Three Los Angeles Fire Department dispatchers seriously bungled calls for help from a man who said his fiancee had passed out and was bleeding, interviews and records show. The incident, in which the woman died, occurred last month after officials vowed to curb such mistakes.
Although paramedics were stationed down the street, it took two phone calls and nearly 20 minutes before they arrived at the Tujunga home of Robert Shaw and Elaina Marie Vescio. When they got there, the 49-year-old woman was dead. She had apparently suffered a heart attack.
"I don't think anyone took me seriously," said Shaw, 42, who wonders if his fiancee's life could have been saved. "I think there was a chance."
It's unknown whether a proper response would have made a difference for Vescio, an outgoing woman who conducted tours at a Valencia entertainment studio.
During subsequent investigations, fire officials found that the system broke down in three important ways:
The dispatcher who first received Shaw's call left his post at the end of a shift without passing along the information so help could be sent. The dispatcher who came on board next wiped out a record of the call in what has been characterized as an inadvertent mistake. When Shaw called again, the third dispatcher ordered an emergency response well below what was required.
The case--the most recent in a string of dispatch problems-- is certain to intensify scrutiny of an operation that has been criticized by some top fire officials as potentially jeopardizing patient care. Since February, dispatch errors have been cited in at least five cases in which patients died.
On Tuesday, Fire Chief William R. Bamattre would not discuss the handling of Shaw's calls because of employee confidentiality. He did say that the incident "is clearly the exception" to the fine job dispatchers do in responding to more than 275,000 emergency medical calls a year.
"Our goal is to eliminate all the errors," the chief said. "That goal is not necessarily achievable, but we need to strive to improve."
Bamattre expressed concern that Shaw's experience occurred after the chief sent a clear message to dispatchers and their supervisors in July to shape up.
That message was sent after an internal report concluded the dispatch operation was in "dire need of complete revision." It mentioned four cases of "grossly inappropriate dispatches" in which firefighters had failed to ask scripted questions to determine proper medical responses.
The report did not provide details, but The Times determined that three of those cases ended in deaths. This week, the department provided the newspaper with information on the fourth incident, which also involved a patient who died.
In that February case, a North Hollywood caller said a middle-aged man was suffering a possible heart attack. The dispatcher improperly sent an ambulance with two firefighters, instead of the more highly trained paramedics.
Fire officials say they believe the recent deaths were not results of the faulty dispatching.
The department has said it recently took steps to enhance oversight, increase training and ensure that dispatchers do not stray from the standardized questions. The response to Shaw's anguished pleas for help raise concerns, not only about the effectiveness of that effort, but about the breadth of the problems at the dispatch center.
Department sources say two of the dispatchers involved in Shaw's case were reprimanded while another received a less severe "notice to improve." One of those dispatchers was counseled for errors after a March incident in which a patient died.
A Series of Mistakes
Here, according to a dispatch tape obtained by The Times, other public records and interviews, is what happened in the early morning hours of Aug. 22:
Shaw last saw his fiancee, Vescio, alive about 9 p.m., when they went to bed in their small home off Foothill Boulevard in Tujunga.
Vescio usually got up about 2 a.m to help open the Valencia film studio where she worked. Before leaving, she always turned off the lights and locked up.
When Shaw woke up at 4 a.m., as he does every day, he knew something was wrong. The lights were on. He called her name, and when no one responded, he ran into the living room, where he saw a light coming from the bathroom. Vescio was sprawled on the floor, a small pool of blood by her face.
Panicked, Shaw checked for a pulse but felt nothing. Although her lips were blue, he hoped she could be revived. She was still warm.
With no phone in their recently rented house, Shaw bolted outside, barefoot and in his shorts. He ran a block to the nearest pay phone.
It was 3:59 a.m.
"I need an ambulance," Shaw told the Fire Department dispatcher, struggling to catch his breath as he recited his address on Day Street.
"What is the problem there?" the dispatcher asked.
"I don't know," Shaw said. "I just woke up, and I found my wife passed out on the floor. And there's blood."
"Is she breathing, sir?"
"I couldn't tell," Shaw said. "I just ran out real quick."
"How old is your wife, sir?"
"OK, we'll have somebody right there. OK, sir? Go, I want you to go back. You don't have a phone at home?"
"No, I don't."
"OK. Go on back and see what you can do for her. OK?"
The dispatcher did not, as generally required, give specific instructions on how to control the bleeding and how to open an airway.
As Shaw ran back toward his house, he stopped, turned and then fixed his eyes on the driveway of a firehouse barely within his sight. Expecting to see flashing red lights, he decided to wait and flag down the paramedics.
But they weren't coming.
Back at the downtown dispatch center, the firefighter who took Shaw's call was ending his shift. He left without completing an essential task: He did not forward Shaw's information to a nearby radio operator responsible for actually sending rescue crews.
The mistake was compounded when the next dispatcher took over. He noticed the call had not been properly completed. But, perhaps by accident, he eliminated it from the center's active emergencies.
None of this, of course, was known to Shaw, who had given up waiting and sprinted back to his fiancee's side. After about 10 minutes of waiting, Shaw ran back to the phone, fearful and angry.
It was 4:13 a.m., and he was about to start all over.
"Where's that ambulance that's supposed to be at my house [on] Day Street?" Shaw hurriedly asked yet a third dispatcher, who seemed confused and then interrupted him.
" . . . What street?" the dispatcher inquired.
"Day Street, in Tujunga," Shaw said with exasperation. "My old lady's laying on the floor. Her lips are blue. There's blood coming out of her nose. And I called 10 minutes ago."
Dispatcher: "I don't have a call on Day. D-A-Y Street?"
Shaw: "Day Street."
"So your calling from Foothill right now?" the dispatcher continued to inquire.
"Yes, I am. I'm sorry for my attitude, but my wife's laying there. . . . "
"How old is she?" the dispatcher asked, interrupting Shaw as he said, "I don't know if she's alive.
"How old is she?" the dispatcher repeated.
"She's bleeding from her mouth you said?"
"From her nose," Shaw corrected. " . . . And her lips are blue."
"Was she awake when you left her?"
"I don't know. I just woke up and found her laying in the bathroom."
"Is it a house or an apartment there?"
"It's in a house."
"OK. No phone number at the house?"
"Just go back to her," the dispatcher concluded. "We'll have somebody come over there right now."
"Please," Shaw said.
The dispatcher, interrupting again said pointedly: "Go back to her. We'll have somebody come out there right now."
"If I don't see somebody in five minutes," Shaw said, "I'm calling you back, buddy. Bye."
Failure in the System
This dispatcher, like the first, failed to give Shaw specific first-aid instructions. The dispatcher also mistakenly categorized the call as a lower-level bleeding incident and noted that Shaw had been belligerent.
Ordinarily, such a dispatch decision would bring two non-paramedics in an ambulance. Under department policy, the dispatcher should have sent four firefighters on an engine, along with the paramedics.
As it unfolded, the mistake was minimized by a dispatch computer downtown. It found that the closest rescuers were down the street from Shaw, at the station he had looked to for help. By happenstance, they also were paramedics who were more qualified to handle such a call.
They were sent at 4:14 a.m. and arrived at Shaw's home four minutes later. Vescio was pronounced dead at 4:22.
"It doesn't seem right at all," Shaw said recently as he sifted through a cardboard box of photos and mementos. "My loved one of five years is lying there on the floor, and no one's even bothering to help me. . . . I shouldn't have had to call them a second time."
After The Times first disclosed the dispatching problems earlier this month, Los Angeles County's emergency medical care regulator ordered a comprehensive review. The mayor-appointed Fire Commission has launched a broader examination of the paramedic system, which is plagued by problems ranging from recruitment to burn-out.
One of the most persistent challenges has been how dispatchers are trained and monitored. In 1995, an outside consultant recommended Bamattre hire a full-time training specialist for the unit. But the position was never funded.
"We keep asking for that," said Battalion Chief Joseph Klein, a one-time dispatcher who is now a commander of the center.
Times researcher Vicki Gallay contributed to this story.
A recording of the emergency calls between Robert Shaw and Fire Department dispatchers can be heard at http://www.latimes.com/rescue
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
EXCERPT FROM THE SECOND CALL
Shaw: "Where's that ambulance that's supposed to be at my house [on] Day Street?"
Dispatcher: ". . . what street?"
Shaw: "Day Street, in Tujunga. My old lady's laying on the floor. Her lips are blue. There's blood coming out of her nose. And I called 10 minutes ago."
Dispatcher: "I don't have a call on Day. D-A-Y Street?"
Shaw: "Day Street."
Dispatcher: "So you're calling from Foothill right now?"
Shaw: "Yes, I am. I'm sorry for my attitude, but my wife's laying there . . ."