It started with a fever, the kind that makes any parent of an infant shudder with anxiety, but usually passes with just a few tears. Ashley Leveillee's body was hot to the touch on July 13, 1996, alarming her parents so much that they called their doctor, who told them to give her Tylenol and put her to bed. They tucked her in hoping that the fever would be gone by daylight.
Peter Greeno, a policeman in Sutton, 40 miles southwest of Boston, got the call at 9:19 p.m. Medical assist. Child had stopped breathing. When he heard the address, he let out a groan. The house was on a cul-de-sac in a corner on the other side of town. Sirens blaring, Greeno slalomed through the back roads to get to Route 146, and followed the highway south just over the border of the neighboring town of Uxbridge. He took the exit for Lackey Dam Road, crossed the bridge onto McGuire Road, and pulled up to the Leveillee's house on Lakeview Circle. Thirteen minutes, start to finish.
Two Uxbridge officers had beaten him there. Greeno saw one of them, Brian McDonald, on the floor holding an oxygen mask over an infant. Ashley was hot and pale as McDonald swabbed her down to lower her fever. She was breathing, but just barely. After another Sutton police officer arrived, Greeno told Ashley's parents the ambulance would be there soon, since it had been dispatched from the neighboring town of Millbury shortly after he was.
So they waited. The cops. The parents. The infant girl. Another Sutton police officer, Wallace Smith, arrived. As police grew increasingly frustrated, knowing every second was critical to 10-month-old Ashley, they overheard the police dispatcher giving the ambulance driver directions over the radio. Greeno, waiting on the front lawn, breathed a sigh of relief as he heard the siren approaching Â— only to hear it fade again into the distance. He says he got on the radio to guide the driver in, and finally Â— 16 minutes and 24 seconds after it had been dispatched, and 22 minutes after Bob Leveillee had called 9-1-1 Â— the ambulance screamed into the driveway.
In an e-mail Greeno wrote that night to his chief, he complained about the incident and the history of slow response times in Sutton. But there would be problems worse than just the long delay in this case, an all-but-unreported incident that raises questions about the reliability of American Medical Response (AMR), which responds to the most calls of any ambulance company in Massachusetts Â— and the state agency that's supposed to make sure an ambulance shows up at your house when you need one. The EMTs, police say, took their time walking up the driveway. Even more time passed before Ashley was brought back to AMR's ambulance. That's where the unthinkable occurred: The lead paramedic, Jim Harper, discovered he had forgotten the key to the drug box Â— the box that held the medicine that could save Ashley's brain.
Ashley Leveillee's eyes are blue and beautiful, and they follow visitors intently across the room where six years ago she lay gasping for her life. She looks like any healthy, albeit small, child until you see the rickety legs that stick out from her plaid jumper. For years, she's weighed less than 25 pounds. A quadriplegic, she can't share in the afternoon Popsicle her sister, Renée, is having. Ashley gets most of her food, a mixture of formula and baby food, injected directly into her stomach through a tube. She loves watching the Food Network, but the most she can have is a touch of chocolate. She'll start vomiting if given anything more.
“She's dependent on us for all of her needs, but she's fully aware,” says her mother, Kathy Leveillee, who gauges what Ashley wants by watching her hand and eye movements. “She doesn't miss a trick. She gets things in a way that no other seven-year-old would get them.”
The Leveillees can't say anything about how their daughter got this way. They sued AMR, and their $10.2 million settlement, the largest known personal injury settlement paid by an ambulance company in Massachusetts, includes a provision keeping their identity confidential and barring them from discussing the case. They talk only after being assured their names had been dug out of public documents. Even if they wanted to, they couldn't tell you about the night they watched their baby Â— who had recently started walking and using simple words like “da-da” Â— turn white and jerk back and forth like a wound-up spring. They can't describe their feelings as they watched minutes tick away waiting for the ambulance. And they have no words to express their indignation at a company that almost got away with it all.
If it weren't for a last-minute review from one lawyer Â— the fourth in three years to have the case on his desk Â— the Leveillees would have been left with nothing, trying to improve Ashley's limited quality of life on the earnings from their pizza restaurant. That lawyer, Marc Breakstone, took advantage of a clause in the confidentiality agreement allowing him to report the basic information of the case to Massachusetts Lawyers Weekly. The legal-industry newspaper then posed a simple question: If doctors are required to report medical errors to state regulators, why aren't ambulance companies? “Every person who uses an ambulance service or one day may have to rely on one should ask why that hole exists,” says the newspaper's spokesman, Aubrey Haznar. The story spurred the Office of Emergency Medical Services (OEMS) to investigate the five-year-old incident and draft new mandatory reporting regulations expected to be passed next month.
But just because OEMS fought for new regulations doesn't mean it was able to satisfy the Leveillees. The report the agency eventually released raises more questions than it answers. American Medical Response was absolved of responsibility, and the paramedic, who still volunteers as an EMT today, got barely a slap Â— a “letter of clinical deficiencies” Â— the second strongest of three warnings the state can issue. In fact, a review of the documents OEMS used in writing its report shows that the department went out of its way to exonerate the company, while failing to hammer it for inconsistencies in the accounts. Some parts of the investigation are laughable. To examine why the ambulance took so long, for example, the state simply typed the starting and ending addresses into the Web sites MSN and MapQuest, getting wildly disparate travel times ranging from 13 to 49 minutes.
Ultimately, the report focuses on three questions: Did the ambulance get lost? Did forgetting the key delay Ashley's medication? Did EMTs falsify information, thereby hiding their mistakes? In all three cases, the state's answer was the same: We don't know.
Febrile seizures occur in only a small number of children Â— about 2 to 5 percent. As far as doctors know, the seizures are a firestorm in the brain caused by a metabolism increased by fever. Most times, they're over in a few minutes. Occasionally, though, some children experience severe and prolonged seizures that cause all the muscles in their bodies to stiffen and their arms and legs to jerk violently. The chest muscles seize up and prevent normal breathing; the resulting interruption in the oxygen supply can quickly cause permanent brain damage, as can the seizures themselves.
Jim Harper knew this as he pushed past the officers into the Leveillees' house, listened to Ashley's chest, and affixed an oxygen reader to her toe. The gauge told him she was hypoxic, meaning her breaths were too shallow to give her body enough oxygen. He had to control the seizures Â— and that meant giving her Valium, the only seizure medication the ambulance carried in its drug box.
Harper and his assistant, Tony Worster, carried the unconscious Ashley to the ambulance, applying ice packs to her body to reduce her fever. Seeing no obvious veins for an IV, Harper determined that the only way to administer the Valium was through a rare and risky procedure in which a needle about the size of a cocktail stirrer is inserted directly into the shinbone of a small child.
According to his deposition, Harper called St. Vincent Hospital in Worcester for permission to begin the procedure before leaving the house. Worster held a mask with a squeezable bag to Ashley's face, trying to force oxygen through her clenched jaws, while Harper stuck the needle into her tibia. Taping the catheter in place, he attached the line for the Valium.
That's about when Harper felt a knot in his stomach. He'd reached into his pocket for the key to the cabinet that stored the drug box Â— and came up empty. He considered breaking into the cabinet but decided it would take too long. Instead, he yelled to Worster to get in and drive, so they could meet another ambulance that would bring them the key.
It was 9:50 p.m. Ten more minutes had passed since they had arrived, minutes in which Ashley had been deprived of enough oxygen to satisfy the demands of her brain tissue. More minutes passed before the ambulance met up with the intercept truck and Harper attached the Valium to the IV. Before they arrived at St. Vincent, Harper gave Ashley three doses of Valium, while he and Worster also tried to open her jaw to insert the tubing that would allow oxygen directly into her trachea. Only after the third dose, he reported, did she begin to relax.
When the ambulance pulled into St. Vincent at 10:11 p.m., Ashley was rushed off for more powerful seizure medication, which finally allowed doctors to insert an airway. She had gone without sufficient oxygen for almost an hour Â— far longer than a brain taxed by seizures can handle. While it's impossible to know for sure, experts speculate that a hypoxic brain can last up to 30 minutes without some permanent brain damage.
Harper's supervisor, Brian Cox, also was at the hospital. But he never asked Harper to complete an incident report to be investigated by the company, and the trip report Harper did file makes no mention of any difficulty in finding the house, the forgotten key, or even that another ambulance intercepted his.
AMR took no action against Harper, who later left the company because of rules that prohibited employees from having beards. Nor did AMR report the incident to the state. It wasn't required to. Current regulations call for reporting by regional, quasi-governmental EMS councils, which monitor such services. But the companies don't have to report to the councils, which is why OEMS heard about the case only when Massachusetts Lawyers Weekly called.
“Often, they don't know about these events because ambulance services are not reporting them to the region,” says Louise Goyette, director of the OEMS for the state Department of Public Health. “But it's extremely unusual for an incident of this magnitude not to be reported.” Because the newspaper didn't report the name of the company, the town in which the incident occurred, or the name of the family, OEMS asked the regional councils to scour their logbooks. The answer came back from Central Massachusetts Emergency Medical Systems: American Medical Response.
This was not the first time AMR had stood accused of lax service. The largest ambulance company in the country, it was started in Massachusetts in 1992 when Paul Verrochi bought up four private ambulance companies with holdings in Delaware, Connecticut, and California. A Cohasset businessman, Verrochi, AMR's then-chairman, made his money by consolidating companies in the cleaning and building maintenance industries. After going public in only six months, AMR became a darling of the financial industry. Forbes named it one of the top 100 best small companies in 1994. The next year, AMR was commended for its quick response to the Oklahoma City bombing, where it was the first company on the scene. By the time of its first acquisitions in Massachusetts in 1995, AMR had a presence in 21 states, with 1,400 ambulances. Over the next few years, it gobbled up other ambulance companies, including Worcester-Himmer/ASA, which served Sutton and other towns around Worcester. The biggest change came in 1997 when Verrochi sold AMR to Laidlaw, a Canadian transportation company that owned MedTrans, merging the companies into one monster operation. AMR was suddenly controlling 60 percent of private ambulance vehicles in Massachusetts. “The concentration of ambulance services in one provider,” said a state study at the time, “requires vigilance, and the public should be aware of this trend.”
But dark clouds were already looming. As AMR expanded across Massachusetts, reports came in from other states Â— Georgia, Colorado, California Â— that the company was lagging on 9-1-1 response times.
In Connecticut, a 1999 investigation by the Hartford Courant found that response times for ambulance companies in the state had risen steadily for eight years, and negligence claims had doubled. It singled out American Medical Response. The newspaper suggested that AMR was busy sending its ambulances out on the routine, but lucrative, calls to transport patients between hospitals, nursing homes, and other sites, while 9-1-1 service was getting the shaft. At the same time, AMR was consolidating service for several towns in one station, increasing the odds that paramedics would be unfamiliar with the towns they were serving and ambulance drivers would get lost or delayed. That year, an antitrust suit brought by the Connecticut attorney general alleged that because AMR had such a huge chunk of the market, it could raise prices while the quality of service declined. The settlement forced AMR to divest 30 licenses and sell 20 ambulances to its competitors, while shedding 40 percent of its turf in Hartford.
In Massachusetts, only isolated problems with AMR have surfaced. Some towns have dropped the service over concerns with response times or increased fees. Only 23 cities and towns now use AMR for emergencies, down from 40 in 2000. OEMS has received 51 complaints about the company in six years. That number amounts to 1 in every 7 the state receives, which speaks well of a company that's transporting one-third of all the patients in the state. In almost every case, the company was found innocent of wrongdoing, receiving a comparatively slight 15 citations in eight cases. Two AMR paramedics have had their licenses suspended, one for 21 days, after a woman showing signs of shock died when the paramedics failed to provide her with oxygen.
Since OEMS doesn't keep a record of ambulance response times, there is no way of knowing how AMR compares to other services in the state. Of the several dozen civil cases filed against the company in Massachusetts, a few of the allegations give pause. Orlando Taylor Jr., who was shot inside a nightclub in Springfield, allegedly waited 45 minutes for AMR to arrive. AMR claimed it took only 11 minutes; the case is still pending. When Joyce Pilicy fainted at her Waltham home in 1997 and her husband called 9-1-1, both AMR operators were allegedly on personal calls. After a dispatcher broke through on the radio, the ambulance got lost on the way to the house. Pilicy sustained brain damage and memory loss. That case was settled.
“No system of people providing care to other people can deliver that without imperfection,” says Kevin Prendergast, a vice president at AMR-Northeast. “We transport 4,000 ambulance patients a week. You can criticize any organization if their numbers are that big.” Prendergast says AMR also has improved the way it reports incidents. “The policies we have require individuals to report to their supervisors and on up the management chain any incident that is a significant deviation from standard treatment protocol.” He also says the company has strict controls on signing narcotics keys in and out.
OEMS, meanwhile, praises the company as being one of the best at self-reporting of incidents. But, then, OEMS doesn't know what's not being reported. In the Leveillee investigation, the state agency ruled out a sanction against AMR, explaining that the company has undergone “such a significant restructuring that it is a substantially different entity today.”
The leap to exonerate AMR is only one of several questionable decisions the state made.
Route 146 is about as straight a highway as exists in this mill town. Had investigators taken the time to drive the route police say they gave Harper and Worster that night back in 1996, they would have found that a car can make the run in 12 1/2 minutes, even traveling the speed limit; presumably, an ambulance with lights on and sirens blaring could chop several minutes off that. Investigators say they didn't drive the route because there were different accounts of which roads were taken. Even taking the most circuitous route possible, a Boston magazine run took 13 1/2 minutes, less than AMR's time of 16 minutes, 24 seconds.
More troubling than the dispute over whether the ambulance got lost is the state's contention that forgetting the narcotics key didn't necessarily delay Ashley's medication. Under careful review, however, the sequence of events just doesn't add up. In Harper's own deposition, he admits there was a delay of about 5 minutes. But the state report practically twists itself into knots to reach its conclusion that there was insufficient evidence to prove this.
In the deposition, Harper says he's sure he placed the IV line in Ashley at the house and discovered that the drug box key was missing before he left there. According to two sources Â— Harper's run report and the regional radio systems log Â— the ambulance left the house at 9:50 p.m. The time listed on the trip report for the first dose of Valium is 9:51 Â— an impossibility, since the trip to the intercept point, seven miles away, would have taken at least 7, if not 8, minutes. Yet rather than home in on this discrepancy, the OEMS report doesn't even mention when the ambulance left the house, seeming to take for granted that the Valium was delivered at the time that Harper says it was.
Instead, the state report constructs a scenario under which Harper was busy en route trying to establish an airway, which it says was a necessary prerequisite before he got the order for the Valium. But records show he had already received the order for the Valium only a minute after the order for the IV, which the state report says he inserted when he was still at the house. The other possibility raised by the report is that Harper placed the IV en route, which is what he told investigators in his interview. If that happened, however, and the intercept occurred at 9:51, that would still leave 20 minutes before the ambulance arrived at St. Vincent at 10:11 Â— a 9-mile trip on major highways. One plausible explanation is that Harper placed the IV at the house, received the order for the Valium a minute later, then was delayed in giving it as time ticked away.
Pinned down in his deposition, Harper admitted that the time given for the first dose of Valium “can't be correct.” He also admitted that the second dose is listed as having been given before the first one possibly could have been. But he offered little explanation for the lapse, other than that he was upset and not thinking clearly when he wrote the report.
That explanation hardly holds water, considering he went back to the report at the station that night and added details about the difficulty of the call, while mentioning nothing about the intercept. OEMS says it is “not uncommon to write or add to the trip report after leaving the hospital.” Other EMS companies disagree. “That's a legal record and should not be altered in any way, shape, or form,” says Stan Portman, president of Action Ambulance, a private company north of Boston. “I can't imagine why someone would do that.”
The OEMS report does cite Harper for omitting the information about the key and the intercepting ambulance, and finds that the “trip report also contained inaccuracies, such as, most notably, incorrect time of first administration of Valium.” But it fails to elaborate on the discrepancy or follow the inaccuracies to the likely conclusion that there was a delay in medication.
OEMS director Goyette says the investigation was hampered by an inability to prove allegations against the paramedics or find any policy lapses by the company five years after the incident. “It was very difficult to make a finding on the ambulance service,” she says. “You can't speculate on where we would have been had we been doing this contemporaneously.” But her department's report never addresses the discrepancies in the timing of the IV and the doses of Valium.
Every house on Lakeview Circle, it seems, has a large wooden playset in the backyard. Ashley Leveillee watches her younger sister, five-year-old Renée, tumble in the soft light that filters down after a morning rain. Flipping upside down to expose her pink leotard, Renée supposes what would happen if she fell on her head. “Then we'd have to call the emergency,” she says, grinning above tortoiseshell glasses. Six years ago, there was an emergency, and her parents did call for help. But help was slow in coming, and, today, instead of playing alongside her sister, Ashley sits in her mother's arms, her head propped up to watch.
“She's going to achieve a lot,” says Kathy Leveillee. “If she needs us to take care of her, we'll happily do that. And if she finds a way to express herself to strangers, I can't see her ever not doing what is normal.” Her husband hangs his arms over the crossbar while watching Renée. “I just wish she could talk,” he says. “I wish she could tell us when she is hungry, when she's thirsty, when she's tired. Now, you have to figure out what she wants. You know you're right because she motions with her eyes or smiles.”
The family can only wonder if a different ambulance company arriving at their door that night might have led to a different outcome. “They brought this case to get answers and ensure that this wouldn't befall another family,” says Breakstone, their lawyer. They may never get those answers, but the regulations to be voted on next month may at least help others. The regulations would require an ambulance company to report serious incidents within five days, and they might never have been proposed if it weren't for this case. “I have no doubt the status quo would have continued, but for the reporting of this tragedy,” says Breakstone. “The unfortunate reality is that OEMS was shamed into action.”
Source URL: http://www.bostonmagazine.com/2006/05/emergency/