Mashpee Fire Department Emergency Response Vindicated

By: Brian Kehrl
Published: 02/18/11

Emergency medical responders from the Mashpee Fire Department were delayed only by circumstances out of their control when they reacted to an incident last September in which a woman died from choking, according to a state report released last Friday.

The investigation, by the state Office of Emergency Medical Services, was initiated after an unidentified citizen complained about the fire department’s response when 39-year-old Catherine E. Gill was choking on a marshmallow at a home on a dirt driveway off Jackbon Road.

It took almost 12 minutes from the time the 911 call was first placed for the alarm to be relayed from dispatchers at the Barnstable County Sheriff’s Office to the fire department and for the first responders to travel the 3.1 miles to Jackbon Road.

The response to the call has come under intense scrutiny, driven in large part by vocal complaints by Brent E. McFarland, Ms. Gill’s fiancé and the owner of the home off Jackbon Road.

Barnstable County Sheriff James E. Cummings has said the dispatcher who answered the call, Rhonda Colburn, did not do her job of providing Mr. McFarland with instructions for how to help Ms. Gill, a shortcoming noted in the report. Ms. Colburn was fired in December.

Mr. McFarland has also railed against the time it took the emergency medical responders to get to his house, asserting that they drove too slowly and did not find his house as quickly as they should have. He has blamed town officials for a confusing address and number at his home—even though his property does not border Jackbon Road, his home was assigned the address of 52 Jackbon Road—which he said led to delays in the arrival of the ambulance. The dirt road leading to his house has since been named Carter Lane.

The report closes the book on one chapter of the tragedy, but the string of investigations is not yet over. A spokesman for Suffolk District Attorney Daniel F. Conley said this week that he has opened an investigation into the case, on behalf of Cape and Islands District Attorney Michael O’Keefe.

“What we are doing is a death investigation to determine if there is criminal conduct on the part of a person or entity,” Erika M. Gully-Santiago, deputy press secretary for Mr. Conley, said this week.

She said Mr. O’Keefe’s office asked the Suffolk DA to conduct the investigation in order to avoid “any semblance of a conflict of interest.”

Ms. Gully-Santiago referred questions on the nature of that conflict of interest to Mr. O’Keefe’s office. “It is not uncommon for any district attorney’s office to refer a case to another district attorney’s office if they believe there is even the potential for a conflict of interest,” she said.

MFD Performance Cleared
The recent report largely exonerates the fire department and the computer systems the town uses to determine the location of homes. However, it does note that the EMTs had trouble locating the house. According to an interview with EMT-paramedic Eric Faulkner described in the report: “Faulkner said they arrived on the street of this incident and as they approached the house number to which they were dispatched, they drove slightly past a driveway and then saw a man on a porch frantically waving a flashlight toward the ambulance.”

“The GIS mapping data shows that this house is situated behind the first house to which the Mashpee FD crew went, where a man was waving a flashlight,” according to the report.

The office of emergency medical services, a branch of the state Department of Public Health, oversees EMS licensing and performance.

After reviewing dozens of records and interviewing the three paramedics and two basic emergency medical technicians who responded to the call, state investigators concluded that the arrival was delayed by the high winds and rain from the remnants of Hurricane Earl and the ambulance mistakenly stopping at the house next door, where a neighbor was madly waving a flashlight, intending to direct the first responders to Ms. Gill.

“The Department determined as a result of its investigation, that the allegation that the Mashpee FD took too long to respond to an incident in which a patient was experiencing an obstructed airway is not substantiated due to extenuating circumstances beyond the control of the EMTs responding to this call,” according to the six-page report. “Any extra time in the ambulance’s response due to these factors was unfortunate, but does not constitute any regulatory violation.”

Mashpee Fire Chief George W. Baker Jr. said the report confirms his understanding of the events that evening.

“The first thing is, it was a horrible incident. A young lady died. That is the fact of the matter. But our response time, as we have said all along, it was what it was. That’s how long it took our folks to get there. The [state] Department of Public Health gives confirmation that there was no wrongdoing,” Chief Baker said.

Chief Baker said the report is significant in that it represents the culmination of an independent, third-party review, a step that should clear the cloud hanging over the department as a result of the investigation being opened.

The investigation was widely reported in the news media.

“It is over and it is clear our folks did their job and did their job properly,” he said.

How They Got There
The report—which was conducted by a state EMS investigator, an EMT compliance coordinator, and the department’s EMS medical director—gives a detailed description of the series of events from Mr. McFarland’s 911 call at 1:46 AM on Saturday, September 4, to the paramedics taking Ms. Gill in an ambulance to Falmouth Hospital at 2:15 AM.

The ambulance arrived at the hospital at 2:34 AM; Ms. Gill was pronounced dead shortly thereafter.

According to interviews with the five EMTs and paramedics who responded to the call, the fire department received notice of the emergency about a minute after Mr. McFarland contacted the dispatcher.

About two minutes later, the ambulance, staffed by two paramedics and one basic EMT, left the fire department.

Another two and a half minutes later, a second vehicle, a pickup truck staffed by one paramedic and one EMT, left the fire department to serve as backup.

The ambulance arrived at the house next to Mr. McFarland’s, 3.1 miles from the fire station, six and a half minutes after leaving the station.

The timing of the response is outside the department’s standard of “seven minutes or less, 90 percent of the time.”

“Most communities set response times against a 90 percent fractal measure to allow for circumstances that will cause delay to EMS, such as weather, traffic, geography,” according to the report.

“In the circumstances of this call, considering the weather conditions, and the lack of identifying markers directing the ambulance crew to the accurate residence, the response time of the ambulance crew that responded to this incident was not unreasonable,” according to the report.

The first responders each recalled difficult driving conditions as a result of Hurricane Earl, which had devolved into a tropical storm and was directly over Cape Cod on the morning of September 4. Mr. Faulkner noted in his interview that weather conditions were “horrible.”

“He remembered the night being rainy and windy with very little visibility,” according to the report. “He stated the EMTs used caution en route to the scene because of the inclement weather. He said the crew knew the specific area of Mashpee to which they were responding.”

According to weather records reviewed by the state investigators, wind gusts of up to 36 miles per hour were recorded in the Mashpee area that morning, along with heavy rain.

After the ambulance drove just past the house, the EMTs noticed someone waving a flashlight, according to the report. They pulled into the dirt driveway, set the vehicle to idle, got out, and began to head toward the light. They soon realized, however, that the person with the flashlight was a neighbor attempting to direct the ambulance to Mr. McFarland’s residence, one house farther up the driveway, according to the report. After realizing their mistake, the first responders got back in the truck, drove it up to Mr. McFarland’s house and again disembarked.

The fire department pickup truck, which was dispatched more than two minutes after the ambulance, arrived as the first EMTs were preparing to enter the house.

According to the report, the EMTs found Ms. Gill lying limply on her back, with blue skin. She was experiencing “agonal respirations,” or shallow, inconsistent breaths that indicate a severe medical emergency and often the onset of death.

They immediately began treating Ms. Gill, in accordance with statewide protocols.

Mr. Faulkner used a scopic tool to look in Ms. Gill’s throat, and saw a white substance. With forceps he removed the object, later identified as a marshmallow. It first broke off in three or four pieces, before the full mass could be removed.

“Upon removal of the obstruction, the patient did not take a breath; the patient was suctioned and ventilated with a bag-valve mask,” according to the report.

As the EMTs performed cardiopulmonary resuscitation (CPR), Ms. Gill was brought out to the ambulance and intubated.