Description of Event or Problem · 1
STRETCHER FAILURE PREVENTING THE PATIENT FROM BEING LOADED INTO THE AMBULANCE IN A TIMELY MANNER, THUS DELAYING NEEDED CARE AND DELAYING GETTING ENROUTE TO THE ER, CONTRIBUTING TO THE PATIENT'S EVENTUAL DEATH. THE PATIENT BECAME ILL AT THE PX STORE, AND 911 WAS CALLED AT 11:41 AM. THE PATIENT SAT IN A WHEELCHAIR AT THE REGISTERS NEAR THE SOUTH ENTRANCE AND WAITED FOR THE AMBULANCE (THE AMBULANCE WAS STATIONED LESS THAN 2.5 MILES FROM THE PX). A TWO-PERSON AMBULANCE CREW (MEDIC 5) WAS SENT TO THE STORE. THE (B)(6) 911 DISPATCHER NEVER TOLD THE STORE PERSONNEL TO HAVE A FLAGGER OUTSIDE (THEY WERE TOLD INSTEAD TO HAVE SOMEONE WAITING FOR THE MEDICS WHEN THEY ARRIVED TO SHOW THEM WHERE TO GO, AND THE STORE DID THIS), BUT THE (B)(6) DISPATCHER TOLD MEDIC 5 THAT THERE WOULD BE A FLAGGER. IN ADDITION, AS EMS RADIO RECORDINGS AND THE PX VIDEO SHOW, THE MEDICS DIDN'T KNOW WHERE TO GO AND ENDED UP GOING TO WRONG ENTRANCES (DESPITE BEING TOLD EXACTLY WHERE TO GO BY THE DISPATCHER), WAITING AT A DISTANCE IN THE PARKING LOT, SPEEDING BY THE PROPER ENTRANCE AND MISSING IT (DESPITE A STORE EMPLOYEE CHASING AFTER THE AMBULANCE AND PEOPLE YELLING AT IT TO STOP), ENTERING THE WRONG ENTRANCE AND WANDERING THROUGH THE STORE, AND DECIDING TO GO TO A COMPLETELY DIFFERENT LOCATION (THE COMMISSARY) WITHOUT PERMISSION FROM THE DISPATCHER, ETC. THIS ALL CONTRIBUTED TO THE AMBULANCE TAKING A VERY LONG TIME TO FINALLY GET TO THE PATIENT. WHEN MEDIC 5 GOT TO THE PATIENT, THE PATIENT WAS STILL CONSCIOUS AND IN THE WHEELCHAIR. THE MEDICS CALLED FOR AMBULANCE TO ASSIST THEM AS WELL AS AN MP. THIS SECOND AMBULANCE (MEDIC 1, A TWO PERSON CREW) WAS DISPATCHED TO THE SCENE. THE MEDICS PLACED THE PATIENT ON THE STRETCHER AND WHEELED HIM OUTSIDE TO THE AMBULANCE. AS THE VIDEO SHOWS, THE MEDICS FAILED TO LOCK/SECURE THE STRETCHER, AND WHEN BOTH MEDICS RELEASED IT AND TURNED TO THE AMBULANCE TO OPEN THE BACK TWO SWINGING DOORS, THE STRETCHER STARTED ROLLING AWAY. ONE OF THE MEDICS LOOKED BACK AND SAW WHAT WAS HAPPENING AND LUNGED FOR THE STRETCHER AND SNAGGED THE CORNER OF IT JUST BEFORE IT ROLLED OUT INTO THE PARKING LOT OF PARKED CARS AND TRAFFIC. MEDIC 5 THEN TRIED TO LOAD THE STRETCHER, BUT IT FAILED, AND THEY STRUGGLED WITH THE STRETCHER FOR AN EXTENDED PERIOD OF TIME DURING WHICH THEY REFUSED HELP FROM (AND RAN OFF) A NUMBER OF BYSTANDERS AND SOLDIERS WHO CAME UP TO HELP. MEDIC 5 WAS NEVER ABLE TO LOAD THE STRETCHER. THEY GAVE UP AND CALLED FOR A FIRE TRUCK TO ASSIST THEM (THIS FIRE TRUCK, (B)(6), WAS THEN DISPATCHED). THE EMS COMMANDER CALLED INTO THE DISPATCHER AND REQUESTED AN UPDATE FROM MEDIC 5 WHICH ANSWERED THAT THEY HAD AN UNSTABLE SITUATION. [THE EMS COMMANDER ((B)(6)) THEN TOLD THE DISPATCHER HE WAS GOING TO BE ENROUTE TO THE SCENE. IT WOULD TAKE AROUND 10 MINUTES 47 SECONDS (BASED ON THE (B)(6) COMPUTER SYSTEM TIMES) BEFORE REED ACTUALLY REACHED THE AMBULANCE AT THE PX.]THE MEDIC 5 CREW THEN STOOD ON EACH SIDE OF THE PATIENT AND WAITED FOR HELP TO COME. THE SECOND AMBULANCE (MEDIC 1) EVENTUALLY ARRIVED, AND THOSE TWO MEDICS APPEARED TO "TAKE THE LEAD" (BASED ON PX VIDEO), AND AFTER A WHILE WERE ABLE TO GET THE STRETCHER LOADED. [IT WAS DURING THIS TIME THAT A SECOND 911 CALL WAS MADE FROM THE PX.] JUST AFTER THE STRETCHER GOT LOADED, THE FIRE TRUCK ARRIVED, BUT THESE FIREMEN/MEDICS WERE SENT AWAY AFTER BEING TOLD BY MEDICS INSIDE THE AMBULANCE THAT THEY WEREN'T NEEDED (ACCORDING TO FIRE RADIO TRAFFIC RECORDINGS). THE TWO AMBULANCE SCREWS (4 MEDICS IN TOTAL) PILED INTO THE ONE AMBULANCE AND ABANDONED THE SECOND AMBULANCE. DESPITE HAVING PLENTY OF MEDICS AND AMBULANCE DRIVERS ON HAND, THEY CHOSE TO SIT IN THE PARKING LOT AND NOT TO GET ENROUTE TO THE ER THAT WAS ONLY ABOUT 2.5 MILES AWAY. THE AMBULANCE WOULD STAY PARKED FOR ABOUT 9.5 MORE MINUTES AFTER THE STRETCHER WAS LOADED. IT WAS DURING THIS TIME THAT THE PATIENT EVENTUALLY WENT INTO CARDIAC ARREST (AROUND 14 MINUTES AFTER THE MEDICS FIRST GOT TO THE PATIENT), YET THE CREW DID NOT ANNOUNCE THE CARDIAC ARREST TO THE DISPATCHER AND STILL DID NOT GET ENROUTE, WAITING, IN PART, ON THE EMS COMMANDER TO ARRIVE IN ORDER TO DRIVE EVEN THOUGH THEY ALREADY HAD A DRIVER. EVENTUALLY, THE EMS COMMANDER ARRIVED, AND AFTER SOME DELAY, GOT BEHIND THE WHEEL AND THE AMBULANCE GOT ENROUTE. THE PATIENT WAS DELIVERED TO THE ER AT (B)(6) HOSPITAL AT (B)(6), STILL IN CARDIAC ARREST AT AROUND 12:22 (ACCORDING TO ER NOTES). THE ER STAFF EVENTUALLY RESUSCITATED THE PATIENT, AND HE WAS LATER TRANSFERRED TO AN OFF-BASE HOSPITAL NEARBY IN THE MEDIC 3 AMBULANCE (IT'S CREW WAS (B)(6)). THE PATIENT HAD SUFFERED SEVERE BRAIN DAMAGE AND DIED THE NEXT DAY. [TWO ADDITIONAL POINTS SHOULD BE MADE. FIRST, SOME SOURCES FROM FORT HOOD POINTED OUT THAT PROPER PREVENTATIVE MAINTENANCE RECOMMENDED BY THE MANUFACTURER OF THE STRETCHER HAD NOT BEEN CONDUCTED ON THE STRETCHER. SECOND, IT NEEDS TO BE POINTED OUT THAT THE EMS REPORT PRODUCED BY MEDIC 5 CONTAINS A VARIETY OF STATEMENTS THAT ARE NOT ACCURATE (AS SHOWN BY PX VIDEO FOOTAGE, (B)(6) EMERGENCY COMMUNICATIONS CENTER'S COMPUTER TIME RECORDINGS, ETC.). FOR EXAMPLE, THE REPORT MAKES IT APPEAR THAT MEDIC 5 GOT THE STRETCHER LOADED, BUT IN REALITY, THE ONLY REASON IT GOT LOADED WAS BECAUSE MEDIC 1 SHOWED UP. ALSO, THE REPORT SAYS THE PATIENT WAS UNRESPONSIVE AND UNCONSCIOUS UPON GETTING TO HIM, BUT THIS TURNS OUT NOT TO BE TRUE. IN ADDITION, THE REPORT SAYS PATIENT CARE WAS IMPEDED BY A BYSTANDER FOR APPROXIMATELY 6 MINUTES. HOWEVER, PX VIDEO SHOW THIS WASN'T TRUE (THE BYSTANDER IN QUESTION IS SHOWN TO BE IN THE PRESENCE OF THE PATIENT/MEDICS FOR ONLY ABOUT 43 SECONDS DURING WHICH TIME THE MEDICS WERE ABLE TO INTERACT/DEAL WITH THE PATIENT). EMS PHONE RECORDINGS OF ONE OF THE EMS OFFICIALS APPEAR TO INDICATE THE MP'S WERE CALLED FOR THE PURPOSE OF CROWD CONTROL SINCE THERE WERE A LOT OF PEOPLE THERE IN THE STORE.]