Report: 'Missteps' in care for collapsed US Navy sailor who died

For roughly 10 minutes after the sailor collapsed, he did not receive CPR or shocks from a nearby defibrillator

By John Keilman
Chicago Tribune

CHICAGO — The call came into Naval Station Great Lakes' 911 center on a cold December afternoon. A sailor who had just finished the final test of boot camp had collapsed, maybe from a seizure, maybe from simple fatigue.

"We had battle stations last night, so he hasn't gone to bed in … about 48 hours," the caller said.

"Yeah, that's probably why," the dispatcher said.

But the sailor, 20-year-old Andrew Adams, hadn't fainted from exhaustion. He wasn't having a seizure. He was in severe cardiac distress, and less than an hour later, he would be dead — the victim of an undiagnosed heart condition and emergency medical care two federal reviews found to be problematic.

According to records obtained by the Tribune, Adams' care was marked by missteps that began with the 911 call, continued when paramedics arrived and carried over to the Lovell Federal Health Care Center, the military hospital where he died.

But the most serious issue, according to the records, was that for roughly 10 minutes after Adams collapsed, he did not receive CPR or shocks from a nearby defibrillator, even though Navy personnel on the scene had been trained in those lifesaving techniques.

"Airway management was one area along with defibrillation and effective CPR (that) may have made a significant difference in the outcome," a Lovell fact-finding report concluded.

Asked why Adams' superiors, known as recruit division commanders, did not perform CPR or use the defibrillator, Navy spokesman Lt. Adam Demeter said they detected a faint pulse and saw that Adams was breathing, albeit with difficulty.

But the American Heart Association, which designs the CPR training recruit division commanders receive, advises rescuers to begin chest compressions on an unresponsive person if he or she is not breathing normally.

"We don't teach them to check a pulse … because we know they can't tell (if it's there), and they'll be wasting critical time if the person actually is in cardiac arrest," said Dr. Michael Sayre, an emergency medicine professor at the University of Washington and a spokesman for the association.

He said cardiac deaths offer an opportunity to improve the response to those emergencies, which can be confusing and difficult to manage. But representatives of the hospital, the base and the Navy's Recruit Training Command defended Adams' care.

"Fire, EMS and security were trained in what they were supposed to do and did what they were supposed to do in a timely manner," said Capt. James Hawkins, commanding officer of Naval Station Great Lakes.

The Navy Criminal Investigative Service, which examines most Navy deaths that are unrelated to combat or terminal disease, is still looking at the case; a spokesman said the office does not comment on open investigations.

But Adams' mother, Maricel Adams of North Port, Fla., said she had read enough in the fact-finding report to question her son's care.

"I was just really shocked," she said. "I just had goose bumps all over. They assumed. For a medical emergency like that, they can't assume. They have to handle it like an emergency. It's life or death."

'Breathing normal?'

Adams grew up near Sarasota, Fla., a quiet kid who was a fan of video games, anime and Dungeons and Dragons. He was part of the Marine Corps Junior Reserve Officers Training Corps at Venice High School, and friends say he had no problem with its physical demands.

After graduating in 2013, he worked at entry-level jobs and briefly studied computer science at a local college before deciding to enlist in the Navy.

"It was largely a means to get his life started," recalled his friend Andrew Moyer. "It was his ticket out of Venice. He wanted to see the world, and he knew that working at McDonald's wasn't going to get him there."

He left Florida in October for boot camp at Great Lakes. His mother said he was excited to go, an enthusiasm that carried on through his training.

"He was enjoying the time at boot camp," she said. "He met all kinds of people. He said he fit in and really loved it."

After eight weeks, Adams and his fellow recruits went through battle stations, an all-night training exercise aboard a simulated military ship. It's the last trial of boot camp, and once recruits finish, they formally claim the designation of sailor and head to other bases for further training.

First, though, they have a chance to relax in Great Lakes' naval exchange, a mall-like building where newly minted sailors can eat fast food, play video games and call their families. Maricel Adams said she heard from her son about 3:30 p.m. Dec. 1, and they discussed her visit to boot camp graduation and his move to Pensacola, Fla., to study avionics.

About 90 minutes later, Navy and Lovell records say, Adams collapsed in front the video game "Guitar Hero." At 5:03 p.m., someone called 911, saying Adams appeared to be having a seizure.

A recording of the call indicates that the dispatcher immediately sent paramedics to the building and then questioned the caller about Adams' condition.

The caller, who was using a phone in a spot where he couldn't see Adams, corrected himself after shouting back and forth with people at Adams' side, saying the young sailor had passed out from exhaustion.

"Is his breathing completely normal?" the dispatcher asked.

"Very shallow," the caller responded.

"Shallow breathing?"

"Yes, ma'am."

American Heart Association guidelines call for dispatchers to instruct those near a possible cardiac arrest victim to begin chest compressions if the person is unresponsive and not breathing normally. Sayre said what appears to be labored breathing can actually be "agonal gasps" — a reflex emanating from an oxygen-starved brain.

The difference can be hard for the untrained to discern, and in 2012, the association published a scientific statement calling for dispatchers to seek follow-up information, such as timing the gaps between breaths or putting the phone next to the victim so the dispatcher can listen.

Time is of the essence during a cardiac arrest: The association says a person's chance of survival drops by 10 percent for every minute that passes without intervention. Numerous studies have shown that those who receive prompt CPR and defibrillation — a shock meant to restore a regular heartbeat — are up to four times as likely to pull through.

A device that delivers those shocks, known as an AED, was in the naval exchange, and Demeter said the recruit division commanders had been trained on how to use it.

But it didn't happen. While the dispatcher told the caller to keep an eye on Adams' breathing and post someone outside the building to guide paramedics to the scene, the recruit division commanders "ensured scene safety … and conducted reassessments of the airway, breathing and circulation of Airman Adams," Demeter said. "It was their determination to not conduct CPR nor utilize the AED."

Adams wouldn't begin to receive that help, Lovell records say, until 5:13 p.m. — one minute after paramedics got to him, and about 9 1/2 minutes after the 911 call was made. By that time, according to the records, "patient was cold, pale, unresponsive, and without a carotid pulse."

Some EMS professionals who reviewed the 911 recording at the Tribune's request said the dispatcher's decision not to push for bystander CPR was understandable.

"The dispatcher seems to have been hampered by the caller being on a landline separate from the patient," said Dr. Joshua Stilley of the paramedic training program at the University of Iowa. "When she asked questions the caller answered but did not seem to provide accurate answers."

Sayre, though, said the phrase "shallow breathing" should have triggered a different response.

"Ideally, that would have been enough to get CPR going," he said. "To me, this is a training issue. This is something that is unfortunately common. Many dispatch centers really need more training of their teams to recognize this scenario."

Code blue questions

The records say the lack of prompt CPR was the most critical issue in Adams' care, but the alleged missteps didn't end after police officers and paramedics arrived.

Paramedics discovered that Adams' mouth was full of vomit, and after suctioning it, they tried to insert a breathing tube. But the records say they had trouble inserting it, and didn't get one in place until 5:21 p.m.

A Lovell committee that reviews CPR issues said in an internal report obtained by the Tribune that the paramedics should have tried other techniques to open Adams' airway, though it noted that more vomiting could have foiled that approach.

The paramedics gave Adams four doses of epinephrine in an unsuccessful attempt to restart his heart, then transported him to Lovell. Emergency room staff met the ambulance in the garage and took Adams to the hospital's "resuscitation room," where they gave him more drugs, performed another defibrillation and assessed his heart function with an ultrasound device.

"Finding no cardiac activity all members of the code team were asked for further suggestions; finding none, the recruit was pronounced dead at (5:59 p.m.)," the fact-finding report said.

But the CPR committee noted that the hospital staff did not call a facilitywide "code blue," an alert that would have summoned an expert who "would have promoted more aggressive resuscitation" using other drugs and medical devices.

The fact-finding report said the emergency room staff thought a facilitywide alert wasn't necessary, given the experience of those caring for Adams. The CPR committee said it should have been done, though it concluded it probably wouldn't have made a difference.

"(The) likelihood of (Adams' heart restarting) after failed out-of-hospital resuscitation would be very low, and most of the outcome was probably sealed by the pre-hospital response," it said.

Lovell spokeswoman Stephanie McCrobie declined to address the CPR committee's report.

'Vigorous' responder program needed

The Lake County coroner's office determined that Adams died of an arrhythmia due to dilated cardiomyopathy — an irregular heartbeat caused by an enlarged and weakened heart. Dr. Robert Bonow, a professor of cardiology at Northwestern University's Feinberg School of Medicine, said the cause of the condition isn't clear, though it appears to be genetic.

He said an echocardiogram or ultrasound test can spot the problem, but they are not part of a typical physical exam, including those administered by the military before boot camp.

"Many times it goes undetected until something horrible happens, because people can look good or feel good," he said.

Maricel Adams said doctors detected an arrhythmia in her son when he was in elementary school, but after follow-up exams, concluded there was no problem. He was never diagnosed with dilated cardiomyopathy, she said.

Dangerous as the condition can be, someone who has it can survive cardiac arrest if he gets timely treatment, said Dr. Jeffrey Goldberger, another Feinberg cardiology professor.

"Most people who have sudden cardiac deaths, if one can get to them and treat them on time with a (defibrillator), most of the time you can resuscitate them," he said.

The Lovell CPR committee concluded its report with several suggestions. It called for ensuring hospitalwide code blue activation in all cases of cardiac arrest, and it conveyed its "concerns" about the dispatcher's failure to direct CPR and the paramedics' approach to managing Adams' airway.

But its top recommendation was that Great Lakes survey "first responder practices" concerning CPR.

"The large contingent of Navy recruits and Navy personnel and several documented cases of sudden cardiac arrest strongly justifies a vigorous first responder program at the base; consistent with national ... and international ... resuscitation guidelines concerning — specifically — public access defibrillation and bystander CPR pending arrival of an (advanced life support) rescue squad," the report said.

Great Lakes spokesman John Sheppard said no such survey has been done. Base personnel "continue to receive lifesaving training in accordance with federal, state and local standards," he said.

Adams was buried at Sarasota National Cemetery, his gravestone reading "Beloved Son and Brother." Maricel Adams said she visits about once a week, wondering what might have been had her son not left home.

"I tell him, 'I miss you and I love you so much,'" she said. "I wish I could go back in time and tell him not to go."


©2015 the Chicago Tribune

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