Backup Documents 05/14/2013 Item #10IMEMO
Date:
May 14, 2013
10
��urrt
Collier County
Office of the County Manager
To: Board of County Commissioners
From: Leo E. Ochs, Jr., County Manager
Subject: Internal Investigation
As per your direction given at the May 14, 2013 Board of County Commissioners
meeting, attached please find the March 12, 2013 memorandum from Chief
Walter Kopka regarding the Internal Investigation of events that occurred on
December 14, 2012.
10 I-cv,
PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND
LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS
DISCLOSURE PURSUANT TO § 119.071(1)(d), FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF
YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR
DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED.
INTERNAL MEMORANDUM
TO: Leo Ochs, County Manager
FROM: Walter Kopka, Chief
THRU: Len Price, Administrator
Dan Summers, Director
DATE: March 12, 2013
RE: Internal Investigation
Situation: On December 14th 2012 at 11:04 am Medic 42 and Engine 72 were dispatched to 5120 Coral Wood
Drive. Medic 42 did not receive initial notification and there was a four minute delay in EMS responding to the
call. When contacted a second time by Dispatch, the EMS crew advised that they did not receive the tones.
Further, the crew documented on the incident report that "the station received no tones and the tablet received
no information ". Details of the event and corrective actions taken follow.
Excerpt from Recording Provided by CCSO (Time Stamped)
11:04:45
Tones sounded, Medic 42 and Engine 72 dispatched to 5120 Coral Wood Dr
11:05:47
Engine 71 responds in place of Engine 72, Engine 72 in service
11:08:44
Dispatch checks the status of Medic 42; Medic 42 advises they received no tones; Second set of tones sent
11:09:59
Medic 42 responds from the station
11:11:59
Engine 71 arrives on scene
11:15:51
Medic 42 arrives on scene
11:17:53
Medic 42 makes contact with patient
Page 1 of 4
10 1 -C4�
PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND
LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS
DISCLOSURE PURSUANT TO § 119.071(1)(d), FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF
YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR
DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED.
11:33:10
Medic 42 leaves for Physicians Regional Pine Ridge hospital with two firefighters on board
11:37:55
Medic 42 arrives at Physicians Regional Pine Ridge hospital
Back-ground Information on EMS Notification Systems
EMS has multiple notification devices to receive information from Collier County Sheriff's Office (CCSO)
Communications Center:
• VHF Pager system (tones) — this system is generated by the CCSO Computer Aided Dispatch sending the
activation for the specific requested apparatus via a transmitter to the specific designated pager frequency.
The page is a six (6) second tone. Any interruption of that six (6) second tone will drop the page and the
pager will not activate.
• This consists of a mounted pager, speakers and antennae in each EMS station.
• Each crew carries a portable pager.
o This is a one way device- it only receives information.
Tablet- this is a handheld device that receives a text message via the CCSO Computer Aided Dispatch. The
text message uses a program to convert the message to a map as well as provides the dispatch information.
o The tablet is a cellular receiving device. As with any cellular device reception is dependent upon all
factors that affect cellular service including (but not limited to) location, tower, carrier and
obstructions.
o This is a one way device- it only receives information.
• Portable Radio — 800mHz
• Each crew member has a portable radio which is a two way device which receives audio information
as well as transmits audio information to dispatch and/ other apparatus.
• As with a cellular device the reception is dependent upon all factors that affect cellular service
including (but not limited to) location, towers and obstructions.
Possible EMS Notification Issues
The reason for the lack of notification of the receiving devices cannot be definitively determined.
VHF Pager: Prior to this incident there were documented pager/ reception issues and hardware upgrades were
made to the system. There are no systems that log or track incoming pages from the transmitter to the receiving
device.
NOTE: A pager in the standby mode is silent. Once the pager is activated, the pager becomes "live" therefore
ANY radio transmissions are heard through the pager. The pager reset button needs to be pressed to put in back
in the standby/ silent mode.
If the pager had activated, the crew would have to reset both the personal pager (carried on person) as well as
the station pager. Each pager is independent and the reset button would need to be pressed on each pager to
reset / silence them. The crew verified that they did not reset the pagers and no radio transmissions were
heard.
Page 2 of 4
10 I-c+z
PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND
LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS
DISCLOSURE PURSUANT TO § 119.071(1)(d), FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF
YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR
DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED.
Tablet: It is not known why the tablet did not receive the text message. While we can verify that the text
message was sent by Dispatch, Sprint I shows that the text message was not received.
Portable Radio: There are many factors that could have contributed to the EMS crew not hearing the dispatch
over the radio.
• The radio scans four (4) channels- therefore one of the other scanned channels could have
blocked out the dispatch.
• Station noise- the crew was vacuuming around that time.
• Reception problems with the radios depending upon location and interference.
Deviations from Protocol
There are two deviations from protocol.
1. Collier County Fire Chief Association (CCFCA) —Communication Manual
Initial Radio Announcement / Dispatch CM 10 -15
Failure to Acknowledge on Call Back
"Any agency that fails to acknowledge responding to an incident within two minutes should be
contacted by Control North or Control South over the radio to see if the agency is in fact responding."
This was not done for four (4) minutes.
2. Collier County Collective Bargaining Unit Contract
Article 28.2 Work Duties
"During the hours of 0830 and noon, employees should perform assigned vehicle/ station duties zone
familiarization, study medical / operational protocols, or community events. Radios will be monitored
between 0700 and 2130 hours."
The Standard Operating Guideline for Standard Station Duties states:
"Fridays
Deep station GI...
Floors including all living areas, office, storage area, garage bays and bathrooms swept and mopped (or
vacuumed in appropriate areas)."
The crew acknowledges vacuuming and performing required station maintenance around the time of this
dispatch, which may have limited their ability to monitor the radio.
Corrective Actions / Mitigation
The Collier County Sheriff's Office has stated the deviation from the Collier County Fire Chief Association
(CCFCA) — Communication Manual was a human error in that the dispatcher missed recognizing a visual
display that two (2) minutes had passed and Medic 42 had not responded yet. Since then, EMS has been
told the notification is not only a visual display- but also an audible tone as well.
Page 3 of 4
10 I-cR
PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND
LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS
DISCLOSURE PURSUANT TO § 119.071(1)(d), FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF
YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR
DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED.
• A reprogramming of the paging system (narrow banding) was completed in January. EMS pagers have
been inventoried and reprogrammed if applicable.
• A protocol has been established that documents when pagers and/ or tablets do not activate. This
report is sent to County staff as well as Sheriffs office staff to determine the cause of the incident as
well as any patterns that can be established.
• A draft protocol change to the Collier County Fire Chief Association (CCFCA) — Communication Manual
has been submitted to the Collier County Fire Chief Association (CCFCA) — Communication sub-
committee to change the notification to 30 seconds (from 2 minutes) from when responding apparatus
must acknowledge a dispatch. This will decrease the amount of time dispatch has to "wait" to verify if
responding apparatus has acknowledged a page. This is scheduled to be heard by the subcommittee this
month and if approved it could be heard by the fire chiefs next month.
• EMS is in the process of changing the protocol that will require one (1) personnel to monitor the radio if
one crew member is working in a noisy environment. Hardware changes are also being reviewed to
determine if better listening devices are available for working in noisy environments. EMS staff should
have final protocol revisions completed in 60 days.
• EMS is reviewing the policy of scanning portable radio "channels" to determine if a policy change will
assure that the proper channels are monitored at all times. EMS staff should have final protocol
revisions completed in 60 days.
• The station pagers / antennas will be reviewed to determine antennae design, condition and
performance.
• EMS field staff is testing an alternative cellular carrier to determine if alternate devices / carriers should
be utilized. An alternate cellular carrier has been tested and has proven to work well. Alternate devices
will be explored in the next 90 days.
• EMS staff have developed an automated query that reports calls in which the response to dispatch is
greater than two minutes. EMS staff is planning to meet with the CCSO staff in the next 30 days to
determine a plan to review the reports.
• There are long term changes to the Sheriff's Office Computer Aided Dispatch system and receiving
hardware and devices. This is a longer term element that will change software and hardware at the
Sheriffs Office level as well as the responder level.
In summary, the four (4) minute difference between the initial dispatch and secondary dispatch has been
reviewed and corrective actions to mitigation recurrences have been taken and will continue to take place
to improve the system. While the EMS response was delayed in this instance, the tiered response system
worked as it was designed. The fire department arrived six minutes after the initial dispatch. EMS arrived
seven minutes after the second dispatch. Had EMS responded at the same time as the fire department
apparatus, the fire department apparatus still would have arrived on the scene prior to EMS and initiated
basic life support protocols. The patient arrived at the hospital 33 minutes after the initial dispatch.
The Medical Examiner's report on this case is not complete at this time.
Page 4 of 4
Collier ambulance delayed an hour in past 6 months - WFTX -TV For...
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Home > News > Local News
Investigation
Collier ambulance delayed an hour in past 6 months
Nearly two dozen calls took ambulance longer than 30 minutes to arrive
By Matt Grant
CREATED FEB. 15, 2013
http: / /www.f�4I c /news/ cal /191478761.html
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NAPLES, Fla. - At least one patient had to
wait an hour for an ambulance to arrive in
the past six months, a Fox 4 investigation
discovered.
On Thursday, we told you how a supervisor
and an EMT were suspended and a driver
was fired in 2010 after an internal
investigation discovered it took an
ambulance 40 minutes to get to a house five
minutes away.
But a Fox 4 investigation discovered that
response time wasn't an isolated case.
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"We attempt to get on the door of the patient in eight minutes or less," said Collier County
Fox a
EMS Chief Walter Kopka last month.
� Like You like this.
Fox 4 requested and received the last six months of ambulance response times in
Collier County. With the help of staff members and our news director we began sifting
through logs of more than 14,000 response calls dating back to last August.
Our investigation found more than 1000 cases where EMT's took 10 minutes or longer to
arrive and nearly two dozen examples where it took more than a half an hour.
Because of privacy reasons, the county would not give us the location of the calls so we
don't know how long the EMT's had to travel or how serious the calls were.
But we did find more than a half dozen cases in the past six months where it took EMT's
1 of 3 5/13/2013 12:23 PM
Collier ambulance delayed an hour in past 6 months - WFTX -TV For...
more than 40 minutes to arrive - including one call that took 54 minutes and another back
in October that an ambulance took a full hour to arrive.
"in these life or death situations," said Dr. Amy Wecker with Internal Medicine Associates,
"those extra minutes are really important."
We spoke with Dr. Wecker last month. At the time, Wecker told us even a four minute
delay could be critical if a patient is without oxygen.
"A four minute delay could be a really big deal," she said. "It could mean the difference
between life and death depending on the situation."
Fox 4 will meet with Collier County Manager Le Ochs on Tuesday. We plan to ask him if
these response times are acceptable.
Matt Grant
mgrant @fox4now.com
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April 17, 2013
101
MINUTES OF THE MEETING OF THE COLLIER COUNTY
PUBLIC SAFETY AUTHORITY MEDICAL DIRECTOR'S
SUBCOMMITTEE MEETING
Naples, Florida, April 17, 2013
LET IT BE REMEMBERED, the Collier County Public Safety Authority Medical
Director's Subcommittee in and for the County of Collier, having conducted business
herein, met on this date at 8:30 A.M. in REGULAR SESSION at the Fire Code
Official Office, 2700 North Horseshoe Drive, Naples, Florida, with the following
members present:
Chairman: Dr. Robert Tober
Dr. Jeffrey Panozzo
Dr. Todd Bethel
Justin Gibson
David Mennini
Bobby Allen
Jose Santana (Excused)
ALSO PRESENT: Maria Franco, EMS Administrative Assistant
1
a
April 17, 2013
1. Call to Order and Pledge of Allegiance
The meeting was called to order at 8:37am. The Pledge of Allegiance was recited.
Walter Kopka - EMS Chief, Wayne Watson - CCEMS, Les Williams - CCEMS, James
Cunningham - NNFD, Tabatha Butcher - CCEMS, Jodi VanSickle — NNFD, Deborah M.
Lopez - MD, Richard Juda - MD, Jorge Aguilera — NNFD, Marting Rizo Patron — Emegear,
LLC, Michael Marcus, Trauma Program Manager Lee Memorial Health System and Janet
Vasey - PSA were also present.
2. Agenda and Minutes
a. Approval of Today's Agenda
Dr. Bethel moved to approve the Agenda. Second by Dr. Panozzo. Carried
unanimously 3 — 0.
3. New Business
a. Protocol Changes Submission Procedure
Dr. Tober reported a form has been developed to standardize the requests for Protocol
Changes. It would require response to 5 questions — The nature of the problem, what are
the benefits of the change, what are the risks of the change, what are the costs associated
with the change and have any alternatives been considered. It would be submitted to
Walter Kopka, EMS Chief and disseminated to the Medical Directors Subcommittee for
review.
Discussion occurred on the following between Subcommittee Members and the
attendees:
• Should the form be required for an initial inquiry.
• The form may hinder an individual from recommending changes or limit free
exchange of ideas.
• The concept could "slow down" the process required for change.
• It may be advantageous to form a committee comprised of qualified individuals
who could develop any recommendations and bring them forth to the Medical
Directors Committee for review.
• A total review of the protocols are conducted on a 2 year cycle and it may be
prudent to review them on an annual basis.
• It may be necessary to develop a tiered process to differentiate between changes
that need to be instituted immediately and long term changes which may require
substantial consideration.
Dr. Tober reported the proposed format is not intended to block a free exchange of ideas
rather instituting a uniform means to request changes. The request would allow Staff,
emergency provider representatives, etc. to review the request. It would not preclude any
applicable party from initiating informal contact on a protocol concern or requesting a
change.
2
10 1-, (21�
April 17, 2013
Michael Marcus, Trauma Program Manager Lee Memorial Health System reported
Lee County encountered similar circumstances regarding protocols changes and to
address the problem a committee comprised of representatives of qualified individuals
forward recommendations to the Medical Care Council approximately 3 times annually.
This allows individuals dealing with issues on a daily basis in the field to provide input to
the process.
No action was taken on the item.
4. Recent Submissions Discussion (this item was heard before item 3)
a. Pediatric Head Injury
Dr. Deborah Lopez was present to address protocol changes for Pediatric Head injuries.
She has reviewed the protocols and identified items in need of change.
Ventilation Rate — 10 breaths per minutes (original protocol) has been determined to be
inadequate and the rate should be based on the age of the child. There is no increase in
cost, but would require training of responders.
Dr. Tober reported a change will be made to this protocol to address the concern.
Other proposed changes include the changes to the CO2 level and elevating the head to
35 degrees.
The Subcommittee agreed with these proposed protocol changes.
b. IO Protocol
i. Different Equipment — different protocol EZ IO vs. B.I.G.
ii. Humeral and distal tibia location
iii. Use of lidocaine anesthetic
Jodi Van Sickle recommended:
1. The protocols be revised to allow use of the EZIO and for use of IO's
(Intraosseous Infusion System) in additional locations - humeral and distal tibia.
2. The protocols allow the use lidocaine as an anesthetic to reduce pain encountered
with injection of fluid.
She expressed concern the B.I.G.'s (Bone Injection Gun) are more suited to a younger
person's bone structure vs. aged hardened bones and are subject to "failure."
Dr. Tober reported the shift from EZIO to B.I.B. was based on cost concerns. A new
bone injection gun is being developed may alleviate the failure rate concern.
Dr. Panozzo noted it would be prudent for the Medical Subcommittee to focus on the
medical care requirements and allow other groups to determine the financial impacts
of any recommendations.
101-0-114,
April 17, 2013
Discussion occurred on the benefits of the proposed changes
Dr. Panozzo moved to approve the use of lidocaine anesthetic with the IO
administration of fluids and drugs. Second by Dr. Bethel. Carried unanimously 3
—0.
Dr. Bethel moved to cite a generic reference for an IO in the protocols.
There was no second to the motion.
Discussion occurred noting it would be prudent to specify the location allowed for
injection of the individual devices.
Discussion occurred on the early field identification of Sepsis.
It was determined an item should be placed on the next Agendafor discussion.
c. X- Collar
Martin Rizo Patron, Emegear, LLC provided an overview and demonstration on the
use of the X- collar, a cervical splinting device which may be utilized by first responders
in the field. It was noted the device is in use in Lee County and may be used in lieu of a
flat board in certain circumstances.
Mr. Allen arrived at 10:1Oam
d. ET Intubation and Subglottic Airways
Dr. Juda reported some patients arriving at the emergency room who were subject to
subglottic airway procedures have had issues including aspirating around the devices. He
recommended the emergency responders be allowed utilize ET intubation, with 1 — 2
attempts, if they fail, then allow the use of subglottic airways procedures.
Discussion occurred on the ramifications of the recommendation including the pros and
cons of various procedures in the field.
No action was taken on the item.
5. General Discussion
None
6. Establish Next Meeting Date
a. May 15, 2013
There being no further business for the good of the County, the meeting was adjourned by
order of the chair at 10:20 A.M
in
April 17, 2013
COLLIER COUNTY PUBLIC SAFETY
AUTHORITY MEDICAL DIRECTOR'S
SUBCOMMITTEE
These Minutes were approved by the Board /Chairman on
as presented , or as amended
5
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(PLEASE PRINT CLEARLY) Agenda Item # Ito QE_1
MEETING DATE S I T 13 101
(Circle Meeting Type) ` egular Special Workshop Budget
AGENDA ITEM TITLE _ M9,1-1L. t
NAME E Q I C. 'E 54 ► D I LU VV► ADDRESS ji'4 S► C.1 1'4115 yL g G fo AAA- L_
Representing/ Petitioner: Other: F'1 NE- 9- 1'b &4e
COLLIER COUNTY ORDINANCE NO. 2003 -53, AS AMENDED BY ORDINANCE 2004 -05 AND 2007 -24, REQUIRES THAT ALL LOBBYISTS
SHALL, BEFORE ENGAGING IN ANY LOBBYING ACTIVITIES (INCLUDING, BUT NOT LIMITED TO, ADDRESSING THE BOARD OF COUNTY
COMMISSIONERS), REGISTER WITH THE CLERK TO THE BOARD AT THE BOARD MINUTES AND RECORDS DEPARTMENT.
YOU ARE LIMITED TO THREE (3) MINUTES FOR YOU COMMENTS AND ARE TO ADDRESS ONLY THE CHAIR
PLACE COMPLETED FORM ON THE TABLE LEFT OF THE DIAS IN THE BOARD ROOM PRIOR TO THE SUB``]ETGT BEING HEARD
ZN , %rr�S QnSer TA'O �'
(PLEASE PRINT CLEARLY) Agenda Item #
MEETING DATE // 3 (Circle Meeting Type) Special Workshop Budget
AGENDA ITEM TITLE Y✓)4r(� p ��t[cnar — S -�ya1Q 11n
NAME Lot— ADDRESS _6f0(
Representing/ Petitioner: PR HS Other:
COLLIER COUNTY ORDINANCE NO. 2003 -53, AS AMENDED BY ORDINANCE 2004 -05 AND 2007 -24, REQUIRES THAT ALL LOBBYISTS
SHALL, BEFORE ENGAGING IN ANY LOBBYING ACTIVITIES (INCLUDING, BUT NOT LIMITED TO, ADDRESSING THE BOARD OF COUNTY
COMMISSIONERS), REGISTER WITH THE CLERK TO THE BOARD AT THE BOARD MINUTES AND RECORDS DEPARTMENT.
YOU ARE LIMITED TO THREE (3) MINUTES FOR YOU COMMENTS AND ARE TO ADDRESS ONLY THE CHAIR
PLACE COMPLETED FORM ON THE TABLE LEFT OF THE DIAS IN THE BOARD ROOM PRIOR TO THE SUBJECT BEING HEARD
(PLEASE PRINT
LJCL /EARLY)
MEETING DATE
AGENDA ITEM TIT�E L
NAME
Representing/ Petitioner:
Agenda Item # U .�
(Circle Meeting Type) Regular Special Workshop Budget
7� ADDRESS Z
Oil. 17�(c
Other:
J
COLLIER COUNTY ORDINANCE NO. 2003 -53, AS AMENDED BY ORDINANCE 2004 -05 AND 2007 -24, REQUIRES THAT ALL LOBBYISTS
SHALL, BEFORE ENGAGING IN ANY LOBBYING ACTIVITIES (INCLUDING, BUT NOT LIMITED TO, ADDRESSING THE BOARD OF COUNTY
COMMISSIONERS), REGISTER WITH THE CLERK TO THE BOARD AT THE BOARD MINUTES AND RECORDS DEPARTMENT.
YOU ARE LIMITED TO THREE (3) MINUTES FOR YOU COMMENTS AND ARE TO ADDRESS ONLY THE CHAIR
PLACE COMPLETED FORM ON THE TABLE LEFT OF THE DIAS IN THE BOARD ROOM PRIOR TO THE SUBJECT BEING HEARD
(PLEASE PRINT CLEARLY) Agenda Item # `
MEETING DATE
AGENDA ITEM TITLE (Circle Meeting Type) Regular Special---- WerlCshop Budget
NAME
Representing/ Petitioner:
ADDRESS
Other:
COLLIER COUNTY ORDINANCE NO. 2003 -53, AS AMENDED BY ORDINANCE 2004 -05 AND 2007 -24, REQUIRES THAT ALL LOBBYISTS
SHALL, BEFORE ENGAGING IN ANY LOBBYING ACTIVITIES (INCLUDING, BUT NOT LIMITED TO, ADDRESSING THE BOARD OF COUNTY
COMMISSIONERS), REGISTER WITH THE CLERK TO THE BOARD AT THE BOARD MINUTES AND RECORDS DEPARTMENT.
YOU ARE LIMITED TO THREE (3) MINUTES FOR YOU COMMENTS AND ARE TO ADDRESS ONLY THE CHAIR
PLACE COMPLETED FORM ON THE TABLE LEFT OF THE DIAS IN THE BOARD ROOM PRIOR TO THE SUBJECT BEING HEARD