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California Oversight of Paramedics Haphazard
A Mustang broadsided Kathy Schroeder's Hyundai sports coupe in a Palmdale intersection, knocking her unconscious. She woke up wedged against the console, covered with an oily film.
"I just remember my eyes and face burning," she said, "like bacon sizzling."
She recalled telling the Los Angeles County Fire Department rescuers at the scene, but said they didn't flush her eyes. After being rolled into a private ambulance, she told the attendants too. They didn't flush her eyes, either, explaining that it would get their floor wet, she said.
By the time the hospital did the flushing, the damage was done. Battery acid and other chemicals had burned her corneas, according to her subsequent lawsuit against her rescuers.
Even now, after five eye surgeries in five years, life on a good day is a blurry video. Unable to resume her job as an advocate for the disabled, Schroeder, now 47, received a $400,000 settlement from the ambulance company.
The people who regulate medical rescuers in Los Angeles County, however, heard nothing about this incident.
County policy requires fire and ambulance officials to report potentially serious medical lapses by paramedics and emergency medical technicians to regulators. But those officials saw no problem with Schroeder's care. Even after the 2004 settlement, neither rescue provider came forward.
It was not the only such case to escape regulatory scrutiny in recent years.
A Times investigation found that oversight of paramedics and EMTs in California is haphazard at best, with nothing to ensure that potentially problematic cases are reported and investigated, or that errant rescuers are held to account.
Countless lives have been spared and injuries relieved by the state's medical rescuers, often the frontline caregivers in a crisis. To many people, they are heroes. Their competence, often, is assumed.
But when things go wrong, The Times found, California is not set up to consistently weed out poor performers or dangerous patterns -- raising the risk of harm to unsuspecting patients.
With little clout, regulators essentially rely on rescue providers to report on themselves, making it nearly impossible to get a realistic picture of where the system is breaking down or how it is performing overall.
The bureaucracy is fragmented. In contrast to other populous states -- such as Texas, Massachusetts and New York -- California has no overarching agency to oversee the state's 15,000 paramedics and 70,000 EMTs.
Paramedics are licensed by and ultimately accountable to the state Emergency Medical Services Authority, which has limited enforcement powers. EMTs, who receive less training and whose duties are more limited, answer to any one of dozens of regional authorities.
"There's a lack of accountability," said Dr. David Persse, a former Los Angeles County regulator who left to become the Houston Fire Department's medical director, partly because the centralized oversight system in Texas was stronger. He cited that state's ability -- lacking in California -- to levy steep fines to bring rescue providers into line. "You got to have some teeth," he said.
An array of shortcomings
THE Times reviewed all regulatory actions taken against paramedics and EMTs in California from 2000 to 2006. It examined incident logs, patient complaints and assorted legal claims; it interviewed regulators, rescuers and patients. Among the findings:
* There is no coherent system for reporting problems or processing complaints that could lead to discipline.
Los Angeles County regulators, for instance, specifically require fire and ambulance officials to report suspected cases of gross negligence or substance abuse by paramedics and EMTs, but Sacramento and Orange counties have no similar policy.
Even when a policy exists, as in L.A. County, "the interpretation of what fits in there may be different from person to person," said Carol Meyer, director of the county's Emergency Medical Services Agency from 2003 until last week.
Without legal authority to penalize anyone for failing to report problems, state officials admit they are stymied. New state laws are needed "to address some of the shortfalls in reporting requirements, so we can get a better picture of what's happening out there in the field," said Dr. Cesar A. Aristeiguieta, director of the California Emergency Medical Services Authority.
For the public, there is no single, obvious place to go to register a complaint. Even when someone files a legal action, as in Schroeder's case, regulators are not necessarily alerted to malpractice awards or settlements.
* The numbers and types of disciplinary actions across regions are strikingly inconsistent.
In six years, the Orange County Emergency Services Agency, with about 2,500 EMTs, revoked two certificates and put one rescuer on probation. Sacramento County took no disciplinary action against its 1,500 EMTs -- not even putting anyone on probation.
But in tiny San Luis Obispo County, with about 550 EMTs, 48 were disciplined, including six suspensions and six revocations.
For its part, Los Angeles County takes pride in its oversight of its 15,000 EMTs and by far took the most disciplinary actions statewide. But the vast majority of these actions involve probation, which allows people to continue working under certain conditions. In six years, just one rescuer's certificate was revoked. Two were suspended.
Former County EMS director Meyer said probation is an effective tool, adding that almost no one disciplined that way has had subsequent problems. But she acknowledged that the regional disparities show the need for centralized certification or licensure of EMTs.
* Communication breakdowns repeatedly occur among regulators and even within fire departments.
EMTs in trouble in one jurisdiction can sometimes start with a clean slate in another. One technician was suspended by Kern County for allegedly impersonating a paramedic, then managed to work and renew her EMT credential in an adjacent jurisdiction.
Paramedics have been suspended or fired by fire departments for patient-care lapses without anyone telling state regulators, as required by law.
Within the city of Los Angeles Fire Department, officials failed to alert their own medical director to instances of alleged medical lapses resulting in death.
* When errant rescuers are identified, regulators don't always move fast enough to protect the public.
A San Francisco paramedic, placed on probation after being found negligent in caring for an elderly patient who died in 1996, was later accused of improperly treating two other elderly patients who died. The state finally revoked his license last year. By then he had left for Colorado, where he now works.
Two months ago he returned to the Golden State. The reason: to teach about caring for the elderly at a continuing education conference for rescuers. ("News to me," said Harvey Eisner, director of the conference, of the rescuer's record. He said he would look into it.)
An Imperial County paramedic was accused of fraud and incompetence in patient deaths in 1999 and 2001 before he lost his license in 2004. The final straw: He was caught repeatedly falsifying a car crash victim's vital signs. According to a state report, he told his supervisor that everyone does it.
Aristeiguieta said one reason the two cases took so long to resolve was that fire departments and regional agencies were slow to alert the state to the initial incidents. Since his arrival 18 months ago, he said, reporting has improved.
But there still "are instances when we learn of a case many months after the incident by reading a newspaper report," he said. "That's troubling."
'Holes in the system'
CLOSE monitoring of medical rescuers is crucial, experts say, because they have less training than many other medical professionals. Though paramedics often receive instructions from doctors or nurses by telephone while treating a patient, records show that they can make dangerous mistakes: administering the wrong drugs, ending resuscitation efforts prematurely or failing to transport seriously ill or injured patients.
Aristeiguieta, who sits on the Medical Board of California, said oversight of medical rescuers needs to be brought more in line with that of physicians and nurses. One example: Doctors who pay medical malpractice awards and settlements of more than $30,000 must be reported to state regulators. That requirement "doesn't exist for EMTs and paramedics," he said.
Problems with rescuers may or may not be conveyed to fire department or ambulance officials, who may or may not report them to regional regulators, who suffer no penalty if they don't pass them on to state officials for investigation.
"There are holes in the system," said Glenn Melnick, a USC healthcare researcher who has studied California's emergency system. "There's very likely big gaps in performance that we just don't know about."
A large part of the problem is the culture in which the emergency response system developed. It was essentially welded onto fire departments, which functioned primarily as public safety providers with a paramilitary tradition -- not as medical caregivers. Now, the bulk of what these departments do is medical response -- but their regulatory standards are still catching up with the rest of the medical professions.
California was a national leader in 1970, when it started its first paramedic program in the Los Angeles County Fire Department. The idea was to treat patients within minutes of their injuries, improving prospects for survival and recovery. The heroic exploits of the department's rescuers were quickly glamorized by the Jack Webb television drama "Emergency."
Other paramedic programs developed here and there, and the state EMS authority, created in 1981, did not begin regulating paramedics until the mid-1990s.
The network of EMTs evolved separately in the 1970s. But regulation of these medics, many of whom are firefighters, came to be scattered over more than 30 regional agencies. Sometimes the agencies oversee a single county, other times several. Further complicating matters, an even larger number of entities can issue EMT certificates, including some local fire departments.
Though rescuers are often viewed as interchangeable by the public, paramedics must receive 1,000 hours of training --10 times what most EMTs get. Unlike EMTs, who perform basic life support such as CPR and wound care, paramedics can administer drugs, do electrocardiograms and even intubate patients. The two types of rescuers often work in tandem.
Which type arrives after you call 911 varies. The ratio of paramedics to EMTs differs substantially by region. Dispatchers generally send paramedics to the cases deemed more critical, but both types of rescuers work for fire departments and ambulance companies.
Reform efforts have foundered
CALIFORNIA'S problems are not unique: To some extent, they are mirrored around the nation. A study by the National Academy of Sciences last year found that fragmented responsibility, poor data, uneven standards and lack of accountability made it nearly impossible to evaluate the care provided by rescue agencies.
"While most Americans assume that their communities are served by competent [emergency medical] services, the public has no idea whether this is true, and no way to know," the study found.
But California is further behind, in some ways, than anywhere else: It is the only state that does not have centralized licensing of EMTs.
Texas puts licensing and disciplinary responsibilities for paramedics and EMTs under one state agency. It offers the public a single, easy-to-access online complaint system. Names of disciplined rescuers and their offenses are posted on the Web, much as with doctors in California.
Fire departments and ambulance companies are closely monitored, said the Houston Fire Department's Persse.
He is required to tell the state about any departure from specific medical standards, and breaches of the rules can bring steep -- and highly effective -- fines.
Persse recalled a case in 2000 in which an investigation of a single EMT -- accused of stopping to grab a doughnut while transporting a stabbed child -- led the entire Houston department to be placed on probation. After state regulators found out that the medic's credential had lapsed, they threatened to impose tens of thousands of dollars in fines unless the department improved monitoring of medical care and tracking of credentials. The city hired eight people for the job.
Recent reform efforts in California have foundered. A bill to have the state EMS Authority license all EMTs was dropped last year, as firefighters pushed for separate legislation that would allow their own departments to take the lead in disciplining EMTs. A new version of the firefighters' bill is pending.
Separately, the state moved two years ago to tighten its scrutiny of paramedics, when a new law required fire and ambulance agencies to alert regulators whenever they suspended or fired paramedics for patient care lapses, substance abuse or criminal convictions. But many of the agencies said they were not told the law existed.
"I don't think that was on anybody's radar screen," said Meyer, the former Los Angeles County EMS Agency director.
'I'm not happy about it'
AT the Los Angeles Fire Department, 30 paramedics were suspended and three resigned pending disciplinary action in the last two years, according to a tally prepared for The Times. At least a third of those cases were related to patient care. Not one was reported to the state.
The city of Los Angeles is in some ways more diligent than most. At least it has a medical director, Dr. Marc Eckstein, to review possible problems in the field and report anything serious to county regulators.
In his office at Fire Department headquarters, Eckstein keeps his radio scanner humming. Sometimes he even rolls out on calls.
"In terms of knowing what's going on," he said, "I have the pulse."
Later, The Times provided him with a list of 19 claims for damages against department medics since 2000. Eighteen of them alleged that patients died because of negligence. Most of those claims were dropped or dismissed, but three resulted in tens of thousands of dollars in financial settlements.
Eckstein said he had never seen most of the cases, including the three that were settled. "I'm not happy about it," said Eckstein, who has no official standing in the department's chain of command. "You need to know what's going on in order to provide the best care."
One case he never reviewed or reported involved Armenui Agazaryan, a 48-year-old grandmother who emigrated from the Soviet Union in 1979.
It was approaching midnight when rescuers arrived in her Little Armenia neighborhood in Hollywood in the winter of 2000. Agazaryan had been vomiting. She struggled to breathe.
Anxious relatives wanted her rushed to the hospital. But the paramedics quickly concluded that she had the flu. "They told us ... in the U.S. you don't call 911 for a doctor," her son, Mike Agazaryan, recalled in an interview. "They said, 'Don't call for silly reasons.' "
"First of all, she was a U.S. citizen. But it shouldn't matter," he said. "She needed help."
The family was "very intimidated" by the firefighters in their uniforms and badges, he said. "We didn't want to be rude."
The rescuers left, he said. Armenui Agazaryan kept vomiting.
Ninety minutes later, the family dialed 911 again. A different paramedic unit rushed the woman to the hospital, where she was pronounced dead from acute pneumonia.
In the end, the city paid the family $150,000 to settle a lawsuit alleging gross negligence and discrimination. Contacted by The Times, two of the rescuers declined to comment. In court records, the city said that the care was appropriate and that the medics had advised calling 911 again if her condition worsened.
"She would be here today," her son said, "if they had taken her the first time."
The Fire Department prepared a confidential report on the incident at the request of the city attorney handling the family's claim, records and interviews indicate. But Eckstein said he never saw it.
Eckstein and his counterparts at other departments have another way to scout for possible problems: It's called quality assurance or improvement and often involves reviewing a sampling of cases from the field. But that process focuses largely on training and improving medical procedures, not investigating potential lapses that could lead to discipline.
California law essentially says paramedics and EMTs can be disciplined or denied credentials for such lapses as criminal convictions, gross negligence and failing to accurately document what occurred at a scene.
Most regulatory agencies are automatically alerted to criminal convictions by the state Department of Justice. That is the most consistent -- and by far the most frequent -- reason for disciplinary action against rescuers.
Less cut-and-dried problems related to patient care may go unnoticed entirely, or be deemed unworthy of investigation by rescue providers or regional regulators.
Consider the statistics in Los Angeles County, where rescuers respond to an estimated 600,000 calls a year.
In six years, just 250 unusual incidents (unrelated to criminal or background checks) were reported to regional regulators by any source, including patients, logs show. The number of formal investigations initiated during that time: six.
Whom to turn to for recourse?
SOMETIMES uncertain where to take a patient-care complaint, members of the public may resort, as the Agazaryans did, to legal action. Others may go to the very ambulance company or fire department that they blame for the problem in the first place.
Theresa Hankins, who manages a family-owned electronics store, took her grievance directly to the brass at the Santa Ana Fire Department.
"Dear Deputy Fire Chief," she wrote, referring to an incident two days earlier in which her husband had collapsed on the floor of the store, gasping for breath. "This is a formal complaint."
Hankins detailed how paramedics, after a "perfunctory" examination, concluded that Gene Hankins, then 47, was suffering an anxiety attack.
"I was then advised to 'take him home, get him a beer and let him rest,' " she wrote.
By her account, paramedics grudgingly performed an electrocardiogram, or EKG, deeming it inconclusive. They discouraged her from having him transported to a hospital, saying he would not be given medication or hooked to monitors but she would be charged for the ride, she wrote. She recalled them joking among themselves, heedless of the family's distress. "I had no intention of entrusting Gene's life to their dubious attentions," she wrote.
Instead, she drove him to the hospital, where he received emergency surgery for a heart attack, records show. He ultimately recovered.
"If I had trusted the diagnosis rendered by [the] Fire Department," Hankins wrote, "my husband, Gene Hankins, would most likely be dead."
Nearly a month later, Deputy Fire Chief Andy Money wrote back, saying a review determined that her husband's medical care was "within the scope of standardized treatment."
He said that Hankins' vital signs and EKG results were within normal limits and that transport to the hospital, though offered, was refused. Money apologized, however, for the "insensitive or abusive comments."
"The employee responsible for those remarks has been admonished accordingly," he wrote. With that, the case was closed.
"They didn't investigate anything," Theresa Hankins said. "They buried it."
A Santa Ana Fire Department spokesman referred questions about the incident to an assistant city attorney, who declined to comment, citing confidential medical and personnel issues. One of the rescuers also declined to comment. The others could not be reached.
The case was not reported to county regulators, who pressed Times reporters for details.
In the case of Schroeder, the car crash victim, a spokesman for the ambulance contractor involved said the firm also saw no need for review by regulators, despite the lawsuit.
"There was nothing in the patient care record to indicate that an incident report should have been filed," said Jason Sorrick of American Medical Response, declining to comment further. The ambulance attendants could not be reached.
Schroeder declined to discuss the settlement, whose details were contained in the court record. Antelope Valley Hospital, also accused by Schroeder of delaying proper care of her eyes, paid her a $250,000 settlement. Officials there declined to comment.
Although Schroeder also sued the Los Angeles County Fire Department, it paid no settlement, records show. The department's emergency medicine experts did not review what happened until two years after the crash -- in response to inquiries from risk management staffers who assess financial exposure.
"There's nothing here that indicates these guys were being poor paramedics," said Chief Deputy Gary Lockhart. The paramedics said she complained about an oily substance but not about burning in her eyes, he added.
Schroeder, who is awaiting her second cornea transplant, said she is not bitter about what happened.
She said she retains the utmost respect for paramedics in general and holds no malice toward those involved in her own care. "I don't think they're bad people," she said.
If anything is to come out of her case, she said, she hopes it is a realization that oversight of rescuers should be tightened so patients are better protected.
As it is, "I don't trust this system," she said.
*
Times staff writer Doug Smith and researcher John Jackson contributed to this report.
*
()
A fractured system
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Discipline of California's 85,000 emergency medical responders varies strikingly, both in number and severity, among the responsible local agencies, reflecting the lack of a comprehensive system for investigating and reporting misconduct. The selected counties include some of the state's largest agencies and some of the widest variation.
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Emergency medical technicians
Emergency medical technicians are certified and disciplined locally. These figures represent actions reported to the state.
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Paramedics
Paramedics are licensed by the state, but cases involving job-related misconduct can originate locally. These are the actions taken by the state agency based on complaints from the county agency, showing that such discipline is extremely rare.
* Figures for EMT'S are from 1999 to 2006; figures for paramedics are from 2000 to early 2007. Actions include probation, suspension and revocation of certificate or license. Numbers provided by the state can differ from those provided by the agency to The Times. Numbers of EMTs and paramedics are estimates provided by the agencies.
**Includes San Bernardino, Inyo and Mono counties.
Sources: California Emergency Medical Services Authority and the local agencies. Data analysis by Doug Smith
*
Making changes
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Several agencies began reevaluating their policies after The Times raised questions about inconsistent oversight:
Statewide
* The director of the California Emergency Medical Services Authority sent a notice in February reminding all fire departments, ambulance companies and regional regulators that they are required by law to report internal suspensions or firings of paramedics and EMTs related to such issues as patient care, substance abuse and criminal convictions.
* In Sacramento County, the Emergency Medical Services Agency is considering requiring ambulance companies and fire departments to alert it to specific problems that could merit investigation and discipline of paramedics and EMTs.
Los Angeles, city and county
* The city Fire Department, which had not been reporting problems with paramedics to regulators as required, approved new procedures to ensure that the law is followed.
* The county Fire Department ordered all complaints and legal claims involving patient care issues to be reviewed by the medical director, a physician.
* The county Emergency Medical Services Agency is considering more specific criteria on the types of incidents that rescue providers must report, such as certain types of patient deaths.
Copyright 2005 LexisNexis, a division of Reed Elsevier Inc. All rights reserved.
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