STATE OF MAINE STATE OF MAINE DEPARTMENT OF PUBLIC SAFETY DEPARTMENT OF PUBLIC SAFETY AINE E EMERGENCY EDICAL S SERVICES MMAINE

MERGENCY MMEDICALERVICES 152 STATE HOUSE STATION 16 EDISON DRIVE AUGUSTA, MMAINE AUGUSTA, AINE 04333 04330
PAUL R. LEPAGE
GOVERNOR

JOHN E. MORRIS COMMISSIONER JAY BRADSHAW
DIRECTOR

Report of Maine EMS regarding the care provided to injured skier at SugarLoaf by NorthStar EMS on January 12, 2012. The patient was skiing with a friend at approximately 15:43 on the Timberline Trail at Sugarloaf Mountain when, according to the Ski Patrol Incident Report, he caught an edge and fell into a tree at speed. The first report of the accident to the Ski Patrol came from a caller at Bullwinkle’s Restaurant, which is located on the mountain. The first responding ski patroller took a cross trail to Timberline to then ski down to the site; however, the actual site was above where it was initially reported and thus above the cross trail. A second call from a ski instructor provided the correct location and another ski patroller who was on the trail and aware of the initial report responded to the scene. Upon arrival at the scene, the ski patroller reported initially there was discussion that perhaps the patient would go to the hospital by private vehicle if needed, but then it was agreed that an ambulance would be called. Ski Patrol communications are not recorded, so the details and times of the communications are unknown. At approximately 16:12, Sugarloaf Dispatch requested NorthStar EMS respond to the ski patrol base for a “…possible leg fracture, probably tib/fib and possible internal bleeding.” The NorthStar crew, Paramedic Charles Twitchell and Emergency Medical Technician (EMT) Wade Browne, were at NorthStar’s Carrabassett Valley base monitoring the ski patrol frequency and heard the report of the accident which was described as a “Code 3.” Code 3 means there is a serious injury, such as a fracture. (Ski Patrol codes range from 1‐5; with 1 being the most critical and 5 being a minor injury.) The NorthStar crew started driving toward the mountain and were already enroute when they were contacted by Sugarloaf Dispatch. They arrived at the Ski Patrol First Aid station at approximately 16:23. The Sugarloaf Ski Patrol First Aid Station is not staffed with medical personnel. However, Ski Patrol members are trained in emergency first aid and certified by the National Ski Patrol. The Ski Patrol Dispatch Center is located at the First Aid Station and was staffed by a dispatcher who is a former Maine licensed EMT and is currently CPR certified.
PHONE: (207) 626-3860 TTY: (207) 287-3659 FAX: (207) 287-6251

With offices located at the Central Maine Commerce Center, 45 Commerce Drive, Suite 1, Augusta, ME 04330

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The patient’s wife had been snowboarding in a different area and was returning to their condo when she learned that her husband had fallen and was being taken to the clinic. The patient’s wife changed out of her ski boots, put on a running jacket, winter boots, took her purse, and drove to the First Aid Station. She arrived at the First Aid Station prior to the Ski Patrol who were transporting the patient in a rescue toboggan. Upon arrival at the First Aid Station, NorthStar personnel conducted an initial primary assessment and began removing the snowmobile suit that the patient was wearing, which took several pair of sheers. Once the suit was completely removed the patient was reassessed and Paramedic Twitchell made the decision that it was essential to get moving toward the hospital as soon as possible. It had been snowing throughout the day and was snowing heavily at the time of the accident. As a result, both LifeFlight helicopters were out of service. The nearest hospital emergency department was Franklin Memorial Hospital in Farmington (~ 45 miles; 1+ hour ground travel time) and the nearest Trauma Center was Central Maine Medical Center in Lewiston (~ 85 miles; 2+ hour ground travel time). NorthStar personnel followed Maine EMS Protocols in preparing the patient for transport to the hospital. As he was being loaded into the ambulance, the patient’s condition changed and at approximately 16:43, while emergency care was being provided, additional personnel were called for assistance. The patient’s wife went back inside the First Aid Station to let them know about the situation and obtain additional help. Responding from the First Aid Station were the dispatcher, and members of the Ski Patrol. The dispatcher went into the back of the ambulance to assist with patient care. NorthStar EMS crew asked one ski patroller to call Dispatch and request additional NorthStar personnel; they then asked the same patroller to start driving the ambulance toward the hospital until they met up with the other NorthStar personnel. The ski patroller is an experienced motor vehicle operator, but was not an experienced ambulance driver and therefore was unfamiliar with the interior switches and controls. The patient was put on a cardiac monitor and additional treatment was provided as the ambulance started toward the hospital. The patient’s wife was in the back of the ambulance initially, but was then directed to sit in the front of the vehicle before transport. Enroute, the ski patrol dispatcher assisted NorthStar personnel with patient care. A short distance later, at the end of Parking Lot C before turning onto the access road, Twitchell told the driver to stop so he could provide additional treatment. At approximately 17:00, Paramedic Twitchell called Franklin Memorial Hospital and spoke with the Physician’s Assistant providing online medical control (OLMC). During this conversation, Paramedic Twitchell described the patient’s condition, the treatment provided, and asked for other medical orders, including medication. OLMC instructed Twitchell to continue to follow Maine EMS Protocols.

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From the front seat, the patient’s wife could look into the rear of the ambulance and stated that she could see that emergency treatment was in progress, knew that this would not have a good outcome, and told the ski patroller that she needed to be in the back with her husband. The ski patroller remembers hearing her express a need to be with children and her request to stop the vehicle. What is undisputed is that the patient’s wife exited the ambulance and the ambulance drove away. Maine EMS does not license or regulate members of the Ski Patrol. As the ambulance continued down the access road, the patient’s wife chased after it and then flagged down two cars that were heading in the opposite direction (toward the mountain). The driver of the second car reported that the patient’s wife initially wanted to try and catch the ambulance, but it was snowing heavily and the driver said she did not recall seeing an ambulance. The patient’s wife then asked to go back to the First Aid Station, which is where she was taken. The ambulance stopped another time near the base of the access road when they met Judith Wills, one of the backup NorthStar EMS providers. Because of a concern that the location was not a safe place to be parked, Wills told the driver to pull into the Mountainside Garage, which is at the intersection of the access road and Route 27. When EMT‐Intermediate Wills got into the ambulance, she assisted with another assessment of the patient, then EMT Browne asked her to check on the wife, who he thought was still in the front seat. At approximately 17:10, Paramedic Twitchell called FMH Medical Control to report that the patient had died. Around this time, the NorthStar crew learned that the patient’s wife was no longer in the ambulance. When Medical Control asked about family members, Paramedic Twitchell told him that the patient’s wife was not with the ambulance. NorthStar then contacted Sugarloaf Dispatch and requested an officer from Carrabassett Valley PD to meet them at the Mountainside Garage. An officer arrived at approximately 17:23 and the patient’s body was transported back to the First Aid Station. After arriving back at the First Aid Station and learning that the patient’s wife and a friend were enroute to the hospital, at approximately 17:40, Paramedic Twitchell called FMH and spoke with another member of the hospital staff to let them know that the patient’s wife was likely heading toward the hospital and may not know her husband was deceased. At approximately 18:25, Paramedic Twitchell and EMT Browne left the First Aid Station and returned to the NorthStar Carrabassett Valley base. While the crew was cleaning the ambulance, they received a telephone call from a nurse at FMH who asked to speak with Paramedic Twitchell. The nurse then handed the phone to the patient’s wife. Paramedic Twitchell was unaware that the patient’s wife had not been

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notified about her husband’s death and when she asked where her husband was, he told her that the patient passed away and that his body was at the First Aid Station. An autopsy was not performed; however, based upon a physical examination the following day by a local Medical Examiner, the immediate cause of death was listed as chest trauma as a consequence of a skiing accident. Investigation Process and EMS Medical Review Interviews were conducted by Jay Bradshaw, EMS Director, and Detective Patrick Gagnon, Office of the Attorney General. Maine EMS obtained additional information from the Franklin County Sheriff Department, Franklin Memorial Hospital, Office of the Chief Medical Examiner, and the Carrabassett Valley Police Department. Michael Baumann, MD, FACEP, performed an independent review of the emergency medical care provided to the patient. Dr. Baumann is an experienced emergency physician, the Interim Chief of the Department of Emergency Medicine at Maine Medical Center, and Professor of Emergency Medicine, Tufts University School of Medicine. Dr. Baumann concluded that there may have been a short period at initial contact where the severity of the patient’s condition was latent or unrecognized due to the patient talking and responding to questions, the snowmobile suit, and the need to provide treatment. Dr. Baumann also noted that while some of the treatment provided could have been initiated sooner, it would not have affected the unfortunate outcome and that the NorthStar crew appeared to act in accordance with the Maine EMS Treatment Protocols. Dr. Bauman noted that the EMS run report documentation could be improved in several areas. Conclusion The investigation regarding Judith Wills and NorthStar paramedic Rebecca Morin were dismissed by Maine EMS because those personnel arrived at the ambulance at the end of the call when the vehicle was parked at the Mountainside Garage and resuscitation efforts were being terminated. Paramedic Twitchell and EMT Browne appeared separately before the Board of EMS Investigation Committee for informal conferences on March 7, 2012, which were held in Executive Session pursuant to 32 M.R.S.A. §90 (A)(3) and 1 M.R.S.A. §405(6)(E) & (F). Regarding EMT Browne, the Investigation Committee concluded there was no violation of Maine EMS rules, statutes, or protocols and recommended that the complaint be dismissed Regarding Paramedic Twitchell, the Investigation Committee found that the evidence could potentially support a finding that the Licensee violated Chapter 11 § (1)(14), “Violation of any standard established in the profession” for run report documentation. However, the Committee recommended that the Board of EMS find that the potential violation does not rise to a level warranting disciplinary action and offer Twitchell a Letter of Guidance to reinforce the importance of proper documentation which will remain in his file until April

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4, 2015. A Letter of Guidance is a non‐disciplinary action that may be considered if there are any complaints about documentation during this period. Regarding NorthStar EMS, the Investigations Committee found that NorthStar has policies and procedures in place to address family members riding in the rear compartment during transport and to activate additional assistance when needed. NorthStar has a Quality Improvement Policy for reviewing patient care run reports. It is also important to note that when the available EMS personnel are needed to care for a critically ill or injured patient, it is not unusual for EMS providers to be in the rear providing patient care while non‐EMS personnel drive the ambulance. NorthStar provides annual training for Ski Patrol to familiarize them with the vehicle prior to the ski season. The Committee found that there was no violation of Maine EMS rules or statutes, and recommended that the complaint be dismissed. At its meeting on April 4, 2012, The Board of EMS reviewed and ratified these recommendations. Contact: Jay Bradshaw Director, Maine EMS Jay.bradshaw@maine.gov 207‐626‐3865