Texas fire chief says diagnosis in fatal crash may 'have been a mistake'

By Brian Chasnoff and Lomi Kriel
San Antonio Express-News

SAN ANTONIO, Texas — The injury looked grave.

Part of the front-seat passenger's skull had caved in after a head-on collision on Loop 410. James McLaughlin, a truck driver who said he witnessed the wreck and rushed to the aid of its victims, crouched beside the mangled Honda Accord and talked to the injured woman, 23-year-old Erica Smith, until a police officer arrived.

Smith had been moaning, McLaughlin said.

"I said, 'Sir, that girl in the front seat is messed up bad. She needs help,"' he recalled.

Yet it was precisely that injury — coupled with an apparent lack of a pulse — that led paramedics to abandon Smith, believing her dead, and instead rush two other victims with non-life-threatening injuries to Brooke Army Medical Center, Fire Chief Charles Hood said on Tuesday.

Smith was actually alive — a detail discovered more than an hour later by a medical examiner's investigator called to the scene to examine her body. Paramedics again were called, and Smith was taken to Brooke Army Medical Center, on Sunday, more than two hours after the early morning wreck. She died at the hospital Monday afternoon.

The paramedics' decision to abandon Smith in the wreckage in near freezing temperatures — compounded by Hood's refusal to apologize for the incident at a news conference Monday — has stoked outrage among some. Tuesday, in an interview with the Express-News editorial board, Hood said he regretted not saying he was "sorry for the family."

Although he conceded that Sunday's misdiagnosis "could possibly have been a mistake," Hood defended the judgment of the four paramedics who abandoned Smith after checking her pulse. Cold weather can mask vital signs, he said, and victims can continue breathing after they are brain dead.

"The body is designed, basically, to function without a brain," he said. "Bodies make noises, bodies move, bodies will sit up on you.

Donald Gordon, a professor of medicine at the University of Texas Health Science Center at San Antonio, said up to 60 percent of patients who gasp are not alive. Typically, he said, the gasp is the result of a spinal reflex.

Hood and Gordon, who has authorized the standard medical operating procedure for the city's Fire Department for more than two decades, said medical privacy laws constrained them from detailing what exactly led paramedics to believe Smith was dead.

But Gordon said national standards prevent medical providers from resuscitating patients if they meet criteria classifying them as an "obvious death on arrival."

And on Tuesday, Hood said publicly for the first time that, "by all intents and purposes, (the paramedics) thought (Smith) was dead."

"She presented as deceased to them," Hood said, adding that paramedics, "when they checked, she had no pulse."

According to the current operating procedure, which Gordon updated last year, patients fall into the category of "obvious death on arrival" if they have "no measurable vital signs," such as a heart beat or pulse, and meet one of four criteria: rigor mortis; when the blood pools to the lowest level of gravity; decapitation, incineration or visual massive trauma; or if the body is decomposed.

"Visual massive trauma" refers to injuries severe enough for a layperson to think they might cause death, such as "part of a V-6 engine sitting in the middle of your chest," Gordon said.

According to McLaughlin, Smith suffered a major head injury.

"I knew that if she didn't get help right away, she might not make it," he said, adding, "My opinion, I think they should have paid more attention to her."

A police officer familiar with the incident said he told paramedics at least twice that Smith was still breathing.

"They kept telling everybody, 'No, she's not. ... She'll die in a few minutes,"' said the officer, who requested anonymity because he is not authorized to speak about the case.

If there's any question about whether a patient meets the required criteria for resuscitation, paramedics are required to call their medical director for an opinion. Gordon, who is the medical director for the city's Fire Department, declined to say whether he was called in Smith's accident.

But typically, he offers such opinions on a daily basis, he said.

It is very rare for someone to be classified as an "obvious DOA" and then return to life, he said, but it has happened. Over the past 20 years, San Antonio has recorded two other such incidents, Hood said Tuesday.

The four paramedics involved in Sunday's incident have been with the department for several years, with the least experienced having worked as a medic for nearly six years. Officials declined to release their names on Tuesday, but said the other three have served in their roles for six years, seven years and 12 years. None was disciplined for the incident and each is expected to return to work this week, Hood said.

Still, the incident remains under investigation, he said, and will force the department to review its policies.

"We need to figure out what to do to avoid this," he said. "Customers in San Antonio need to have faith in their department."

Smith was one of three people inside the Accord when a Pontiac G5 veered into an oncoming lane on Loop 410, striking the Accordshortly before 4 a.m. The driver of the Pontiac, Jenny Ann Ybarra, 28, was taken to a hospital after complaining of back pain. She has been charged with intoxication manslaughter and her bond set at $50,000. A jail official said she had posted bail, but was awaiting an ankle monitor so that she could be released.

Smith's friends — Sabrina Shaner, 22, the Accord's driver, and back seat passenger Amber Wilson, 22 — suffered serious but non-life-threatening injuries.