level.”

Mr. Edwards said the District “actually ought to be commended” for undergoing the testing — which he insisted should be termed an “assessment,” since no grades were given and no licenses or certifications were at stake. He said such assessments are useful to identify systemic problems and target training dollars.

“When you work to develop a training program, the first step is to perform an assessment,” he said.

Mr. Edwards said MFRI handed over the results of the tests to D.C. fire officials without evaluation or interpretation.

Dr. Augustine said there was no passing grade in the written tests and that the results were misleading, in part because D.C. paramedics were tested on practices and procedures that are in use in much of the country but in some cases are not part of the District’s protocols and in part because paramedics were not instructed to study.

But Dr. Williams, who declined to speak for this article, said last year that he had personally vetted the test questions and that while they were “challenging,” they covered things a paramedic should know. He said the test was part of an effort — required by the Rosenbaum task force — to bring the District’s standards in line with nationally recognized practices and procedures.

“Frankly, a paramedic should be a paramedic should be a paramedic. They should be interchangeable with minor variations in protocol. But the assessment skills that would tell you if you’re sick or not sick should be the same,” Dr. Williams said.

Mr. Werfel, asked what expectation should be associated with a working paramedic taking a national registry test, said: “One would expect they should pass it.” He said differences in protocols between jurisdictions did not explain the poor performance in the videos.

“The issues on these guys’ exams were not local issues, they were global issues,” he said. “The stuff I’m talking about is not protocol driven. The difference in protocols doesn’t explain the long delays in very basic patient care.”

A top priority

How much work has been done to fix the problems identified in the assessments is unclear. Meeting minutes obtained by The Times for several D.C. fire department executive staff meetings show that by June 9, 2008, it was declared that the “MFRI audit is complete.”

A notation in the July 14 minutes says the “paramedic remediation class is still in the planning stages.” The same notation is in place in the minutes for the Aug. 4 meeting.

But August — the same month Dr. Williams left the department — is the last reference in the minutes to a paramedic remediation class.

In a December interview, Chief Rubin told The Times that because of staffing shortages and budget constraints, the testing process was not complete and that about 75 paramedics still had to be sent to MFRI to take the test in coming months.

“And then what we’re really hoping to be able to do is to take everybody who can reasonably improve and — the ones that need to — and then make sure that they go through an improvement cycle,” he said.

The statement issued by Mr. Fenty and Chief Rubin said that “within a few short months” of the MFRI tests, “all paramedics have begun receiving specific focus area training, with more being planned.”

But the time frame — 13 months after the first test was taken — is again at odds with the expectations Dr. Williams laid out in the interview more than a year ago.

When asked in February 2008 if this would take weeks or months or years to complete, Dr. Williams said: “Months — and less than that. This is a top priority for the mayor; it’s a top priority for the fire and EMS chief; it’s a top priority for me to make sure that we identify deficiencies and we begin to address them as quickly as possible, be it individual or systemic.

“To say we’re excited is probably putting it mildly,” he said at the time.