How an antiquated 911 system killed a woman

Two years ago in this space, I passed along Peter DeMarco’s open letter to the people who tried to save the life of his wife, Laura, who died after an asthma attack. He had written it for the New York Times.

It was dedicated to the nurses.

They asked me to leave the room for a moment, and when I returned, they had shifted Laura to the right side of her bed, leaving just enough room for me to crawl in with her one last time. I asked if they could give us one hour without a single interruption, and they nodded, closing the curtains and the doors, and shutting off the lights.

In the Boston Globe Magazine over the weekend, DeMarco tells the other side of the story.

Laura knew she was dying when she called 9-1-1 for help. She tried to tell the dispatcher where she was.

She was just outside her car, she said, on the street.

It took 10 minutes to find her. That’s long enough for her brain to die.

She wasn’t in some far-off parking lot, DeMarco reveals.

She was at the door of the hospital’s emergency room, which was locked.

In just 41 seconds, Laura managed to relate seemingly everything the operator needed to know. Laura said she was having an asthma attack, one so severe that she felt she was going to die; she said she was at Somerville Hospital, outside the emergency room, and that she couldn’t get in.

Laura was an amazing communicator — it was her profession — and, with her life on the line, she did not waste a single word.

Her cellphone call had been relayed to a regional operator 18 miles away. After explaining where she was, her call was sent to the local police department where she had to tell her story all over again.

By then, she could barely speak.

“She’s outside of the Somerville Hospital,” said the regional operator, jumping in while still on the line, DeMarco said in the Globe article, which includes audio of the call. “She’s having an asthma attack. She can’t get into the hospital there.”

How cracks and flaws in our health care system — communication errors, overburdened staffs, lack of fail-safes — snowballed into one woman’s unimaginable death. On the doorstep of a Boston-area hospital.

Posted by The Boston Globe on Saturday, November 3, 2018

A ping of her cellphone was inaccurate, he said. It showed her at the hospital’s mailing address, not at the ER’s front door.

While an Uber or Lyft driver seems to know where you’re standing, and marketers can track your every step via apps on your phone, the same often can’t be said for police and fire responders who receive 911 cellphone calls, because our nation’s 911 infrastructure hasn’t adapted nearly fast enough to our wireless world.

When you use an app involving your location, your phone constantly transmits where you are, in a way like a homing beacon. But when you make a 911 voice call, that doesn’t happen. Instead, a satellite must be pinged, and that information is integrated with other bits of data your carrier knows about your phone to trace where you’re calling from, a more complex Theand often inexact process.

Federal Communications Commission rules merely require carriers to locate 911 calls “generally to within 50 to 300 meters” of a 911 caller’s location. So potentially, a caller can be more than three football fields from the location of the ping, in any direction — a vast area for emergency responders to search for someone in trouble.

The fire department guessed where she might be; they guessed wrong. That took another minute. Nobody seemed to have a direct line to the ER, but a moment later, police reached a charge nurse inside.

The nurse, who didn’t think one of the door’s to the ER was locked, looked anyway and found it locked.

It’s the pivotal moment, as Laura has been unconscious less than three minutes. It has been possibly less than two minutes since her heart stopped beating. The odds were still strong she could have been saved, if only Nurse X walked a few feet to find Laura on that bench.

But Nurse X did not do that.

On the surveillance video, you see Nurse X take one step outside the ambulance-access door, going no further than an arm’s reach from it. In the predawn darkness, Nurse X cranes her neck a bit to see, but she doesn’t spot Laura on the bench, which is almost straight ahead of where she’s looking, albeit in a shadow.

There were only two entrances, within 100 feet of each other, that could have led to the emergency room.

But Nurse X never strayed from the sliding door, as if she were afraid it would close on her.

The nurse told police she didn’t see anybody outside the door. Three minutes later, retracing Laura’s steps, firefighters found her.

By then it was too late.

A police officer’s incident report says he ran to the ER for help.

“I ran inside and no one was at the security desk. I ran to the entrance of the Emergency Room and looked inside the windows and did not see anyone. I started to bang on the glass with my ring and from in the back I heard someone yell, ‘Relax’ in a very [annoyed] tone, and then as she turned the corner and saw me she said, ‘Take it easy’ in that same annoyed tone.

I was standing there in full uniform and could not believe the attitude on this woman. I said, ‘Are you kidding me, the firefighters are working on someone on the sidewalk and need help and a stretcher.’”

DeMarco writes that when he made it to the hospital, nobody told him the correct story of where his wife was found.

No one said anything days or even weeks later, after he’d penned his tribute to the nurses.

I am not going to sue the Somerville police or fire departments, or the State 911 Department — nor can I, as state laws grant them powerful immunity regarding 911 response errors. But the mistakes made in the transferring of information between emergency responders that morning also dictated Laura’s fate.

I hope emergency operators and dispatchers who read this story learn from those grave mistakes, make efforts to react with greater urgency to asthmatic callers, and establish protocols for reaching out not just to ambulance companies, but to the nearest possible source of help when that’s the best chance someone has of surviving.