A very comprehensive news report from the Boston Globe that highlights the many challenges across the country for beleaguered EMS agencies, regardless of provider type.
No highlights on this one - it's all an important read!
A PDF version of the story can be accessed below:
Boston Globe Report - Where were all the ambulances.pdf
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When a Winthrop toddler stopped breathing, where were all the ambulances?
A Globe investigation reveals a broken EMS system that has become dangerous, and in some cases deadly.
By Adam Piore, Globe Staff
December 5, 2024
https://www.bostonglobe.com/2024/12/05/metro/when-winthrop-toddler-stopped-breathing-where-were-all-ambulances/
About 15 minutes after her 2-year-old daughter went into cardiac arrest, Andrea Feeley realized an ambulance was not coming to save her.
Just before 10:30 a.m. that January morning, Feeley was kneeling in front of the couch trying to entice her curly-haired little girl, Yuna, to take a drink of Pedialyte when she suddenly went limp and stopped breathing. Yuna had been sent home from day care two days earlier with a low-grade fever, but until that morning Feeley had no reason to believe she was seriously ill.
Feeley’s son called 911. Within minutes, town firefighters converged on Feeley’s tidy, two-story clapboard home in Winthrop and took over chest compressions and CPR on the toddler. It was immediately clear she needed the kind of advanced life support that trained paramedics could provide.
“Better step up that ambulance,” Captain Dan Flynn radioed.
But there was a problem. Action Ambulance Service, the private company that provides ambulance service to Winthrop, did not have an ambulance available to respond to the call, the dispatcher said.
“Is she breathing yet?” Feeley kept asking. “Is she breathing?”
Finally, as the minutes ticked away, and no one showed up, Fire Chief Scott Wiley gathered up Yuna, still wearing her “CoComelon” pajamas, carried her outside to his Chevy Tahoe, and drove her to Mass. General. But it was too late. A team of doctors and a chaplain soon found Feeley sitting in a private waiting room and delivered the news: Yuna was dead.
What happened the morning of Yuna’s death was the result of a broken EMS system across Massachusetts that means there isn’t always an ambulance or ambulance staff immediately available when patients critically need care, a Globe investigation found.
When one city’s ambulances are tied up, as in Yuna’s case, other towns are supposed to provide ambulances to cover for them. But there is no central or regionalized system to track the location of
ambulances in real time, and no one evaluating whether the number of ambulances on the road is sufficient.
For ambulances that are in operation, chronic staffing shortages mean sometimes badly needed ambulances that are supposed to be in the field stay parked in garages, unused.
And when the ambulances are staffed, in some cases the same overworked EMTs and paramedics are sent out over and over again during long shifts that can result in serious mistakes, interviews and documents reviewed by the Globe suggest. Numerous ambulance staffers said that double and triple shifts are not uncommon.
The Globe identified three deaths, including two in Winthrop, that occurred in the months immediately preceding Yuna’s death in which paramedics were subsequently investigated by the state for negligence.
In at least two of those cases, exhaustion and burnout clearly played a role.
The Globe reviewed hundreds of pages of documents, including incident reports filed by ambulance companies with the state and follow-up investigations conducted by the Department of Public Health’s Office of Emergency Medical Services, the state agency charged with regulating them. The Globe also analyzed town-by-town ambulance response times, visited ambulance stations to speak with front-line workers, and conducted more than 50 interviews with industry experts, current and former EMTs and paramedics, CEOs, emergency medicine doctors, and others.
In response to questions from the Globe, Department of Public Health officials said serious incidents and complaints involving ambulances are up across the state.
“We know that some of these issues are related to the overarching health care landscape, which has become increasingly stressed,” the statement said. “There is a pressing need for more EMTs and paramedics to handle the increasing demand for emergency medical services.”
‘A poor patient outcome’
What happened at the home of Yuna Feeley provides a stark illustration of the potential consequences of this seriously overtaxed system.
On that January morning when Feeley’s son called 911, both of Action’s Winthrop ambulances were responding to other calls.
Like all but nine of the state’s 362 municipalities, Winthrop relies on help from neighboring towns through the state’s “mutual aid” system when demand for ambulances exceeds supply.
When Action’s dispatcher received Feeley’s son’s call, they immediately contacted two ambulance companies in neighboring towns and asked if they could help.
When those services said their ambulances were busy, the Winthrop dispatcher requested help through the Boston Area Mutual Aid Network, or BAMA, a communication hub for emergency responders in Boston and surrounding communities.
“The Winthrop & surrounding 911 systems were taxed, and unfortunately there was a poor patient outcome,” an Action Ambulance executive would later write.
As Wiley tore down the streets of Winthrop into East Boston and hurtled through the Sumner Tunnel at speeds reaching 85 miles an hour and headed toward Mass. General Hospital, two firefighters worked furiously in the back seat to keep Yuna alive. One gently gripped the underside of her jaw and pressed a ventilation bag over her mouth to keep the seal, slowly infusing oxygen into her lungs.
The other performed chest compressions. They stopped only once, pressing their backs against the SUV windows to avoid touching the little girl as a defibrillator delivered a jolt of electricity to her heart.
Had paramedics been with the child, they could have given her more advanced emergency care, experts told the Globe. They might have applied drugs such as epinephrine or used more advanced defibrillators with a better chance to shock her heart back into action.
They could have given her IV fluids to ensure her blood continued to reach her vital organs and supply them with enough nutrients and oxygen to keep them from failing.
Yuna’s official cause of death is listed as “necrotizing pneumonia in the setting of RSV and strep,” according to an autopsy report Feeley received from the state medical examiner’s office.
In the wake of Yuna’s death, the Department of Public Health promised a “thorough investigation.” The results, released in May after the Globe submitted a public record request, consist of a four page document, written by an executive with Action Ambulance, the company that runs EMS service in Winthrop, and reviewed and accepted without comment by the Department of Public Health.
Action Ambulance followed “all appropriate policies and procedures,” the executive concluded.
But for Feeley, her daughter’s death did not feel like the result of anything that resembled proper protocol.
After the hospital workers told her Yuna was dead, she was haunted by the feeling that something had gone irrevocably wrong.
“They asked us if we wanted to go in and say goodbye to her,” Feeley said. “So we did that. But I was not allowed to touch her. That was hard.”
Not enough ambulances or staff
The ambulance company best positioned to help Action the morning of Yuna’s death was Cataldo Ambulance, which has an outpost with two ambulances in nearby Revere.
But Cataldo, like many ambulance companies around the state, had been facing staffing shortages so severe its ambulances sometimes sit in garages because there’s no one available to staff them, said Dennis Cataldo, president and CEO of Cataldo.
“You can’t staff ambulances without people,” Cataldo, who is also president of the Massachusetts Ambulance Association, said.
The supply of ambulances in Massachusetts is determined in part by what each local market can support. While some towns run their own EMS services, about 80 percent of the state’s licensed ambulances are operated by private companies that bid for the right to serve each town’s population.
One notable exception is Boston, which runs a nationally recognized public EMS service through the city health department. It is fully unionized and receives city subsidies that account for more than 25 percent of its budget.
In most cases, however, the companies’ revenue depends on reimbursements pegged to Medicaid and Medicare rates, which have failed to keep up with rising costs, Cataldo said. That hampers the companies’ ability to staff their ambulances.
At the time of Yuna’s death, about 15 percent of Cataldo’s positions remained unfilled, about where staffing is today.
More lives lost
A review of state investigative documents suggests the staffing shortages have become dangerous. In the two years leading to Yuna’s passing, at least two people in Winthrop were declared dead while receiving treatment from Action Ambulance paramedics, according to state investigative documents contained in the Globe’s public records request.
In one of the cases, a paramedic on an ambulance was summoned to a marina not far from the Feeley home to treat a patient in cardiac arrest in 2022. She forgot a medicine bag in the ambulance, failed to
administer potentially life-saving medicine, did not shock the patient’s heart correctly, and misrepresented her actions to a state medical control doctor, the physician charged with exercising clinical oversight, whose permission is needed to cease resuscitative efforts.
As a result, the control officer prematurely signed off on her request to cease efforts to revive him.
In an interview with a state investigator, she said she had been “working a lot of hours” and wasn’t feeling well but “felt she had to stay on the shift because she was the only paramedic on duty.”
“I knew I should have gone home. . . . I think about this call every day since it happened,” she said.
She surrendered her license after Action accused her of “gross negligence.”
A few months later, in March 2023, another Winthrop paramedic pressured an inexperienced EMT to intubate a patient in cardiac arrest, using a technique the EMT was not legally qualified to perform.
“Just do it,” the paramedic told her, according to a complaint investigation report obtained by the Globe through a public records request. “I want to go to lunch.”
The paramedic then called a designated medical control doctor to seek permission to cease resuscitation efforts, reporting that the patient’s heart had stopped beating, when in fact there were still
signs of activity, and lied about the extent of the efforts made to revive him. State investigators later determined this resulted in a “failure to transport a treatable patient.” The state revoked the paramedic’s license until at least 2025.
In a third incident from 2023, an Action paramedic operating in Western Massachusetts misdiagnosed a patient suffering from sepsis and pneumonia and administered a series of medications that sent him into cardiac arrest, eventually causing him to die of anoxic brain injury, according to a state investigation.
Michael Woronka, president and chief executive of Action Ambulance Service, said the three deaths identified by the Globe reflect an “error rate” that compares favorably to that of his competitors, since his
company has tens of thousands of patient interactions a year. “If other services don’t have a similar error rate, then they’re not reporting them because everyone’s going to have an error rate,” Woronka said, adding that it was his company’s own “quality assurance systems” that initially identified and reported the incidents.
Cataldo, speaking in his role as president of the Massachusetts Ambulance Association, said such deaths are extremely rare.
The Globe was unable to determine whether the negligence cases and deaths it reviewed were outliers: The deaths were contained in a batch of documents obtained through public records requests submitted in January and February, but the state failed to provide all the requested documents, citing understaffing and a backlog of other requests.
There are no national standards for an acceptable error rate or any published data on clinical error rates, because most clinical errors are not reported to state regulatory agencies, and are instead handled internally by local agencies and medical directors, said Matt Zavadsky, past president of the national association of EMTs and a nationally recognized expert on EMS.
Action has been singled out by the state before. In 2017, the state issued the company two consecutive “provisional licenses,” the equivalent of putting the company on probation, citing a failure to properly store and account for controlled substances and a number of equipment code violations, among other problems. But the state later withdrew the provisional licenses as part of a legal settlement after Action sued for $10 million, claiming it had been denied an opportunity to defend itself. To make the case it had been unfairly targeted, Action documented a wide array of violations by its competitors — including an instance in which a competitor fielded an ambulance with passenger side floor boards that had rotted out, providing a view of the concrete passing beneath the vehicle.
Possible fixes
In the months leading up to Yuna’s death, there were ample warnings that the state’s EMS system was stressed to the breaking point. Six months prior to her death, the union representing Boston EMS, the largest municipal EMS system in New England, warned that staffing shortages had grown so severe that public safety was at risk. A spokeswoman for Boston EMS said the company has made significant progress in filling staffing shortages in recent months, thanks to an advertising campaign on city buses and federal grants that offer scholarships and helped fund recruitment efforts, among other things.
Just a month before Yuna’s death, the Board of the Metropolitan Boston Emergency Medical Services Council, an advisory group consisting of hospital medical directors, EMS coordinators, and first responders, signed a letter to Kate Walsh, secretary of health and human services about “the staffing crisis we face.” In a statement to the Globe, a spokesperson for the Executive Office of Health and Human Services acknowledged the shortage of EMTs and paramedics and said the agency had made investments and regulatory changes to address the issue. “We will continue to work with municipalities, ambulance providers and health care facilities on additional improvements to ensure residents receive ambulance service and high-quality medical care when they need it and prevent tragedies like this.”
Last year, the state allowed staffing of Advanced Life Support level ambulances with a single EMT and a first responder driver, rather than two certified EMTs. And it has invested nearly $60 million across fiscal years 2024 and 2025 in Medicaid reimbursement rates for EMTs.
But many say it’s not enough.
One way to address the problem may be through regionalization. Efforts to overhaul the state’s ambulance system have been hampered in part by a “culture of parochialism” that relies on town- and city based services, when a growing number of states, including California, Maryland, and North Carolina, have regionalized, county based services that are better able to track and manage limited resources, said Zavadsky, the EMS expert.
Smitty Pignatelli, a state representative from the Berkshires, has been lobbying state officials to implement policies that will make it easier for towns to make the politically unpopular decision to raise taxes to pay EMTs and paramedics more competitive wages and add more ambulances.
Back in Winthrop, Feeley is struggling to come to grips with Yuna’s death. She still sometimes slips into the present tense when talking about her little girl — about her hazel eyes, fair skin, and dirty-blond ringlets. About the astonishing level of joy she could derive from a plastic dinosaur.
“If an ambulance had come, could they have intubated her?” Feeley wonders. “Could they have given her something? What if there was something on the ambulance that they could have done?”
Wiley, Winthrop’s fire chief, is also haunted by what might have been.
“Maybe having an ambulance wouldn’t have made a difference, but it would’ve given her a better shot,” he said from behind his desk a few months after her death.
”We’re all parents. Some of us are grandparents. It’s devastating. It’s not supposed to happen. It’s a horrible, horrible thing.”
