This is getting very concerning. It seems that at least once a week I’m reading a story about a disastrous EMS incident. Sadly, I could rename this blog “The Journal of Iatrogenic Medicine” and have plenty of material.

This is a story from down in Texas right next to Austin.

Pflugerville widow struggling with support year after husband died of medical negligence

In the autopsy report, pathologist Satish Chundru said Samerigo received a cricothyroidotomy, an incision through the skin on the throat, that he did not need. It also said that after Samerigo received two doses of the nerve-blocking agent midazolam intranasally, he could have only survived if an airway was established. When one was not established, it compromised his heart and led to his death, according to the report.

Keep in mind that this is a non medical publication, however that description is a bit confusing, at least to me. The description of the cricothyroidotomy is correct, but the description of Midazolam is confusing. Midazolam, better known as Versed is a drug somewhat similar to Valium. It’s has somewhat different effects, but a nerve block is not one that I ever knew about.

It is used for procedural sedation, anesthesia, seizures, and acute behavioral emergencies. So, I don’t know Mr. Samerigo actually received Midazolam or received a neuromuscular blocking drug of the type to induce chemical paralysis during surgery or other procedures requiring that.

Although I know what a cricothyroidotomy is and have done one, I don’t know why or even where in the patient contact that was done. In reference to the airway, that is what a cricothyroidotomy is supposed to provide. It is also not the first type of airway that I’d consider UNLESS the patient had either severe facial injuries or his jaw was clenched so tightly that an oral airway couldn’t be placed. Even then, I’d consider a nasal airway before a surgical airway.

The Texas Department of State Health Services investigated the 2023 incident and found that the paramedic, Hiram Edmundo Ortega, violated state codes related to providing emergency medical services. On Sept. 13, the department sent Ortega a notice of intent to revoke his license.

The Texas Department of State Health Services (DSHS) is pretty aggressive in investigating and disciplining EMS practitioners. If you read the state codes linked above you’ll see that there are a lot of things for which EMS practitioners can be disciplined. It’s not a surprise that they decided to revoke Mr. Ortega’s license.

The article then goes on to cite a lot of recent difficulty with EMS in Pflugerville. I’m not going to quote any of that, but you should definitely read it.

Just to help you out in many parts of Texas outside of major cities voters agree to create Emergency Services Districts (ESD). An ESD is a government entity, but operates independently. So, although they call themselves the Pflugerville Fire Department, they are not a city agency. PFD doesn’t provide transport, they provide first response. They then hand off the patient to whoever the transporting service. At one time it was Austin/Travis County EMS, but there were complaints that ATCEMS had long response times. The ESD known as Pflugerville Fire Department tried it’s hand at running an ambulance service, but the taxpayer complained about the cost and the ESD opted to contract with a private service.

For a very short time, they used Acadian Ambulance Service, however there were complaints (again) that Acadian took too long to respond. The city of Pflugerville also complained about the cost.

The ESD then contracted with Allegiance Mobile Health, which while not nearly as big as Acadian has widespread operations in Texas. There website says that they provide 9-1-1 services to a variety of  cities, counties, and other places in Texas.

Allow me to editorialize on EMS in general, not specifically this case.

EMS is expensive to operate. While a top quality ambulance for emergency responses can cost over $250,000.00 if fully equipped that’s not the most expensive part of the operation. Neither is additional equipment or supplies. Or insurance, for that matter.

The most expensive part of an EMS system in paying EMTs and paramedics to work on those ambulances. The work is not easy and EMS has a high burnout rate. Even without that people often leave to find jobs that pay more, they like better, or give them more time off. Or some combination of those.

EMS system operators will cut corners where they can. One of those is on paying their EMTs and paramedics. To have a good service you need to have good care providers. To have good care providers who will hang around for a while you need to pay them well and give them benefits. If you don’t you’ll have a lot of turn over and a lot of inexperienced care providers in critical roles.

Low pay is common in the private service industry, along with poor benefits, and a hard schedule. There is a lot of turnover as providers look at better job options in and out of EMS.

There is no good and cheap EMS. You can have good EMS, but it will cost you. You can have cheap EMS, but it will likely end up costing you even more.

Sadly, that’s a lesson that is only learned the hard way and all too often the lesson doesn’t stick.