The Following is taken from “Quality of Care Review of Emergency Medicine Services Response to Fatal Motor Vehicle Collision Involving Zak Maun Quappe (deceased)”

Prepared for Ministry of Home Affairs, Health and Government, Cayman Islands

By Dan Cass, BSc, MD, FRCPC June 7, 2015

Executive Summary
Zak Maun Quappe is a 21-year-old male who suffered life-threatening injuries in a motor vehicle crash that occurred in George Town, Cayman Islands, in the early morning hours of May 18, 2013. The response by EMS and other providers was timely and within the established response time standards. Paramedics assessed Mr. Quappe, who was still trapped in his vehicle, and determined that he was unresponsive with no signs of life. Resuscitation was not attempted.

The paramedic response deviated from established protocols for the Cayman Islands EMS service in terms of the completeness of certain aspects of the assessment and in the decision not to initiate resuscitative measures in the absence of specific direction from their medical control physician.

Because a full post mortem examination was not performed, the exact nature and extent of Mr. Quappe’s injuries are not known. The injuries which are known with certainty (including bilateral femur and tibia-fibula fractures and blunt trauma to the head) would be considered serious and potentially
life-threatening even in the absence of additional internal injuries. Based on the medical literature and the clinical experience in other jurisdictions regarding the survival rates of blunt trauma patients who are vital signs absent with an initial cardiac rhythm of asystole, it is my opinion that that Mr. Quappe’s injuries were likely not survivable, and that earlier assessment and/or initiation of CPR and other resuscitative measures by paramedics would not have altered the ultimate outcome.

In reviewing this case, I have identified opportunities for improvement in the quality of care provided by the Cayman Islands emergency response and EMS systems, and I have made six recommendations to support such system improvements:

1. Consider equipping Cayman Island police and fire first responders with automated external defibrillators (AEDs) and training them on their use.

2. Develop and implement a paramedic protocol specific to the management of patients with traumatic cardiac arrest.

3. Reinforce existing paramedic policies and protocols through continuing professional education. In particular, this should focus on: indications for seeking direction from the medical control physician; management of the patient with traumatic cardiac arrest, and; decision-making around withholding or discontinuing resuscitation.

4. Consider the development of additional EMS-specific fractile response time standards, linking the target response times to patient acuity.

5. Remind all paramedics of the importance of documenting observations, rather than conclusions or medical diagnoses.

6. Synchronize event recorders throughout the system.

Background to Review
I was engaged by Ms. Jennifer M. Ahearn, Permanent Secretary & Chief Officer – Health & Culture, Ministry of Home Affairs, Health & Culture, Cayman Islands Government, to conduct a review of Emergency Medical Services (EMS) response to a fatal motor vehicle crash. This review is in response to a complaint lodged by the family of the decedent in the incident, and examines the EMS response to the incident, including the response times and the care provided to the decedent.

Qualifications of Reviewer
My clinical background is in emergency medicine. I completed the Emergency Medicine residency program of the Royal College of Physicians and Surgeons of Canada at the University of Toronto, and practiced at an academic trauma centre Emergency Department in Toronto, Canada for 16 years (10 of these as Chief of Emergency Medicine). Throughout that time, I was involved with EMS activities, both informally in the clinical setting, and as a member of the Paramedic Program Committee for Toronto EMS (now Toronto Paramedic Services) for more than 10 years.

In 2009, I left clinical emergency medicine and accepted a role with the Office of the Chief Coroner for Ontario, initially as Regional Supervising Coroner for Toronto West, and then as Deputy Chief Coroner for Investigations for the province. I served as Interim Chief Coroner for Ontario for a six-month period in 2013. At the Office of the Chief Coroner, I also chaired the Patient Safety Review Committee, which
reviewed healthcare-related deaths (including those occurring in the pre-hospital setting) with a view to identifying recommendations to prevent future deaths in similar circumstances.

I hold an academic appointment as Associate Professor, Division of Emergency Medicine, Department of
Medicine, at the University of Toronto.

I have recently assumed a new administrative and clinical role at a Toronto hospital. For clarity, I have conducted this review independently, and neither this report nor its conclusions is in any way meant to be representative of the views of my current or past employers.

In preparing this report, I acknowledge my duty to:
a) Provide an opinion that is fair, objective and non-partisan;
b) Provide an opinion that is related only to matters that are within my area of expertise; and
c) Provide such additional assistance as may reasonably be required, to determine a matter in issue. Further, I acknowledge that the duty referred to above prevails over any obligation which I may owe to any party by whom or on whose behalf I am engaged.

Scope of Review
The review focusses on the specific incident in question; namely, a fatal motor vehicle crash which took place on May 18, 2013, involving Mr. Zac Maun Quappe. The key issues as I understand them relate to the response time, and the actions of the EMS providers. In specific, there have been concerns raised that proper procedures and protocols were either not in place, or were not adhered to. The overall aim of the review is to identify any deficiencies that may exist, with a view to learning from this tragic incident to improve the quality of care by paramedics in the Cayman Islands, and potentially to prevent similar deaths in the future.

In scope:

 The details of the incident itself, including but not limited to ambulance call reports, medical records of the treatment of the decedent by EMS providers and hospital staff and physicians (as applicable)
 Relevant existing policies, procedures and protocols for EMS response from the Health Services
Authority in the Cayman Islands
 Relevant training and certification standards for EMS providers in the Health Services Authority in the Cayman Islands
 Relevant standards, best practices and guidelines for EMS response, education and certification
from other jurisdictions and/or the published literature which might be useful in guiding practice on a go-forward basis

Out of scope:

 An evaluation of the 9-1-1 call taking and dispatch processes themselves
 An evaluation of subsequent investigations into either the incident itself, or into complaints or concerns raised by Mr. Quappe’s family or others

Recommendations for Improvements to EMS Response
The following recommendations arise from my review of the facts of this case, and of the paramedic treatment policies, procedures and protocols and response time standards and targets in place in the Cayman Islands, and in other jurisdictions. They are intended to assist with the continuous quality improvement of the EMS system in the Cayman Islands.

1. Consider equipping Cayman Island police and fire first responders with automated external defibrillators (AEDs) and training them on their use.
Rationale: PC 352 arrived on scene 1 minute and 22 seconds before Medic 3, at 03:19:24. If Cayman Islands Police first responders were equipped with and trained to use AEDs, there would have been an opportunity to assess the decedent and provide defibrillation (if indicated) more than one minute earlier than would have been possible by Medic 3. There is no way of knowing whether the decedent was in a cardiac rhythm of ventricular fibrillation or pulseless ventricular tachycardia at that time (or, indeed, at any point) for which defibrillation would have been indicated. Arguably, however, the most critical and effective prehospital intervention in cardiac arrest is timely defibrillation, and consideration should be given in any emergency response system to provide defibrillation as quickly as possible when indicated. This recommendation is particularly germane given the inherent geographic and logistic challenges to ensuring timely response times for paramedic services throughout the Cayman Islands with a limited number of paramedic units in service at a given time.

2. Develop and implement a paramedic protocol specific to the management of patients with traumatic cardiac arrest.
Rationale: As noted above, cardiac arrest from a medical condition is a very different situation from cardiac arrest arising from trauma (in terms of both cause and likelihood of survival), and merits a different approach. In this case, the decision by the paramedics not to initiate resuscitation of the decedent would, in many jurisdictions, have been considered appropriate. However, in order to ensure that paramedic decision-making around the management of trauma patients with cardiac arrest is consistent with accepted practice, it is critical that any protocol used to guide paramedic treatment is clear with respect to the criteria for withholding or withdrawing resuscitation, and who (paramedic or medical control physician) is able to make this decision. In the absence of such a protocol, resuscitation should be initiated and continued unless and until a decision is made with medical input to cease resuscitative efforts.

3. Reinforce existing paramedic policies and protocols through continuing professional education. In particular, this should focus on: indications for seeking direction from the medical control physician; management of the patient with traumatic cardiac arrest, and; decision-making around withholding or discontinuing resuscitation.
Rationale: Notwithstanding the need for a specific Cayman Islands EMS paramedic protocol for the management of traumatic cardiac arrest, several deviations from accepted practice and existing protocols were identified in this case. Ongoing continuing professional education is critical for all health providers, including paramedics, and should include reinforcement of key concepts and critical protocols, especially those which may be used infrequently.

4. Consider the development of additional EMS-specific fractile response time standards, linking the target response times to patient acuity.
Rationale: Standards currently exist for Cayman Islands EMS response times, including the Call Processing Standard, En Route Standard, and Travel Standard. However, these are portrayed as absolute values, irrespective of the condition of the patient. Many jurisdictions have adopted fractile response time targets which are linked to the acuity of the patient’s presenting problem, in order to assist with dispatch prioritization and quality assurance efforts. Adopting a validated prehospital triage scale (such as the Canadian Triage Acuity Score (CTAS)) can assist with this process.

5. Remind all paramedics of the importance of documenting observations, rather than conclusions or medical diagnoses.
Rationale: Documentation by paramedics in this case included both objective observations and more subjective conclusions and medical diagnoses with respect to findings. Documentation by paramedics should focus on what is observed through the course of their patient assessment, rather than including definitive statements about the presence of specific diagnoses if this is not, in fact, within the scope of their assessment skills at the scene.

6. Synchronize event recorders throughout the system.
Rationale: Event times in this case were logged through a variety of systems, including: the Department of Public Safety Communications (DPSC) Centre Computer Aided Dispatch (CAD) system; the DPSC’s 911 system; and the DPSC logging recorder system. These three systems vary by as much as 1 minute and 45 seconds from each other, and it is necessary to manually correct the time points from each system in order to establish a reliable and accurate sequence of events. While the Incident Timeline provided to me as part of the documentation included these corrections, ideally the three sources should be synchronized to each other (just as the CAD system is synchronized to the atomic clock) to eliminate this potential source of error and the additional effort required to correct these discrepancies.

Concluding Statement
Zak Maun Quappe suffered life-threatening injuries in a motor vehicle crash that occurred in George Town, Cayman Islands, in the early morning hours of May 18, 2013. The response by EMS and other providers was timely and within the established response time standards. Paramedics assessed Mr. Quappe, who was still trapped in his vehicle, and determined that he was unresponsive with no signs of life. Resuscitation was not attempted.

The paramedic response deviated from established protocols for the Cayman Islands EMS service in terms of the completeness of certain aspects of the assessment and in the decision not to initiate resuscitative measures in the absence of specific direction from their medical control physician.

Because a full post mortem examination was not performed, the exact nature and extent of Mr. Quappe’s injuries are not known. The injuries which are known with certainty (including bilateral femur and tibia-fibula fractures and blunt trauma to the head) would be considered serious and potentially life-threatening even in the absence of additional internal injuries.

Without knowing the full extent of Mr. Quappe’s injuries, it is not possible to state definitively whether or not the outcome could reasonably have been affected by any actions that could have been taken by paramedics. However, based on the medical literature and the clinical experience in other jurisdictions regarding the survival rates of blunt trauma patients who are vital signs absent with an initial cardiac rhythm of asystole, it is my opinion that that Mr. Quappe’s injuries were likely not survivable, and that earlier assessment and/or initiation of CPR and other resuscitative measures by paramedics would not have altered the ultimate outcome.

In reviewing this case, I have identified opportunities for improvement in the quality of care provided by the Cayman Islands emergency response and EMS systems, and I have made six recommendations to support such system improvements.

In closing, I would like to extend my personal condolences to the family and friends of Mr. Quappe. While nothing can truly lessen the extent of your loss, it is my sincere hope that the clarification and analysis that I have attempted to provide this this review, coupled with the opportunity to improve care for others in the future, will offer you some degree of comfort in the days ahead.

END

See also iNews Cayman’s Editorial today “Quappe family response to Quality of Care Review to son’s death is exemplary”

AND

“Cayman Islands Health Ministry replies to Quality of Care Review on road death victim” also published today.