Tex. Paramedics Under Investigation After Disputing Care for Crash Victim

Austin American-Statesman

Emergency officials are investigating whether paramedics who responded to a hit-and-run last fall did enough to help a dying man, raising the question of how far first responders should go to save a gravely injured patient.

The issue arose after body camera video captured a roadside dispute between medics from Austin-Travis County Emergency Medical Services and Travis County Fire Rescue, who pressed for permission to keep working on 73-year-old Joe McKoy after they discovered he was still breathing following the Sept. 27 crash.

McKoy, who suffered a severe head injury, was not taken to the hospital. He was pronounced dead at the scene near Texas 130 and Pearce Lane about 30 minutes after the crash. Records show medics called a doctor for consultation and, later, to declare him dead.

"There was a feeling that we could have more aggressively advocated for the patient," Travis County Fire Rescue Chief Ken Bailey said. "This particular case was difficult for our crews to process. It's a failure on our part for what our mission is."

The case highlights how medics must sometimes grapple with the extent to which they should continue care when training and experience indicate that survival chances are low or whether they should be empowered to deem a patient no longer viable for treatment, as officials say medics did with McKoy, and stop.

Dr. Mark Escott, medical director for Austin-Travis County Emergency Medical Services, confirmed he and his office have been investigating whether first responders followed the agency's standards for care. He said he could not comment further because such clinical reviews are confidential under state law. He said the matter is also being referred to other EMS officials for an administrative review to determine whether the medics violated departmental policies.

The medics have not been disciplined and remain on the job. The Texas Department of Public Safety is still investigating the crash and trying to find the driver of the other car.

"Our city's first responders are committed to the pursuit of excellence in clinical care and risk their lives on a daily basis to help others in need," Escott said in a statement to the American-Statesman. "While our EMS and fire department strive for perfection, as with any other aspect of health care, the office of the medical director consistently reviews our clinical practices in order to continue to improve the care provided to our community."

McKoy's husband, Jesse Stewart, was dead when paramedics arrived at their mangled pickup.
Body camera video taken by first responders from Travis County Fire Rescue (Emergency Services District 11) captured tense moments with medics from Austin-Travis County EMS during which they discussed McCoy's injuries and debated whether to proceed with treatment.

It shows some responders on the scene appeared stunned when a medic—the one with the most credentials on at the scene—instructed them to cease efforts to aide McCoy because of the dire nature of his injuries.

The American-Statesman, KVUE-TV and McKoy's family have sought copies of the video from Travis County Fire Rescue, but the agency's attorney has appealed to the Texas attorney general, seeking to prevent the public release of the video. The department argues that because the body-worn cameras are used for medical review purposes, the video is confidential.

McKoy's brother, Errol McKoy, who is handling his estate, declined to comment.

Documents list all of the emergency responders at the scene, but officials would not identify who objected to further treatment of McKoy, a retired examiner from the Internal Revenue Service who lived in Southeast Travis County. The men's neighbors think they had been grocery shopping when the crash happened.

According to EMS policy, resuscitation efforts should not be initiated or continued if a patient is "pulseless or apneic"—meaning, isn't breathing. They also should not try to revive a patient if he has been underwater for more than 20 minutes or has "obvious mortal wounds," which the policy describes as "severe trauma with obvious signs of organ destruction."

The video shows the senior EMS medic believed the nature of McKoy's injuries were such that they met that criteria because of his head wound. Records also show he was bleeding from his head and suffered severe brain trauma.

The policy also establishes an on-scene hierarchy and instructs medics on how to handle instances where they disagree about patient treatment.

It says it is the responsibility of the "on-scene credentialed providers to reach consensus as to the most appropriate care of the patient." It says if that doesn't happen, the senior on-scene provider has the final say.

"All significant or unresolved conflicts regarding on-scene management of patients should be reported via the chain of command and will be retrospectively reviewed," the policy states.

In a memo to the staff Friday, Bailey, the Travis County Fire Rescue chief, said the final call about whether to take a person to the hospital remains with the transport provider, which was Austin-Travis County EMS in McKoy's death. However, Bailey pointed out that his department has other options, including arranging other transportation.

"While the expectation is to be professional in our communication with others, this should not be a passive effort, but rather a clear communication of your concern," Bailey wrote.

Dr. Pat Crocker, a former emergency room doctor in Austin who worked closely with EMS, said medics often contacted him for counsel about how to proceed with a patient in similar situations.

"In general, a patient who has signs of life—a pulse, breathing—should be transported," he said. "A paramedic making that call in the field has a lot of challenges, in the midst of a lot of excitement. There have been a number of times in my career when I felt like this patient was a goner ... and a week later, those patients walk out of the hospital."

Dr. James Kempema, the medical director for Travis County Fire Rescue who also reviewed the incident, said he agrees that McKoy would not have survived his injuries, even if the medics would have continued aggressive treatment.

However, he said the incident shows the difficult decisions medics must make in an emergency situation about whether to rush a person with the most dire injuries to the hospital. Doing so can put the crew and public at risk by an ambulance racing to a hospital. It also comes with an extra financial cost to the agency, he said.

However, he said taking them to the hospital can give a possible opportunity for organ donations and allow doctors and other medical experts a second chance to review a patient's injuries.

Kempema said he is aware of instances in which paramedics transported patients with injuries similar to McKoy, even though they were near-certain they would die enroute. He said he thinks it is usually proper to do so.

"Trying to determine when to stop resuscitation efforts is a challenge," Kempema said. "My recommendation is that if there is evidence of vital signs and we have a trauma center that is fairly immediately accessible, my general recommendation would be to pursue transport. There are some things we might be able to do, with the full understanding that the likelihood of survival is very, very low."

Bailey said his medics also have reviewed their actions that day. He said they also have repeatedly second-guessed whether to stop care on McKoy and whether they should have more aggressively insisted on doing more.

"We are uncomfortable trying to make those decisions," he said. "We believe those decisions are best made in the emergency room. Ultimately, our job is to continue to provide care."