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EMS agency scrutinized in boy's death

The boy was not transported by ambulance from the scene of a motorcycle accident until 51 minutes after it happened

By Alex Breitler
The Record

LODI, Calif. — A series of missteps by emergency responders likely contributed to the death of a 10-year-old motorcycle racer earlier this year at a private track near Lodi, investigators have concluded.

The boy, identified in news reports and social media as Zaden Florez of Salinas, was not transported by ambulance from the scene of the accident until 51 minutes after it happened, the San Joaquin County Emergency Medical Services Agency found. The boy was pronounced dead shortly afterward.

The investigative report shows plenty of blame to go around: a paramedic and emergency medical technician who were stationed at the racetrack failed to properly assess the situation; their managers failed to prepare them with a plan ahead of time; an air ambulance was slow in arriving and emergency dispatchers made key errors.

On Tuesday, San Joaquin County supervisors will decide whether to assess a $50,000 penalty against the nonprofit Manteca District Ambulance Service, which had been hired to provide an ambulance on standby at the racetrack that day. The county also plans to require additional training for a number of first responders who were involved that night.

One critical error came when the ambulance crew that was standing by when the crash happened decided to wait for an air ambulance to take the boy to a hospital, officials said.

"The failure to initiate ground ambulance transport to the U.C. Davis Medical Center or closer trauma center... when such transport was immediately available likely contributed to the death of the patient," county investigators found in their final report, which was made public as part of Tuesday's meeting agenda.

Ted Simas, president of the Board of Directors for Manteca's ambulance service, said Friday that he could not talk about specifics of the case but said his organization accepts the conclusions of the report.

"Quite frankly, this is the first tragedy of any sort like this — and it was a tragedy, believe me — since the nonprofit was established in 1951," Simas said. "We have a wonderful team here. But we do want to improve. The more training, the more things we can learn, the better it is for everyone."

Dan Burch, administrator of the county emergency services agency, could not be reached this week.

The accident happened on April 15 at the Lodi Cycle Bowl. The boy was coming out of a turn on the dirt track when he made contact with another bike and crashed.

He was in the process of standing his motorcycle back up when another bike, traveling between 40 and 50 miles per hour, struck him in the chest, investigators found. The boy was thrown an estimated 45 feet.

The Manteca ambulance crew was escorted onto the track, where they found a "chaotic" situation and a victim who needed immediate care. The crew had not been watching the race, however, and didn't realize that the boy had been struck in the chest and suffered severe internal injuries, investigators said.

Believing incorrectly that they were "tethered" to the event and unable to transport the boy themselves, the ambulance crew asked emergency dispatchers for an air ambulance, but were unable to provide the address of the race track nor specific details about what had happened, investigators said.

The situation was further complicated when the air ambulance crew gave dispatchers an "ETLO" (estimated time of lift-off) that was misinterpreted at the race track as an estimated time of arrival, meaning the medics on scene were expecting the helicopter sooner than it actually arrived. Later, a dispatcher incorrectly reported that the helicopter had already taken off when in fact it had not.

In the end, it took the helicopter crew 23 minutes to take off from Stockton Airport — longer than usual because the pilot was making his first solo flight, the report says.

By the time the helicopter had arrived at the race track and taken off again with the patient, 51 minutes had gone by since the crash. In another 34 minutes, the boy would be pronounced dead.

Copyright 2017 The Record

McClatchy-Tribune News Service

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