Justice for Jason Brady. No accountability when he died in MetroAtlanta Ambulance Srv care

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Aug 25, 2014 my brother, Jason died in the hands of people who were supposed to help him. Just before 5am that morning I found him in the bathroom struggling to get water. He began coughing then hyperventilating. He had no prior cardiac or respiratory history. He had a metabolic disorder, autism and for months up til this night severe gout. He could not walk or bear weight at all. He crawled as it was the only way he could get around.

His breathing worsened while I was on the phone with 911 (48 bpm) he was sweating profusely. He made it back to his bed and sat there in a tripod position. Fire rescue arrived within 10 min and did an assessment. His BP was 200/122, resp rate 32, pulse 164, spo2 94%, decreased perfusion of skin, diminished breath sounds bilaterally in all fields. The ambulance arrived while they were doing vitals. They brought no equipment into the house......just the stretcher left outside at the bottom of the steps.

For the next 20 min I stood there as he was told to "try to slow down his breathing" and to get up into the stair chair fire rescue had brought up. I watched him helplessly try to comply but he simply wasn't able to. My brother did not have good hygiene and in addition to his heavy sweating it appeared no one wanted to touch him to assist him into the chair. My roommate stood there beside me as I yelled at them to help him.

A few moments after they had him under his arms his body slammed back....my first thought was he was having a seizure. After a couple secs I realized this was different. His body was locked straight as a board with his head back, feet pointed down, arms straight, hands fisted and turned out. The lead medic who had control of the scene stepped back and said he couldnt do anything til after it was over. Once it stopped there was kind of a what in the hell just happened moment where no one moved...just stood there looking at him.

I was stunned as I looked at his chest...it seemed so big to me. My roommate asked if he was breathing and said he didnt think he was breathing. After he said that lead medic knelt down checked his pulse at neck then wrist and used his forearm to feel for breathing. He stood quickly and whispered to one Fire rescue....this was the moment the realization hit he was in trouble. He knelt back down and checked pulse a second time as his partner went to go get a sheet.

At this point I went to go downstairs to call my aunt back....I passed her as she came up with the sheet. The look of sheer fear. I was standing in the kitchen when they got my brother to the landing of the split level stairs. They stopped and realized another sheet was needed as it was difficult to carry him being as tall and big as he was (6'2" 250 lbs) and he was slippery. I could hear him making a gurgling noise....his eyes were open but he was unconscious.

Once they got him outside and to the stretcher I came back inside to get my husband up and kids up for school. I was completely unaware how serious his condition was. After I got dressed about 15-20 min later I stepped out on the porch while I was on the phone with my aunt and both fire rescue and ambulance were still there. I walked down there confused and saw movement through the front of ambulance. I came around to the back and my heart sank as I saw something doing chest compressions. All 4 of them were in the back. 3 failed IV attempts, first attempt intubation failed due to far left tracheal shift and its size. It took 5 min from the time his heart stopped before he was successfully intubated and CPR began.

I followed right after they left to transport him to the hospital. I was brought to a waiting room which was directly across from the room where he was. I prayed harder than I had ever prayed in my life. The curtain was partly open and I could tell they were still doing CPR. Shortly after the doctor came in and told me he was sorry, they did everything they could. A part of me died in that room. I called my husband to come up there. I couldnt go in that room where he was alone.

Later that afternoon my aunt came to my house. We talked...cried...she tried to comfort me. I was still unaware that the ambulance crew screwed up. Later that night my roommate came in from work and asked about Jason....hoping maybe a miracle happened. We told him no and as he began to cry he said they killed him. My aunt was a cardiac care CCU RN (retired) and started asking questions about what he meant then asked me a series of questions about everything that happened.

We went to fire rescue and spoke with a lieutenant who directed us to where to go get the rescue report. Initially the only issue was I didn't have documentation proving next of kin so I got redacted versions. Came back with numerous papers including death certificate and was told no. County attorney got involved when I questioned why. I couldnt obtain unredacted audio or CAD from 911 either. I found out much later that the lead medic was moonlighting with the ambulance company (he was a paramedic field supervisor and his fulltime job was with the fire dept (he was sergeant and had been there for better part of a decade).

The next day went to ambulance service and got the PCR. I voiced what happened to the lady at the front desk. I began reading the PCR and found that it was falsely documented. The PCR reflected a different version of what happened. Unbeknownst to me at the time the PCR got flagged by their quality control software the main problem being he forgot to get the receiving physicians signature on tube placement and it was a mess. It was not left with the hospital....it was faxed 3 hours later No one at this point in time would even call me back to address my complaint. I tried multiple times to get a meeting with someone. Not until I filed a complaint with DPH (nov that year).

Had a meeting with ambulance service 6 months after his death...they kept throwing out possibilities saying well if it was a PE he would have died anyways. They were informed exactly what happened. This prompted another investigation into the paramedic. I didnt see any of that documentation until earlier this year when DPH sent it to me hoping I would just go away. Paramedic did not follow protocol including scene management, universal patient care protocol.

No EKG was done, no oxygen, no IV...nothing until AFTER he crashed. He was in severe respiratory distress....medic lied and documented treatment was given. Obtained EKG that validated it was only done once AFTER..I could prove the PCR was false based on conflicting statements with all the documents and audio from the medical director himself. He seemed really confused when we told him O2 was not on him at any time inside the house. Total on scene time was 46 min.

DPH allowed the service to handle it themselves instead of validating that DPH policy AND GA code had been violated as well. Open records is extremely revealing when they think you are not looking. Conflicts of interests among other vested interests prevented my complaint and others to not be handled properly. They looked the other way and all the while there is a serious problem here. Training is deficient and there is no accountability if EMS makes a mistake.

It is happening with other companies too. Funny how many complaints don't get investigated when the owners sit on the council and/or hold high positions on EMS advisory council.  All people involved including Office EMS and Metro Atlanta Ambulance service had a rapport together for years.  The problem is so bad in Cobb County that there is a backdoor process with Cobb Fire to handle complaints from Cobb Fire EMS employees who have an issue with Metro employees.  These complaints never made it to the state.  Others have died.  The complaints consist of patient care complaints, delayed response times, delayed on scene time, not bringing equipment they are required to have, etc.  As zoned 911 provider they must meet strict criteria.....but they don't.

There needs to be accountability sanctions for DPH personnel violations.  There also needs to be a review board with community members not employed by EMS system for accountability of staff.  DPH region 3 allowed MAAS complaints to slide.   I haven't gotten anywhere with anyone on a state level so I am asking my state senators to do something.  Silence is a pretty good indication that no one wants to hear it.  EMS who break the law AND DPH employees who sweep it under the rug need to be held accountable!!

The investigation was not handled properly.  It was going to be closed without having the required documentation to determine if standard of care had been met or not.  Originally they were going to say that medic followed protocol without error.  That is until I put out there that I had audio of the meeting I had with Metro.  DPH say that no dept rule or GA code had been broken.  Despite Metro's medical director stating in a final outcome letter that his medic did not adhere to his protocols (which is a violation) DPH decided to not validate.

During the second investigation it became clear through open records request that the Deputy director had no intention on doing anything.  According to these emails "He made his decision" prior to receiving the investigative records from Metro Ambulance Service.  Falsifying a patient record is illegal in the state of Ga.  DPH's second outcome letter stated "errors" occurred and was quite condescending. 

EMS personnel have a DUTY TO ACT.  Along with that duty is STANDARD OF CARE.  When that standard of care is not met then there is a BREACH OF DUTY.  Standard of care is Defined as the level of care at which the average, prudent provider in a given community would practice. Ethical responsibilities include:

Treat all patients with dignity and respect without respect to factors such as race, gender or creed

Maintain knowledge and skill competencies as an EMT/Paramedic.

Exercise honesty and integrity when documenting.

Advocate for the patient's best interest at all times, even off-duty.

 

 

 



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