Heart of the Problem

As the city probes EMS efficiency, it faces questions about a death that should not have been.

by Mike Newall

public safety

Lauren Nash LOSING A FRIEND: At El Azteca II, co-workers still mourn Burke. (CLICK IMAGE FOR LARGER VERSION)

"He died of a heart attack while waiting for a train."

So reads Andrew Burke's makeshift memorial, which is posted on the front door of El Azteca II, the Chestnut Street restaurant where the affable 41-year-old known for his practical jokes, love of '80s dance music and Swedish meatballs worked as a waiter before suffering cardiac arrest at 30th Street Station on Sept. 19.

Burke collapsed on his way home to Somers Point, N.J., where he was to celebrate his birthday with his parents and sister. He died waiting for a train, but he also died waiting for an ambulance that, had it arrived, could've helped restart his heart. Burke had the misfortune of having to rely on Philadelphia's Emergency Medical Services to save his life, a system so overworked, understaffed and poorly mismanaged that, for nearly two years, desperate, hard-working paramedics have been pleading with city officials for a systemwide overhaul.

It's also a system at the center of a recently filed federal lawsuit, one that is the now subject of a wide-ranging audit from the City Controller's Office.

"This city's EMS system is in dire distress," says one angry paramedic, echoing the refrain of the two dozen paramedics and firemen interviewed for this story. "If you're really sick and you call us, there's a strong chance you might die."

Burke's heart stopped beating on a typically slammed day for the city's EMS services. Emergency calls were flooding the Fire Communications Center (FCC), a cramped windowless room in the basement of the Fire Administration building, and available ambulances were running low. Because of the small number of ambulances the Fire Department dedicates to ever-increasing emergency medical calls — 28 full-time squads and 17 part-time squads service more than 200,000 emergencies — the city routinely runs out of ambulances, sometimes on a daily basis. The International Association of Fire Fighters recommends Philadelphia deploy between 70 and 80 full-time ambulances [Cover, "Emergency Breakdown, Mike Newall, May 12, 2005].

According to fire department records, however, there were two available Advanced Life Support ambulances (ALS) just minutes away at the time of Burke's collapse. But an overwhelmed and undertrained dispatcher instead assigned a Basic Life Support Ambulance (BLS). ALS ambulances are staffed by highly trained paramedics who could've hooked up Burke to a heart monitor, inserted an intravenous tube and given him an assortment of drugs to restore the flow of oxygenated blood to his failing heart. The dispatched BLS ambulance was staffed by two rookie firemen untrained in the invasive medical treatment needed to treat cardiac arrest patients.

The first responding firemen did, however, bring Burke's pulse back by administering CPR and delivering a successful shock from a defibrillator. It was at this point, sources working that day say, that Burke desperately needed the advanced life care that paramedics could've provided.

"The firemen did the best they could," says one paramedic, "but the chain of care was interrupted because ALS paramedics weren't on the scene. The firemen did not have the medical training or drugs to sustain Burke's pulse."

In light of the dearth of resources, dispatch sources say Fire Department protocols recently changed, allowing dispatchers to assign BLS units to cardiac arrests calls when there is no ALS unit available. But paramedics working the day of Burke's death say a medic from one of the nearby ALS units made repeated radio requests for dispatch to assign them, arguing that they could respond just as quickly as the BLS ambulance, and could offer Burke the advanced care he needed. But, FCC dispatchers receive little training in the geographical layout of the city other than having to memorize the locations of firehouses and hospitals.

Moreover, the million-dollar global information system (GIS) the department installed three years ago to help dispatchers better track the location of ambulances and more easily deploy resources has yet to be fully integrated.

"The new dispatchers are not adequately trained for the pace and pressure of this room," says one dispatcher, who handles upward of 150 emergency calls on a 12-hour shift.

Department sources say the dispatcher handling Burke's call had been on the job less than a year. The ALS paramedic requests to respond were denied and Burke was pronounced dead shortly after reaching the hospital. Deputy Fire Commissioner Daniel Williams would not address inquiries as to whether any investigation is under way, but paramedics and firemen refused to place blame for the mishandling of Burke's call squarely on the shoulders of the individual dispatcher. Rather, they describe Burke as just another casualty of a broken system.

In the last two years, at least four Philadelphians have died after waiting too long for ambulances to arrive. (Under recommended state and federal guidelines, an ambulance should be on the scene of a cardiac arrest within eight minutes.)

Danny Rumph, a 21-year-old stand-out guard at Western Kentucky University, suffered cardiac arrest on a Mount Airy basketball court and died after waiting 31 minutes for an ambulance. Ricky Badway, 22, suffered cardiac arrest at his girlfriend's house in Roxborough and died after waiting 22 minutes for an ambulance. Rotan Lee, a prominent education reformer, suffered cardiac arrest at his West Philadelphia home and died after waiting 19 minutes for an ambulance. And a 5-month-old baby girl suffered cardiac arrest in Wissinoming and died waiting for an ambulance that never even arrived.

"And these are just the cases the press knows about," says one paramedic. "This happens all the time. It's a silent epidemic."

Although promising reform, Fire Commissioner Lloyd Ayers has done little to fix Philadelphia EMS, having added just five part-time squads to help ease the landslide of emergency medical calls.

While Ayers did not respond to repeated requests for comment, recent developments may force the city's hand.

Richard Badway Sr. recently filed a civil lawsuit against the city in the United States District Court for the Eastern District of Pennsylvania. Badway claims his son's civil rights were violated after he died waiting 22 minutes for an ambulance. Autopsy reports revealed that Ricky, an otherwise healthy individual, suffered sudden heart arrhythmia, a condition paramedics could have treated with invasive medical procedures. EMS experts label patients like Ricky as the "most savable cardiac arrest victims" and consider their survival rates to be the gold standard of measuring an EMS system's efficiency. Cities with the proper amount of resources dedicated to EMS save 40 percent to 45 percent of these individuals; Philadelphia saves only 4 percent.

The policies of the Philadelphia 911 system result in "a state-created danger," argues Tony Bocchino, Badway's attorney. The city has created a monopoly on public safety, he says, since it fails to route EMS calls to private ambulance providers even when there are no available city ambulances. (The ambulance that eventually responded to Ricky sped nine miles to get there.)

"The city is putting people in a zone of danger," says Bocchino. "People are informed to call 911 without being given any other options for care and then are left waiting for help that comes way too late."

Deciding to file suit took some "serious soul searching," says Badway Sr., "but my son didn't get the best chance for survival, and people have died after him and people will continue to die if this system doesn't get fixed. The people of Philadelphia need to know this is a dangerous place to get sick."

City attorneys did not return requests for comment, but are expected to argue that the city is not financially liable since adequate EMS protection is not mandated in the city charter.

Also scheduled for sometime this month is the release of what sources say will be an extensively detailed audit of Philadelphia EMS by the City Controller's office. For months, the Controller's Office has been interviewing paramedics and poring over thousands of fire department stats investigating whether Philadelphia EMS response times conform to national standards.

In September, representatives sat down with seven randomly selected paramedics, one of whom prepared written remarks that began, "This system has been dismissed, ignored, and ridiculed for far too long by its own administration and political leaders. The service that this system provides is disgraceful and the treatment of its field providing paramedics is inexcusable."

First Deputy Controller Harvey Rice could not comment on the audit since it is still ongoing but did say that "all of the information collected in our meetings with paramedics will certainly be considered in our final findings and recommendations."

Many paramedics hope it will call for an independent and empowered EMS leadership separate from the fire command. "EMS protocols and procedures are written by firefighter officers," one says. "They have very little field experience and almost no formal education in EMS."

A city official familiar with the audit says that although the report's findings will not be binding, "hopefully, the report will help facilitate next mayor's decision making process as to any personal changes he'd wish to make within the fire department."

For his part, Mayor-elect Michael Nutter wouldn't comment on whether he'll retain Ayers as fire commissioner and noted that he had yet to hear about the controller's report, but he "will certainly read it when it is published" and make decisions from there.

Life stumbles on at El Azteca II, the Mexican restaurant where Andrew Burke waited tables. There, his former co-workers miss their friend Andy's laugh and his jokes — like pinning guest cards for Paula Abdul and the Pointer Sisters to the reservation board, or breezing into the kitchen to inform the line cook, "Did you hear the news? You've been nominated for the Cook of the Month award." They also miss his little paper napkin cartoons, his minor blowups and the heartfelt apologies that always came afterward.

"We all loved Andy," says Burke's co-worker Travis Waldron. "It's hard enough without him. To think he didn't get the help he needed just makes it all the more worse."

(editorial@citypaper.net)