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| Jason Azo Brady Nov 13. 1974 - Aug. 25, 2014 |
MY BROTHERS MEDICAL HISTORY
Hypoparathyroidism........his body could not absorb calcium/magnesium from foods.
Metabolic Disorder........if K+,Ca, Mg got too low could have Grand Mal seizures.
Gout........both ankles/feet were inflamed and swollen
Autism.....He had a learning disability since childhood
Hyperlipodemia.......he lost 70 lbs after a diet plan was started.
Metabolic Disorder........if K+,Ca, Mg got too low could have Grand Mal seizures.
Gout........both ankles/feet were inflamed and swollen
Autism.....He had a learning disability since childhood
Hyperlipodemia.......he lost 70 lbs after a diet plan was started.
OTHER HISTORY
He was 39 years old and a gentle giant. He was very child-like and had a lack of understanding (impressionable). He was not good with personal hygiene. Previous visits to the hospital he was known for being helpless with the nurses and asked for help when it wasn't needed.
MEDICATIONS
Calcitriol.......prescribed vitamin with enzyme to help facilitate absorption
Lamictal.......prescribed anti-seizure
Allopurinol.........prescribed anti-gout
MagOX.........OTC magnesium supplement
Calcium Carbonate.........OTC supplement
Endomethycin........previously prescribed for gout flares PCP stopped
Lamictal.......prescribed anti-seizure
Allopurinol.........prescribed anti-gout
MagOX.........OTC magnesium supplement
Calcium Carbonate.........OTC supplement
Endomethycin........previously prescribed for gout flares PCP stopped
PAST HISTORY WITH AMBULANCE & HOSPITAL
I had to call 911 on 3 prior occasions. The previous call he had a severe gout flare. I arrived at the hospital to take him home. His nurse helped me get him into the car. He wasn't exactly clean, he never was good with personal hygiene and this gout flare made it even harder because he had a hard time being mobile. I engaged in conversation with her explaining the hard time he had been having. She gave me a heads up that she heard the medics talking about making a report to APS. She also said he had a reputation for not being clean and being helpless. She told me a nurse took it the wrong way when he asked her help him with the urinal. He had a pulled back muscle and he could barely move. He was the talk of healthcare personnel.......it was embarrassing to know he was talked about like that
Social worker called me to arrange an interview. He showed up and I explained to him the situation, My brother came to live with me set in his ways after our father died. No one had ever taught him the importance of hygiene. I tried but in the end he was not my child and I had children and a house to take care of. His room was a disaster area, I found out later he stashed food as if he thought he wouldn't have it. Our mom was horribly abusive and his weight had always been a thing she could hurt him with. I showed the social worker his room and he interviewed him. Afterwards he laughed and said the report he got couldn't be further from the truth. The case was unsubstantiated and closed. I believe this reputation played a role in what happened that night.
911 call....warning operator's voice is extremely loud...turn your volume down. At 2:43 he was trying to talk and he was TERRIFIED. He was WORSE when help arrived. IMAGINE what you heard being worse and there are 4 people just standing there wanting you to "control" the breathing and while in that state expecting you to get up and walk without assistance. They IGNORED this.
FIRST RESPONDERS/EMS ARRIVAL
Keep in mind we did not get the unredacted report until many months after, the county attorney denied access. Paulding Co. Fire Rescue arrived 5:11a.....vitals 5:13a.....Provider Impression: Respiratory Distress
BP 200/122...pulse 164...resp. rate 32...spO2 94%...skin DECREASE perfusion...cap refill 2 secs**respiratory rate was actually 48 per Dr. Lairet Metro's medical director...I also counted and got 48.
SEE COMMENTS AT BOTTOM FOR DETAILED AMBULANCE PCR. AS WITNESSED BY MYSELF AND MY ROOM-MATE THERE WERE 2 FIRST RESPONDERS + 1 LEAD PARAMEDICS Jason Woody/1 A-EMT Laura Stassfort.
SEE COMMENTS AT BOTTOM FOR DETAILED AMBULANCE PCR. AS WITNESSED BY MYSELF AND MY ROOM-MATE THERE WERE 2 FIRST RESPONDERS + 1 LEAD PARAMEDICS Jason Woody/1 A-EMT Laura Stassfort.
When Metro Atlanta Ambulance Service arrived I told the paramedics what had happened prior to their arrival and his history. I also told them he had not been ambulatory and I suspected his potassium was low. He was sitting in a tripod position on his bed. They started telling him to slow down his breathing but he was unable to. When two of them left to go get the stair chair I was able to get close to him. I saw his nose was pouring mucus and part of his bottom lip was blue.
I pointed that out to them. A few min later the stair chair was brought up. They told him he needed to get into the chair. My brother tried repeatedly but he couldn't as his limbs were useless at this point. I observed him trying to wipe his nose......it was bothering him. They continued to stand there and tell him slow down his breathing and get in the chair. He attempted again to get up......his arms and legs were really floppy........he was frustrated because he couldn't do it......they continued to STAND there.
After 20 min I got really irritated no one had yet to assist him so I yelled at them to HELP HIM! FINALLY Jason Woody and 1 first responder reached down to lift him under his arms. Then my brother's body went back (head back, feet pointed down, hands turned out). Both of them stepped back while lead medic said they couldn't do anything until it was over. It lasted for less than 10 sec then his body relaxed. He was unconscious and appeared lifeless. My room-mate said he didn't think he was breathing and asked if he was breathing. No answer. Woody checked his pulse at 2 locations twice.
Then he put his lower forearm over his face to feel if he was breathing. Woody stood up and whispered something to first responder. This was moment it clicked he was in serious trouble. I passed Laura Stassfort as she was bringing up a sheet to call my aunt back and the look on her face said it all. They looped the sheet under his arms to gain some leverage. There was 250lbs of dead weight and they were struggling so my room-mate jumped in to help them. On their way downstairs I heard a gurgling noise coming from him.
They proceeded to take him outside to the stretcher. I told them I would meet them at the hospital. As I was on the phone I went to wake up my husband and kids (they had school that morning) and began getting dressed to go up to the hospital. 15 min later I told my aunt I had to go until I noticed they were still in the driveway. I said to my aunt why are they still here.....I couldn't understand why they had not left yet. I walked to the driveway and through the back doors I saw him with a device on his chest doing compressions.
All four of them were in the back of the ambulance. Why wasn't one of them driving and on the way before then while the other two rode in the back. One first responder stayed behind so he could drive the rig. I arrived at the hospital 10 min later. They brought me to a waiting room . The doctor came in after awhile and said they did everything they could. I asked what happened....he didn't know. My husband came to the hospital and we went in to say our goodbyes. Went home and my room-mate asked hoping for a miracle he was ok. When we said no he said "Oh my God, they killed him!" This began our journey to get the records.
RECORDS
Went to Paulding Co Fire Rescue and E911 to get reports. Fire Rescue initially gave me redacted report and that I had to prove I was next of kin to get unredacted one. Once I got all the necessary proof (13+ documents) that I was next of kin the clerk gave me a redacted copy of the report. When I asked why she said the county attorney said no. We went to E911 and had the same problem. They gave me a redacted copy of CAD report and audio. I filed a complaint with Office of Civil Rights against both of them. OCR determined Fire Rescue infringed my rights but even with this letter county attorney still said no. OCR did not find any infringement on E911 as it was no a covered entity under HIPAA so I had to go to probate in order to be able to get the full audio of the 911 call /CAD report.
Went to Metro to get the PCR and discovered the incorrect information. I called them to find out how to get the EKG. When it was ready we came to pick it up. My aunt and I looked over it to find the 5:17 entry and it wasn't there. I asked the records lady where it was and she said she "couldn't magically produce something that doesn't exist" This confirmed what I had seen......no EKG was done initially as PCR states
Obtained death certificate and Wellstar Paulding ruled his death was due to complications of seizure disorder. No foul play was suspected and death in itself wasn't suspicious as to warrant autopsy. I begged the county coroner to do an autopsy and he decision was already made unless I had $4000 to pay for it. Cause of death should have been UNKNOWN since there was no autopsy or crystal ball to state otherwise. Er doctor and deputy coroner were going by what the PCR said which was incorrect and misleading.
Audio below demonstrates he did not have a seizure. He exhibited decerebrate posturing (which can happen as a result of hypoxia) then shortly after went into respiratory/cardiac arrest. He had some kind of event that caused his respiratory distress. Whatever it was it had absolutely nothing to do with a seizure. The one tell tale sign he did have was his trachea deviated to the far left. The tracheal shift can occur when there is edema (fluid), spontaneous pneumothorax (air between lung and pleural cavity), pulmonary embolism (he didn't fit the criteria since he in hypertensive crisis), cardiac tamponade.
Audio below demonstrates he did not have a seizure. He exhibited decerebrate posturing (which can happen as a result of hypoxia) then shortly after went into respiratory/cardiac arrest. He had some kind of event that caused his respiratory distress. Whatever it was it had absolutely nothing to do with a seizure. The one tell tale sign he did have was his trachea deviated to the far left. The tracheal shift can occur when there is edema (fluid), spontaneous pneumothorax (air between lung and pleural cavity), pulmonary embolism (he didn't fit the criteria since he in hypertensive crisis), cardiac tamponade.
BREAKDOWN OF PCR
911 call ......My nephew was having difficulty breathing. My niece was in a panic state as she told the operator she had not seen her brother (my nephew) in this condition prior. She was afraid.
PCR: Chief C/O: Cardiac Arrest ..It should have been Chief C/O: My brother is having difficulty breathing.
EMT ARRIVAL: 5:14 AM
EMT ASSESSMENT : 5:15 AM ………… A & O X 3, Tachypnea,Trachea Midline, Patent
Airway, Breath Sounds Diminished All Lung Fields, Respiratory Rate 30, Diaphoretic,PERIL.
EKG NSR (though none could be found by ambulance staff ).
5:17 AM ………………. Non Rebreather documented as placed . This could easily be seen by the two witnesses. IT WAS NOT DONE.
5:17 to 5:41 AM …………….. NOTHING............Note: The Lead EMT stated my nephew was on a stretcher and he had a seizure. He stated the obstacles: My nephew was a large person and there were stairs. The stretcher was outside the house. My nephew was carried outside wrapped in a sheet, after he was lifeless
5:41 AM ………NOW OUTSIDE AND ON THE STRETCHER……THE.LEAD EMT DOCUMENTS: PLACED ON MONITOR- NSR, Attempted IV access X3 unsuccessfully, PLACED ON 0XYGEN DURING 3RD IV ATTEMPT.
* If an initial EKG was done why wasn't he still being monitored and where is the EKG?
* Remember , his condition was "peril".
* If my nephew had a seizure why was it not documented per Protocol? The Type , How long it lasted, vital signs and oxygen Saturation
* He had no IV placed early on or the attempts would not have been necessary later.
* Hum, it was stated he was on a Non Rebreather at 5:17 AM....SO....why was he placed on
Oxygen with the 3 rd IV attempt?
Shall we continue:
5:44 AM……………………….RESPIRATORY ARREST
5:46 AM……………………….INTUBATION ATTEMPT X1 FAILED 2nd to trachea deviated excessilvely to the left,
2ND ATTEMPT SUCCESSFUL
5:46 AM………………………….CARDIAC ARREST........ASYSTOLE (No Heart Rate-Flat line),
CPR started, MEDS GIVEN IO (Intraosseus) via the leg.
* Why was it necessary for 2 First Responders and 2 EMTs to be in the back of the ambulance with my nephew?
* My nephew was very tall, weighed over 200 pounds, was lifeless. What could 4 people be doing in the back of the ambulance to assist him? There is limited space.
* Why wasn't one EMT driving to the hospital?
* Not that it mattered, at this point, because the EMTs could not recognize Decerebrate
Posturing before my nephew was removed from the the house.
* My nephew was wrapped in a sheet and carried by 5 ( 1 witness, 2 first responders and
2 EMTs ).
* He was already brain dead . His vital signs took a few to catch up.
*Nothing was done to assist my nephew during the 27 PERIL minutes +/- 3- 5 minutes to remove him from the house to the stretcher..
These are the written facts of the PCR and the observations of my niece and another witness.
** Were these EMTs never trained to remove a large patient, go up or down stairs, respond to a vehicle accident in which the car had gone down hill and the patient had to be brought
up hill (to the ambulance)?
Thank you ,
Mary Alice Kelly, RN (retired Critical Care RN )
PCR: Chief C/O: Cardiac Arrest ..It should have been Chief C/O: My brother is having difficulty breathing.
EMT ARRIVAL: 5:14 AM
EMT ASSESSMENT : 5:15 AM ………… A & O X 3, Tachypnea,Trachea Midline, Patent
Airway, Breath Sounds Diminished All Lung Fields, Respiratory Rate 30, Diaphoretic,PERIL.
EKG NSR (though none could be found by ambulance staff ).
5:17 AM ………………. Non Rebreather documented as placed . This could easily be seen by the two witnesses. IT WAS NOT DONE.
5:17 to 5:41 AM …………….. NOTHING............Note: The Lead EMT stated my nephew was on a stretcher and he had a seizure. He stated the obstacles: My nephew was a large person and there were stairs. The stretcher was outside the house. My nephew was carried outside wrapped in a sheet, after he was lifeless
5:41 AM ………NOW OUTSIDE AND ON THE STRETCHER……THE.LEAD EMT DOCUMENTS: PLACED ON MONITOR- NSR, Attempted IV access X3 unsuccessfully, PLACED ON 0XYGEN DURING 3RD IV ATTEMPT.
* If an initial EKG was done why wasn't he still being monitored and where is the EKG?
* Remember , his condition was "peril".
* If my nephew had a seizure why was it not documented per Protocol? The Type , How long it lasted, vital signs and oxygen Saturation
* He had no IV placed early on or the attempts would not have been necessary later.
* Hum, it was stated he was on a Non Rebreather at 5:17 AM....SO....why was he placed on
Oxygen with the 3 rd IV attempt?
Shall we continue:
5:44 AM……………………….RESPIRATORY ARREST
5:46 AM……………………….INTUBATION ATTEMPT X1 FAILED 2nd to trachea deviated excessilvely to the left,
2ND ATTEMPT SUCCESSFUL
5:46 AM………………………….CARDIAC ARREST........ASYSTOLE (No Heart Rate-Flat line),
CPR started, MEDS GIVEN IO (Intraosseus) via the leg.
* Why was it necessary for 2 First Responders and 2 EMTs to be in the back of the ambulance with my nephew?
* My nephew was very tall, weighed over 200 pounds, was lifeless. What could 4 people be doing in the back of the ambulance to assist him? There is limited space.
* Why wasn't one EMT driving to the hospital?
* Not that it mattered, at this point, because the EMTs could not recognize Decerebrate
Posturing before my nephew was removed from the the house.
* My nephew was wrapped in a sheet and carried by 5 ( 1 witness, 2 first responders and
2 EMTs ).
* He was already brain dead . His vital signs took a few to catch up.
*Nothing was done to assist my nephew during the 27 PERIL minutes +/- 3- 5 minutes to remove him from the house to the stretcher..
These are the written facts of the PCR and the observations of my niece and another witness.
** Were these EMTs never trained to remove a large patient, go up or down stairs, respond to a vehicle accident in which the car had gone down hill and the patient had to be brought
up hill (to the ambulance)?
Thank you ,
Mary Alice Kelly, RN (retired Critical Care RN )
AFTERMATH
MEETING WITH METRO ATLANTA AMBULANCE SERVICE
**Voiced my concerns with Metro........no response
**Filed complaint with Georgia Dept of Public Health........helped facilitate meeting with Metro
**At meeting with Lee Oliver VP of Operations/Dr. Julio Lairet Medical Director voiced definite concerns pertaining to the lack of documentation. We added that there was incorrect info as well. AS concerned with time on scene as well.
**They asked us what we wanted...........the truth
**Questions they asked were redirected by us using the Patient Care Report.
**Lee Oliver stated "if" it was a pulmonary embolism there would have nothing they could do anyways.....does that change lack of care?
**We continued to stress it wasn't about how he died......it was about lack of care under their paramedics/EMT
**Oliver was questioned about the time gap where nothing was documented.......he hesitated and said Mr. Woody stated my brother was combative to explain extended time on scene.
**Both were informed that was not what happened......that wasn't documented either.
**We assumed they heard 911 audio....they had not so we played redacted version.
**Dr. Lairet asked to hear it again and was visibly disturbed by what he heard.......this confirmed how serious it was
**They told us they would reinterview both EMT's..........requested followup meeting after interview......they agreed.
**Meeting lasted 2 hrs
**Never heard from them again
**Paramedic still has his job and license
The audio below is of Metro Atlanta Ambulance Service VP Lee Oliver and Medical Director Dr. Lairet. It was documented O2 was placed when it wasn't. You hear Dr. Lairet say more than once that when he interviewed the paramedic Jason Woody said he attempted to put O2 on my brother. After this meeting it was found in their investigation that NO EQUIPMENT was brought into the house. The entry was falsified so the medic LIED.
DEPT OF PUBLIC HEALTH
**I was contacted by region 3 EMS director EJ Dailey regarding my claim.
**Sent all the documentation to her and verified she got it all.
**Was informed complaint had merit and was transferred to Deputy EMS Director Ernie Doss.
**Meeting took place with ambulance service before DPH panel
**M. Doss sent me email with attached letter with decision.
**Recently requested any/all documentation relating to my complaint via Open Records Act......someone enlightened me I could request those though I was told I wasn't entitled to them
**I discovered that the Pete Quinones owner MAAS is Council Chairman of the EMS council that the regional director presides over. Lee Oliver is President of Board of Directors Office of EMS/council chairman of a different region. Both Pete Quinones/Lee Oliver and EMS deputy director Ernie Doss are members of the Office of EMS Advisory Council. Big conflict of interest here being since deputy director/regional director had shared connections with MAAS.
**I also discovered the first draft DPH letter....the one that never got sent to me....after I told Mr. Doss about the recorded audio of meeting. You could presume that he knew that audio could dispute the outcome of the first letter.....which said this medic followed protocol without error.
**Yet there are letters and emails regarding the remediation this medic received by a field training officer because he did NOT follow protocol.
**Jason Woody was entered into information database as following protocol without error....so basically DPH allowed MAAS medical director to handle corrective action instead of bringing action against him by the state.
**Sent all the documentation to her and verified she got it all.
**Was informed complaint had merit and was transferred to Deputy EMS Director Ernie Doss.
**Meeting took place with ambulance service before DPH panel
**M. Doss sent me email with attached letter with decision.
**Recently requested any/all documentation relating to my complaint via Open Records Act......someone enlightened me I could request those though I was told I wasn't entitled to them
**I discovered that the Pete Quinones owner MAAS is Council Chairman of the EMS council that the regional director presides over. Lee Oliver is President of Board of Directors Office of EMS/council chairman of a different region. Both Pete Quinones/Lee Oliver and EMS deputy director Ernie Doss are members of the Office of EMS Advisory Council. Big conflict of interest here being since deputy director/regional director had shared connections with MAAS.
**I also discovered the first draft DPH letter....the one that never got sent to me....after I told Mr. Doss about the recorded audio of meeting. You could presume that he knew that audio could dispute the outcome of the first letter.....which said this medic followed protocol without error.
**Yet there are letters and emails regarding the remediation this medic received by a field training officer because he did NOT follow protocol.
**Jason Woody was entered into information database as following protocol without error....so basically DPH allowed MAAS medical director to handle corrective action instead of bringing action against him by the state.
DETERMINATIONS
**According to this DPH letter Deputy director stated that MAAS Medical Director determined his protocols were not adhered to and took corrective action on his employee.
**However, Deputy EMS Director Doss determined none of its Dept's rules/regulations were violated.
**Mr. Doss never took my calls or responded to my emails either when I asked why and how they came to that decision. I was not invited to attend this meeting.
**DPH left MAAS to discipline their own employee without validating state protocol had been broken as well
**PLEASE EXPLAIN...Medical Director Dr. Lairet contributed to the development of the Ga Dept of Public Health Prehospital Assessment Protocols. The same protocols his employee violated. Wouldn't he go by the same protocols he was part of in the first place.
**Is there a minimum standard when it comes to state EMS protocol? That leaves the impression that it's ok to not follow what Dept Public Health has outlined in it's OWN guidelines
**I have contacted the commissioner for DPH Brenda Fitzgerald....waiting on a response....I have emailed every state agency I can find......the investigation needs to be reopened with impartial officials who don't pose a conflict of interest. And those who knowingly participated should have their positions evaluated.
**Gen Counsel Sidney Barrett emailed that case will be reopened and reevaluated by the EMS licensing section. I asked specifically who that was.. He didn't answer that question but stated that the head of the licensing division was doing it..I had to call office of EMS to find who it was...the same people who originally closed the case. Deputy Director and Director are in charge of licensing. According to him there is no one else.....there is the Health Protection Director but he wants no part in it. He stated that communication between myself and DPH must be strictly limited in scope, so as to avoid the appearance of impropriety.
I sent all the documentation to DPH Mr. Barrett via Priority Mail with signature confirmation. In an email he told me that Office of EMS cannot respond to the Attention letter I sent to every one of them. He mentioned in the email that they can't respond because the complaint was currently under review. I ask how can they review it when they don't have all the records. Earlier records I sent to them disappeared and were not included in my open records request.. He stumbled as he mistakenly addressed the lead medic as my brother. Complaint was closed the second time without any additional action
**Email from Attorney General Office requesting more information on my complaint. Being since I had submitted 2 (Fire Rescue/E911) and was working on the 3rd (DPH) I called to see if she could look at all of them as a whole. She stated she could. I spent better part of an day putting together information in separate emails as it was a massive amount of information. Her response was that since I did get the records they couldn't do anything. She couldn't do anything with DPH either because they are a CLIENT of theirs. First of all she knew I got the records as I told her......it was the lengths I had to go to get them where my issues was. And she also knew I had a complaint regarding DPH...told her that too and she did not indicate they were " A client of theirs" until AFTER I sent her everything I had. Nice Move as it turns out because General Counsel for DPH was previously Asst Attorney General and AG represents DPH so of course they can't do anything. In her email she stated that DPH was made aware of my complaint as if it applied to the current investigation. My complaint was about the way the investigation was handled the first time around before I did the open records request.
MY ATTENTION LETTER TO ALL INVOLVED Ga Dept Public Health Office of EMS and Metro Atlanta Ambulance Service VP/Medical director
Deputy Director Ernie Doss....Why was the original drafted resolution letter changed? It appeared to have been in response to the email I sent you when I told you I recorded the meeting with MAAS VP Lee Oliver/Medical Director Dr. Julio Lairet. Or was it because the case was going to be closed without proper investigation? Why didn't you follow up with Lee Oliver previous to drafting first resolution letter? You had to ask for a formal response because you did not get any indication on whether standard of care had been met or not. That shows OEMS was going to close the case without having the required response from Oliver on whether or not the allegation of breach of standard of care/documentation of care was substantiated. It obviously was since the medic required remediation with a field training officer in addition to passing a protocol test/rhythm strip test. That audio disputes the statement "Jason Woody followed the standard protocols without error and as approved by Medical Director Dr. Lairet". This leaves the appearance that corrective action was taken by ambulance service to avoid the conflict that the recorded meeting would show.
Deputy Director Ernie Doss...the simple fact you avoided responding to my email when I asked how you came to that decision speaks volumes. You forwarded an FYI to Director Robert Wages and Associate General Counsel Zain Farooqui but never responded back to me. That Is WHY I sent a second email. I went in depth with how prehospital protocols were specifically broken. Like Farooqui states "Why is there no violation of EMS rule here?" You had to look at the resolution letter to jog your memory. There was clear violation of EMS rule. You think it's odd "I'm inquiring after so long/perplexed by the timing." Ask yourself would you feel the same way if it happened to your family member and you didn't get answers. I am sure you are also aware that the PCR data standard was not met. Much like the rules pertaining to EMS personnel there is a PCR data standard that requires specific accurate honest information as it becomes part of the patients permanent medical record. Georgia signed a letter of intent to support the NEMSIS data standard and GEMSIS was developed from that standard. The EMS-IMS status dated May 1, 2015 is incorrect as it says Jason Woody followed Ambulance Service Medical Director protocols without error.
DPH Regional Director -3 EJ Dailey....You "did not find abnormalities in the assessment or treatment modalities in the narrative as stated by Jason Woody." That is because the PCR was "sugar coated" with false/misleading/omitted data. You told me my complaint had merit when you called me to let me know you were passing it to Ernie Doss. When I finally did get the entire EKG report from Metro I emailed Doss and called him...he said he didn't need it. Why...when it would have verified that the first EKG documented didn't exist and the entire run of the cardiac activity previous that resulted in a cardiac arrest. He didn't need the audio of the meeting with MAAS either. I also sent him the unredacted 911 audio...you can actually hear his "respiratory distress " worsen while I was still on the phone with 911. You were the only one who seemed concerned and that was reflected in your email to CEO Pete Quinones. You knew my complaint had merit and it's not your fault that your superiors were not up to the task.
Associate General Counsel Zain Farooqui you stated "There is a common misunderstanding that the dept sets the medical standard for medics to follow and that there are set out in your regulations".... Yes while the state sets the standards laid out in the Code, Rules, and Regulations..those standards were guided by the Dept public Health Prehospital guidelines**(Dr. Lairet was a contributor to the development of those guidelines). Your Dept does in fact have its own rules/regulations. There is a National Standard and each state sets its own requirements using the National Standard/Georgia Standard as a model. Georgia Rules do not deviate far from the National Standard just as EMS companies protocols do not deviate far from the State Standard. A guideline I.e. prehospital guidelines is exactly that...a guide for minimum rules be set. This applies not only to duties in the field..it also applies to licensure. The quality of prehospital care is assured through licensure and approved medical protocols must be followed.
**Reference p.2 Authority The authority for implementing these guidelines for care of pre-hospital patients is found in state law OCGA 31-11-60.1 (b) and (c), OCGA 31-11-50 (b), and the Rules of the Department of Public Health Chapter 511-9-2. It is the responsibility of each medic to be familiar with the laws, rules and regulations, and guidelines and adhere to them. Even an order by a physician does not justify procedures not in accordance with laws, rules and regulations.
Office EMS Director Robert Wages......you were right when you said that "no amount of attempted clarification would help." I knew Office of EMS let Jason Woody slide in regard to Dept rules/sate rule and regulations. You need to take a good hard look at what is going on in Office of EMS. You are the Director and your Deputy Director Ernie Doss did NOT investigate properly. You didn't either since Mr. Doss lack of attention/action reflects on you as his superior. The case was going to be closed before having the required documentation by MAAS. Not finding Jason Woody liable in failing to abide by the state data standard requirements and by failing to act sets a dangerous precedent for future complaints filed. How many other complaints were not investigated....or forgotten about perhaps? Did anyone do any REAL investigative work? Is anyone truly held up to the high standards/ethics of Dept of Public Health.
Office EMS Compliance Officer Dwight Strickland.... "Jason Brady had been ill and bedridden for 3 days prior to 911 call." This has absolutely no bearing on the complaint. His ACUTE respiratory symptoms began just prior to 911 call. You stated "I am in agreement this medic followed protocol and that there have been no violations of OEMS rules 511-9-2 or OCGA 31-11".....Refer to packet with Region 3 director's acknowledgement letter along with these rules. You can not justify lack of patient care and paramedic responsibility based on his condition previous to the sudden onset of respiratory distress in addition to dangerous vital signs. It is CLEAR that in this case no one actually cared about what happened to my brother. You only cared about how you could "help each other out" by being dismissive to the merit of this complaint.
OEMS operating report "The purpose of EMS regulation is to assure public safety, uniform standard of care, Georgia's new rules and regulations strengthen the ability to insure that all of Georgia's citizens receive medically appropriate prehospital care from qualified and licensed EMS providers. "Effective regulation begins at a local level through Regional EMS offices which are coordinated in concert with state policies", "The ultimate goals of EMS regulation is the safeguarding of patients/communities" "Additionally, EMS rules/regulations must be enforced statewide on a uniform basis."
Lee Oliver VP of operation MAAS.... It took DPH involvement BEFORE you made any attempt to contact me or address my complaint. At meeting you and Dr. Lairet voiced definite concerns pertaining to the lack of documentation. We added that there was incorrect data also. You expressed concerns with extended time on scene as well. We were asked what we wanted and our response was "The TRUTH". Questions you asked us was redirected by us using the Patient Care Report. You asked us what we thought happened. We don't know since coroner decided his death wasn't suspicious enough to warrant autopsy even after I expressed EMS screwed up. I didn't have $4000 or a crystal ball to tell me what the exact mechanisms of death was. While I don't know HOW he died....I do KNOW that MAAS failed to provide standard of care consistent with Dept/Ga rules and MAAS own code of ethics, procedure, policies, and protocol.
The comment was made that "if it was a massive pulmonary embolism there wouldn't have been anything they could have done"...That is NOT the point and PE does not ALWAYS cause death...it can if intervention is not taken. Just ask Dianna Bolick, she survived PE despite the negligent care she received by same ambulance service and lucky for her she lived to tell about it. Justification doesn't change the lack of care. We continued to stress it wasn't about how he died, it was about the lack of care under their medics. A possibility of death doesn't negate the duty to provide quality standard of care. We questioned them about the time gap when nothing was documented......Lee Oliver hesitated before he said that Mr. Woody said my brother was combative to explain extended time on scene. That doesn't answer the question explaining the time gap with no treatment. Both of them were informed that was not the truth. Mr. Woody needed an excuse but he must have forgot that the supposed "combativeness" was NOT documented on either reports. I'm actually surprised he wasn't combative being since he couldn't breathe.
His limbs were useless and floppy presumably because his extremities were beginning to clamp down to compensate to the lack of oxygen. The only mention to barriers of care was he became unconscious --THAT was because he wasn't moved prior to becoming unconscious as there was no urgency to the severity of his condition. Delayed on scene due to large patient and multiple stairs. He was 6'2" 260 lbs ….were they not trained to manuever stairs? Come on! He wasn't stuck down a steep rocky ravine....he was sitting on his bed in tripod position trying to comply while 4 people just stood there. We asked if they heard the 911 audio, they had not so we played it for them (redacted version). They were visibly disturbed and asked to hear it several more times. That was when they realized how downplayed his condition was according to the PCR. Dr. Lairet agreed that he was in severe respiratory distress and should have been a load and go. You stated they would reinterview both medics and agreed to a followup meeting. We never heard from you again. The meeting was 2 hrs, 10 min (we have the audio).
Fire Rescue/E911/Other Conflicts
MAAS owner Pete Quinones serves as Council chairman to region 3 EMS and he also serves on EMSAC alongside Lee Oliver and Ernie Doss. There is an established rapport between Office of EMS and Metro. Dr. Lairet didn't see the need for further action.....Of course not because that would put his role as medical director under question. Medical Director is legally responsible for all clinical/patient care aspects of its operation. The prehospital medical care provided by medics is considered an extension of the medical director's license. It was OEMS job to make that decision, not take recommendation by medical director of the company that the complaint was filed against.
Lee Oliver serves as Council chairman to Region 5 EMS. He has served region 5 for over 20 years. I wonder how many complaints were not properly investigated. Office of EMS cannot efficiently handle complaints when there is clear conflicts of interest. How can the "Investigator" investigate when the company that the complaint is filed against has such a close business relationship together. There "is no one else who can" as DPH General Counsel Sidney Barrett said. When you conduct an investigation like this it leaves the appearance of "Impropriety".
Another conflict presented from the Paulding County Attorney's office when I tried to get the fire rescue report and 911 CAD/audio. We wanted to compare the vitals on the reports and have a copy of the 911 audio. The only info I had from fire rescue that night was the pulse ox I witnessed and I asked what his BP was. My aunt and I initially went to fire station who was dispatched and spoke with the chief. He told me I had to go to Fire station in Hiram to obtain records. Unbeknownst to us the County attorney's office got a phone call from Fire Rescue warning them I was asking questions. We arrived at station and filled out the HIPAA form/records request. It was redacted so all the info I was looking for was blacked out. The secretary informed me I had to prove I was legal next of kin in order to obtain an unredacted copy. We returned with all my documentation....only this time the secretary said County Attorney said I wasn't entitled. I asked who their attorney was and she refused to answer. I had find out on my own. I emailed all of them to find out why I was denied access. Attorney who replied said I had to show I was a legally authorized agent. He CC these emails to the administrative secretary Marie Turner at fire rescue. I asked him to specify what that meant. **Refer to OCR letter w/ attached emails
I had the same problem with E911....One can assume they got an email/call from attorney advising them as well. Silence confirmed that when I made a comment saying "SO I guess the County Attorney alerted you"I got a redacted CAD report and audio. I was told by the open records officer that according to the Open Records Act a sibling is not entitled. It only goes as far as spouse; if no spouse then parents; if no living parents then adult children. Most people have one of the above but in my case the Act wasn't specific enough. An attorney told me that even though it does not specifically state a SIBLING is entitled that I was IN FACT his LEGAL next of kin since he had no spouse/children and both our parents were deceased. I am on the death certificate as being next of kin...I handled final disposition of his remains.
I filed a complaint with Office of Civil Rights and explained I was denied access even though I produced every single document proving I was entitled. OCR sent me a letter stating that if County Fire Rescue denied me access to my brother's medical record when I provided documentation with my request verifying my involvement in his healthcare that that reflected a violation of 45 C.F.R 164.524 …We went back to Fire rescue with the OCR letter. Before I had the chance to ask for the forms the secretary said county attorney still said no. I was forced to go to Probate Court to get Letters of Administration. Why is it that the attorney who represents County was so making it nearly impossible for me to obtain the rescue report. Three reasons I suspect.
1. The fire rescue report vitals and assessment showed his vitals were significantly worse than ambulance vitals. Since Fire Rescue was doing their vitals when Metro showed up they didn't feel the need to do a set yet. I did not see Metro do any vitals inside the house. I assume they were going to 1st set of vitals once they got him in the ambulance then a 2nd set before transferring care to hospital. Fire rescue BP indicated Hypertensive Crisis (that possibly became a Hypertensive Emergency) Pulse indicated Tachycardia, RR indicated Tachypnea, Pulse Ox 94% considered hypoxic with decreased skin perfusion. I added comments to the narrative on report.
2. In my research I found that an attorney in the firm Talley, Richardson, & Cable that represents Paulding County is a member of the Paulding County Chamber of Commerce along with Devan Seabaugh MAAS Vp of Administration. Upon further digging I found that Devan Seabaugh AND the attorney who denied me access to fire rescue/911 were BOTH on the Wellstar Foundation Board of Trustees and Board of Directors. I am sure this crossed his desk as one of the tasks performed by his staff is open records requests. Word got around Metro what my complaints were.
3. Paulding County attorney's office essentially ran the clock out on me as long as they possibly could until I was financially able to obtain Probate Letters. They unlawfully prevented me from obtaining the records necessary to validate his actual condition as documented by fire rescue and 911 audio/CAD. I obtained unredacted records in Late April 2015.
I recently found out that the paramedic was also a full time Paulding Fire employee...a Sgt
3. Paulding County attorney's office essentially ran the clock out on me as long as they possibly could until I was financially able to obtain Probate Letters. They unlawfully prevented me from obtaining the records necessary to validate his actual condition as documented by fire rescue and 911 audio/CAD. I obtained unredacted records in Late April 2015.
I recently found out that the paramedic was also a full time Paulding Fire employee...a Sgt
I posted a timeline in the comments below.
According to DPH policy there are 3 different areas where rules/regulations are cited
Ga Rules & Regulations Subject 290-5-30 Licensure of Ground Ambulance
5. All emergency medical services personnel shall comply with appropriate policies, protocols, requirements, and standards of local medical director for that service, or the policies, protocols, requirements, and standards provided by the regional medical director for those services not having a medical director, provided that such policies are not in conflict with these Rules and Regulations or other state statutes. It is documented that medic did not adhere to MAAS protocol, policy, & procedures.
Ambulance providers shall not misrepresent or falsify any information on forms filed with the department or completed as a result of any ambulance response. PCR reflects both.
290-5-30-.16 Disciplinary Action Against Emergency Medical Technicians.
(1) The department may refuse to issue a certificate to an applicant or may take disciplinary action including revocation or suspension of a certificate issued to an emergency medical technician, after notice and an opportunity for hearing pursuant to the Georgia Administrative Procedure Act O.C.G.A. Chapter 50-13, as amended, if the department finds such applicant or such emergency medical technician has committed any of the following acts:
(a) Deliberate misrepresentation or falsification of information on the application or any other document connected with an emergency medical service;
(b) Professional or mental incompetency;
(c) Violation of any department rule or regulation under O.C.G.A. Chapter 31-11, as amended;
(d) Failure to adhere to the protocols established by the medical director, or gross deviation from a physician's instructions which are consistent with quality emergency care;
(e) Mistreatment or abandonment of a patient;
(m) Violating a statue, rule or regulation of the state of Georgia, any other state, the department, the United States, or any other lawful licensing authority, which statute, rule or regulation relates to or in part regulates emergency medical services, when the certificate holder knows or should know that such action is violative of such statute, rule or regulation, or violating any lawful order of the department;
(n) Any act or omission which is indicative of bad moral character or untrustworthiness;
(o) Any gross deviation from the minimal standards of acceptable and prevailing care required of an emergency medical technician; or. These rules were just repealed a few weeks after my open records request from DPH. https://dph.georgia.gov/sites/dph.georgia.gov/files/3415_001.pdf
REVISED RULES.......511-9-2-.07
1. Failure to comply with any of the provisions of O.C.G.A. Chapter 31-11, DHR Chapter 290-5-30 of the Rules and Regulations for Emergency Medical Services, or policies established by the OEMS;
13. Intentionally falsifies a patient record, or any other document required by Georgia Code, these Rules and Regulations, and/or OEMS Policies;
21. Violates any rule or standard that would jeopardize the health or safety of a patient or that has a potential negative affect on the health or safety of a patient, including mistreatment and/or abandonment of a patient;
31. Violating any statute, Rules and Regulations, or Policy of the state of Georgia, any other state, the United States, or any other lawful licensing authority, which statute, rule or regulation, or policy relates to or in part relates to or regulates emergency medical services, when the license holder knows or should know that such action is in violation of such statute, Rule or Regulation, or Policy; or
f. All emergency medical services personnel shall comply with
appropriate policies, protocols, requirements, and standards of the
ambulance service medical director for that service or the policies,
protocols, requirements, and standards provided for in subsection
(b) of this Code section.
g. Conduct which would otherwise constitute a violation of
subsection (f) of this Code section shall not be such a violation if
such conduct was carried out by any emergency medical services
personnel pursuant to an order from a physician, the ambulance
service medical director for such person, or the protocol of that
ambulance service as approved by the ambulance service medical
director for such person.
GA CODE 31-11-81
(1) "Emergency condition" means any medical condition of a recent
onset and severity, including but not limited to severe pain that
would lead a prudent layperson, possessing an average knowledge of
medicine and health, to believe that his or her condition,
sickness, or injury is of such a nature that failure to obtain
immediate medical care could result in:
A. Placing the patient's health in serious jeopardy;
B. Serious impairment to bodily functions; or
C. Serious dysfunction of any bodily organ or part.
GA CODE 31-11-82
(a) Once a person with an emergency condition presents himself or
herself to an emergency medical provider for emergency services,
that person shall be evaluated by medical personnel. This evaluation
may include diagnostic testing to assess the extent of the
condition, sickness, or injury if such testing is appropriate to
stabilize the patient's condition. For purposes of this Code
section, the term "emergency medical provider" includes without
limitation an emergency services provider.
