By Diane Jakopovic
Having worked as a Registered Respiratory Therapist (RRT) in a pediatric hospital for over twenty years, over 10 years of which were in exclusively in the intensive care units, and 5 years working as a Registered Polysomnography Technician (RPSGT) in the Neuro/Sleep Lab, I felt qualified to address some of what was written in the official report of the Sandy Hook School massacre. I am also certified as a Specialist in Pediatric/Neonatal Respiratory Care. However, I am not a physician, a nurse, an emergency responder, and I don’t live in Connecticut, so I felt it necessary to defer my logic and opinions to what their guidelines and protocols were, prior to the Sandy Hook shooting. Unfortunately, I was not able to find information to fit the exact circumstances at Sandy Hook (pediatric mass casualty) other than their Triage algorithm. I also found information that dealt with gunshots, transporting, etc. so pulled that information into my comments. Whenever possible, I included a link to those online documents.
(Section 1 – Triage & Tagging)
I began by reviewing their START Triage Protocol and pulled out some pertinent information. My comments are at the end:
S.T.A.R.T – SIMPLE TRIAGE AND RAPID TREATMENT
A multiple or mass casualty incident can be defined as any incident in which more casualties are present than an initial response assignment can reasonably handle. More assets are required for triage, treatment, and transport than can arrive in a timely fashion.
SCENE SIZE UP
2. Take BSI (Bodily Substance Isolation – take precautions to avoid contact with bodily substances.)
3. Determine the number of patients. If there are multiple or mass casualties, communicate that fact through the proper channels, establish command, and establish a medical officer and triage officer.
I referred to their JumpStart algorithm, (for pediatrics, not adults):
From the final report:
Book 6 – –1 (Kullgren): “When the search was complete we determined it was safe to begin evacuating students and staff.”
Book 6 – 00002113 (Cassavechia (Paramedic)): “Cassavechia stated that four separate patient assessments were made to guarantee no one was resuscitatable. Cassavechia said that the victims were formerly triaged using the SMART triage program.”
In the case of Sandy Hook, there were plenty of other care providers and ‘transport assets’ available. If it was safe enough to evacuate the students, as Kullgren stated, then why wasn’t it safe enough to let additional EMTs enter at that time?
According to their protocol, personal protective gear should have been worn and changed between patients. This should include gloves at the very minimum; there was scant evidence of gloves used anywhere at the scene of the injuries and definitely no packaging they would have come in.
The importance of changing gloves between each patient cannot be understated. Not only do gloves protect the caregiver, but they also protect the patients. In the case of multiple patients with open wounds, changing gloves is vital to prevent cross contamination of blood-borne pathogens. Also, in a criminal case, changing gloves between each patient would help prevent the transference of DNA between patients.
Cassavecchia said each victim was assessed four separate times. Gloves should have been changed between each victim assessment, so a very minimum of 80 pairs of gloves, and packaging, should have been scattered around. Since gloves carried by emergency personnel are packaged individually (in pairs) it’s highly unlikely that the Cario, Dragon and the 3 paramedics had that many gloves with them, or even in their vehicles, so other rescuers should have been allowed in, with additional supplies. Officer Dragon apparently used his only pair of gloves when assessing Dawn and Mary.
I found it very interesting that Cassavecchia said the victims had been triaged using the SMART system. SMART tags are the colored identifiers placed on or near the victims as they are being triaged. However, according to their statements, it was the paramedics, including Cassavecchia himself, who placed the SMART tags, so why did Cassavecchia basically say that the victims were previously sorted using the SMART program? Of course, we will never know for sure what he said exactly, since the original statements were completely redacted and the officers basically reinterpreted the witnesses’ statement, not word for word, but in the 3rd party.
One more thing about the SMART tags at the scene used for the victims in the bathroom, Paramedic Reed (00002358) said that they placed the SMART tags on the thermostat, while Paramedic Meehan (00019275) says they hung the tags on the bathroom door knob. So which one is correct?
(Section 2 – Defining and Responding to a Mass Casualty Event)
I then tried to find Connecticut protocols specifically for classifying an event as a mass casualty, and also for the determination of death, for both adults and children. I chose to follow the guidelines in these documents, which are the most current ones that I could find before the 2012 shooting.
This 2009-2010 protocol deals with mass casualty events in Connecticut Region 3. Newtown is in Region 5. For some reason, their protocols are not available on the internet, but my assumption is that there would be very little difference between regions, other than where to transport patients.
The treatment protocols follow those of the START MCI Triage protocol. I included this as a link, because it is an example of how a mass casualty situation should be handled.
I also found a statewide trauma system document which was valid at least through June 2006. Although I wasn’t able to find any updates to this system, the current link on the Connecticut Dept. of Public Health webpage, to the statewide trauma system document, is still the same.
From the above document, I pulled these items: 19a-177-5. Field triage protocols
(2) – 2. Assess the anatomy of the injury. Trauma patients with any of the following injuries shall be taken to a Level I or Level II trauma facility: (A) gunshot wound to chest, head, neck, abdomen or groin;
And a bit about the transport of pediatric patients:
4. Severely injured patients less than thirteen (13) years of age should be taken to a Level I or II facility with pediatric resources including a pediatric ICU. 5. When transport to a Level I or II trauma facility is indicated but the ground transport time to that hospital is judged to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with local medical direction. 6. If, despite therapy, the trauma patient’s carotid or femoral pulses cannot be palpated, airway can not be managed, or external bleeding is uncontrollable, determination of destination hospital shall be in accordance with local medical direction. 7. When in doubt regarding determination of destination hospital, contact medical direction.
My comment: Nowhere, in any document that I found, did it say that the patients should NOT be transported, regardless of whether they were alive or not. If the victim was not breathing, the decision was not whether or not to transport them, but which hospital to transport them to. There is more about this in Section 9.
(Section 3 – Determining and Declaring Death)
To determine death, I used these 2010 guidelines for emergency responders. However, these guidelines are specifically for adults, and for a non-mass casualty event. I was unable to find a more recent one, other than the START and JumpSTART triage protocol. I also used the 2007 Southwest Connecticut Pediatric Guidelines for Emergency Responders (EMS) as a reference. I pulled out some pertinent information:
“All clinically dead patients will receive all available resuscitative measures including cardiopulmonary resuscitation (CPR) unless contraindicated by one of the exceptions defined below. A clinically dead patient is defined as any unresponsive patient found without respirations and without a palpable carotid pulse. The person who has the highest level of currently valid EMS certification (above EMR level), has active medical control, has direct voice communication for medical orders, and who is affiliated with an EMS organization present at the scene will be responsible for, and have the authority to direct, resuscitative activities.
Resuscitation must be started on all patients who are found apneic and pulseless UNLESS the following conditions exist (SECTION I (a-d) are applicable to an EMR level provider):
I. Traumatic injury or body condition clearly indicating biological death (irreversible brain death), limited to:
a. Decapitation: the complete severing of the head from the remainder of the patient’s body.
b. Decomposition or putrefaction: the skin is bloated or ruptured, with or without soft tissue sloughed off. The presence of at least one of these signs indicated death occurred at least 24 hours previously.
c. Transection of the torso: the body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed.
d. Incineration: 90% of body surface area 3q burn as exhibited by ash rather than clothing and complete absence of body hair with charred skin.
Section (e) and (f) require additional assessment and/or confirmation found under “General Procedures,” a-d.
e. Dependent lividity with rigor mortis (when clothing is removed there is a clear demarcation of pooled blood within the body, and the body is generally rigid). DOES NOT APPLY TO VICTIMS OF LIGHTNING STRIKES, DROWNING OR HYPOTHERMIA in which case follow your specific protocols.
f. Injuries incompatible with life (such as massive crush injury, complete exsanguination, severe displacement of brain matter)
II. Pronouncement of death at the scene by a licensed Connecticut physician or authorized registered nurse.
GENERAL PROCEDURES: In cases of dependent lividity with rigor mortis and in cases of injuries incompatible with life, the condition of clinical death must be confirmed by observation of the following:
a. Reposition the airway and look, listen, and feel for at least 30 seconds for spontaneous respirations; respiration is absent.
b. Palpate the carotid pulse for at least 30 seconds; pulse is absent.
c. Examine the pupils of both eyes with a light; both pupils are nonreactive.
d. Absence of a shockable rhythm with an AED for 30 seconds or lack of cardiac activity with a cardiac monitor [paramedic] (in at least 2 leads) for 30 seconds.
If all the components above are confirmed, no CPR is required.
If any of the findings are different than those described above, clinical death is NOT confirmed and resuscitative measures must be immediately initiated or continued and the patient transported to a receiving hospital unless paramedic intercept is pending….”
“TERMINATION OF RESUSCITATIVE EFFORTS (PARAMEDIC LEVEL ONLY):
5-03 ROUTINE PEDIATRIC PARAMEDIC LEVEL CARE
8. Treat the patient based on his/her condition and the information obtained, following appropriatepatient care guidelines.
9. Transport the patient as appropriate to patient’s condition.
10. Maintain Warmth.
5-13 PEDIATRIC MULTI-SYSTEM TRAUMA/HYPOVOLEMIA
Field time for multi-system trauma patients and hypovolemic patients must be kept to a minimum.
Airway and C-spine control are the primary goals of pre-hospital care for the multisystem trauma
All other treatments should be performed while en route to the hospital.
I. Routine Pediatric Paramedic Care.
II. Basic primary and secondary surveys should be accomplished during on-going resuscitative measures.
III. Begin transport to an appropriate hospital/specialty center as quickly as possible. Continue treatment en route and CONTACT MEDICAL DIRECTION AS SOON AS POSSIBLE.”
Because the school had been declared safe enough to be evacuated and to allow 3 paramedics and other officers to enter into the school, there is no logical reason that other EMS personnel shouldn’t also have been allowed in, to provide assessment and possible care. Knowing this, if more people were available to provide care, equipment and supplies (including assessment and resuscitation equipment) there would have been no reason to continue on with the Triage protocol of declaring a child dead without effort at resuscitation.
For a non-mass casualty event, with adult patients, a licensed Connecticut physician or nurse must to be the ones to pronounce death, and they had to be present at the scene. Possibly, because the Sandy Hook shooting fell within the limits of a mass casualty, but because many of these were children, this was not considered a requirement and was disregarded? However, there were several adults who were supposedly shot, so the pronouncement of death for the adult victims was required to be done by a physician at the scene. There were none at the scene.
Debunkers (those who seek to prove that everything we are told is true) often use the triage protocol to prove that emergency responders can pronounce death.
However, there is nothing that says this is true. The triage system is merely a way of sorting victims, based on a quick check of a few vital signs, to determine who should receive care (who has the most likely chance of survival.) As the victims are triaged, they are marked with a colored SMART tag. Although first responders may triage patients as deceased, there is nothing in the triage system which says that emergency responders have the authority to officially pronounce death. And again, for adults, pronouncement of death MUST be done by a licensed physician or nurse, at the scene.
In the case of the Sandy Hook victims, apparently all of the victims were pronounced dead at 11:00am, as a group, with no record of a doctor or nurse present. Unfortunately I’m not able to find out who can pronounce the death of minors, and under what circumstances, at a mass casualty event.
At the minimum, logic and professionalism seemed to be unused in this event, but without seeing more definitive guidelines, I can’t say that they technically did anything wrong by pronouncing the children deceased by a paramedic or a physician via the telephone, but they absolutely violated the law with the adult victims.
(Section 4 – Hmmmm…..What Was Wrong with Those Bodies?)
CSF 1200704597 – 00118939 is the scene report that details what investigators found at the crime scene before and during the removal of the victims, evidence collection, ballistic retrieval, trajectory documentation, etc. It should be the most concise report in the entire report as to the details at the scene of the crime.
This portion of 00118939 deals only with the victims found at the scene, as described by the CSP.
It does not include resuscitation efforts that were mentioned in the report, or evidence of patient mismanagement or endangerment that was included in the report. Only pertinent information about the position of the bodies and their clothing is included here.
“All victims sustained mortal injuries to various areas of their bodies with many of these injuries being catastrophic. All injuries appeared consistent with gunshot wounds. For all injury descriptions and locations please refer to the autopsy report completed by the OCME.”
…. Dawn Hochsprung…. was lying on her back….. Mrs. Hochsprung’s feet were touching Mrs. Sherlach’s left shoulder. Mrs. Hochsprung had brown hair and was wearing a grey and red hooded sweater, red long sleeve shirt…..
…. Mary Sherlach was positioned lying on her back with her head to the south and her feet to the north and her head adjacent to the south side of the hallway. Mrs. Sherlach was wearing a blue long sleeve shirt, tan tank top shirt,
…. Mrs. Anne Marie Murphy …. She was positioned face down and partially on her left side with her right arm entirely over the chest of a child later identified as (redacted)…..
…. She [Anne Marie Murphy] was wearing a pink long sleeve sweater, tan top with straps, …..
There was a gold necklace and pair of glasses in her right front pocket.
…. (redacted) …. He was positioned face up on his back with both his legs bent completely at the knees and each adjacent to the right and left sides of his hips. His left (east) side was partially underneath Mrs. Murphy’s right (west) side. Mrs. Murphy’s right arm was entirely around the chest of (redacted) …
…. (redacted) was located northwest of Mrs. Murphy and in close proximity to Mrs. Murphy’s right foot. (redacted) was observed in a crouched face down position with her left leg bent at the knee and hip and positioned under her left side.
…. (redacted) was located …. His shoulders and head were underneath the second western-most desk. His head was to the south and his feet were to the north. He was lying on his left side facing west with his legs bent at the knees and hips in a west direction
…. Victoria Soto …. was observed to be lying on her left side with her legs bent at the knees and hips in an east direction….. . Mrs. Soto was wearing a green wool scarf, white long sleeve turtleneck sweater, green tank top, ”
“There were three children left in the bathroom after checking for signs of life. These children were (redacted) was located slumped to the floor in a seated position partially on her right side on the south side of the toilet (redacted) was located, adjacent to the southwest corner of the bathroom, in a standing position and bent over the south side of the toilet. (redacted) was located in a seated position with her back against the west wall on the north side of the toilet.”
…. Rachel D’Avino was in a crouched position; face down with a south direction against the west bathroom door jamb and partially inside the bathroom. Her right leg was positioned fully bent at the knee and hip and positioned under the right side of her torso. Her left leg was bent at the hip and knees and positioned on the east side of her body. Rachel D’Avino was wearing a black, grey and white short sleeve sweater, white shirt with straps,
…. Lauren Rousseau was positioned lying on her back partially on her right …. wearing a grey and white herringbone patterned long sleeve sweater, grey top with straps….
In Book 6 – 00002358 (Reed) “….. Reed stated they all understood that it is a crime scene, but was told by command staff to do what they needed to do. Reed stated they assessed all the victims that did not have apparent fatal injuries….”
My comments on the above statements in the report #00118939:
Note: there is more detailed information about cardiac monitoring in section 7 of this document.
1) According to Reed’s statement, paramedics on scene were authorized to “do what they needed to do” which would include repositioning the victims, removing clothing, and moving them, as necessary.
2) Following the Triage Protocol for Pediatrics (and ALL national standards,) the first step is to open the airway and assess the patient’s breathing. One child victim was found lying on his side, with his head & shoulders underneath a desk. In order to have followed the triage protocol to assess breathing, the boy would have had to have been rolled to his back while securing his neck, and pulled from beneath the desk.
In addition, if the above mentioned patients were found in the positions stated, many of them could not have had their breathing effort assessed. Assessing breathing is done by rolling the patient to their back, assuring the airway is patent (open), and then by audibly hearing or physically feeling for breath, and by observing chest rise. This could not have been done if the victim’s body was lying on his side with his head and shoulder’s beneath a desk. Breathing could not have been assessed in any of the other victims not found lying flat on their backs.
It’s particularly notable that none of the kids in the bathroom were described as lying on the floor, but were said to be seated or standing over the toilet. There is absolutely no way these children could have had their breathing effort determined in those positions.
3) If the above victims were found in the documented position at the time the investigation began, then how could cardiac monitor electrodes (*or AED pads, if needed) have been applied to any of them? Again, the victim’s bodies should have repositioned to their backs and that’s how the crime scene investigators should have found them. (See Section 7 for more information about cardiac monitoring)
*Note: Tranquillo 1 photos show what appears to be two Lifepak cardiac monitors and one Lifepak defibrillator at the scene, in the north hallway.
4) Clothing should have been removed or cut open, to expose a bare chest since electrodes (necessary for cardiac monitoring) must attach to bare skin. Many of the victims are described to have been wearing sweaters or tops that could not have been unbuttoned. Some victims were described as wearing layers of clothing. The time taken to pull these items up high enough to expose a bare chest would be longer than it would have taken to cut them. In addition, raising a shirt might disturb wounds even further; clothing should always be cut off for anyone severely injured. (See Section 7)
5) Dawn’s feet were touching Mary’s left shoulder. Ms. Murphy was found with her arm over a child’s chest. That would not have been allowed during assessment with a cardiac monitor for three reasons:
a) a false positive could have been picked up from the victim without the monitor, if their heart was beating, and
b) if both victims happened to be alive and a shock was required, it would endanger both of them since electricity travels through tissue. That is why it’s mandatory to not touch any patient who is receiving a shock.
c) With an arm over the child’s chest it would not have been possible to apply the electrodes to either victim, which was necessary to assess the heartbeat. (See Section 7)
**In the case of Nancy Lanza’s body, they did note the presence of the packaging from the EKG pads (Bk 1 – 00263454). Why did they not do this for the crime scene at the school?
In summary, if medical assessment of the victims by Paramedics Cassavechia, Meehan and Reed was performed as the report stated it was, every victim should have been found positioned on their backs with their bare chests exposed and with nothing obstructing access to their heads. If the bodies were found as the report states they were, then either the paramedics did not assess them properly (or at all,) or they replaced their clothing and repositioned their bodies… or it’s all a lie.
6) No mention of any evidence of any resuscitative efforts was mentioned in the area, such as or packages for items such as **cardiac pads, gloves, gauze to wipe the skin, ekg gel, etc.
(Section 5 – First, Do No Harm)
Every first responder must undergo, at minimum, basic first aid training. Someone who responds to an injury or an illness who doesn’t know what they are doing, or who ignores the basic tenets of first aid care, can do a lot more harm than good.
Book 6 – 00024911 (Katrenya): I observed a Newtown Officer carrying out a young girl who appeared to be deceased. He carried her towards the cars in the parking lot….
Book 6 – 00026724 (Cario): Det. Dragon or I had carried a little boy out of the building and I was attending to him near the curb outside the front doors. This victim came from Room #8.
…. I then observed Newtown Police Lieutenant Chris Vangheli outside a black SUV near the front of the school. I told him I needed to get a victim to an ambulance and needed a ride. He agreed and looked into the passenger compartment to make arrangements. Seeing that the cargo area was empty, I told him to open the rear hatch. I picked up the boy and climbed into the back of the SUV, telling Lt. Vangheli to leave the hatch open. Lt. Vangheli sped to the end of the driveway, having to drive up over curbs and swerve around the rush of parents. I kept speaking to the injured boy although he was completely unresponsive. I knew his condition was grave, but he was still breathing and had a pulse. Looking down the driveway I observed only two ambulances on scene.
….. I lifted the little boy from the back of the SUV and moved him to the ambulance. TFC Kick assisted me.
Book 6 – 00041707 (Kick): I grabbed the lower half of the child’s body and carried him over to the ambulance where I had put the female victim. Sgt. Cario and I put the child victim on the soft seat next to the female victim.
Book 6 – 00047345 (Smith): During that time, Officer Chapman had checked everyone else in the room for a pulse and located one female child with a pulse. Officer Chapman carried the female out of the building and I remained by the classroom door.
Book 6 – 00085751 (Chapman): Officer Chapman stated that he removed the child and carried her to an ambulance.
Book 6 – 00258158 (Chapman): .” I went back into the classroom and (Redacted) picked her up and carried her out of the building. I saw Lt. Vanghele and told him that I needed an ambulance. I began running across the parking lot towards Dickenson Drive with the girl in my arms praying that she would live and telling her that she was safe, that Jesus loved her, and that I was protecting her. I stopped several times and got down on one knee to check her pulse.
Book 5 – 00163580 (Redacted): While in the parking lot, (Redacted) stated that she saw a police officer carry a young child to an ambulance that had showed up way after her arrival.
Book 6 – 00073537 (Dragon): After this initial entry I then noticed that there was a little boy (later identified as (Redacted)) lying on his side, eyes closed, with what appeared to be (Redacted).
Once I had this little boy cradled in my arms, without cover, I ran out of the room and down the north hallway to the front entrance of the school where I exited and then placed this little boy down on the concrete sidewalk in order to perform a more focused survey of this little boy before he could be placed into an ambulance. While running out of the school with this little boy I told him that he was safe and that I was there to help him. (Redacted). I then advised Sgt. Cario that we need to get this little boy into an ambulance. However Sgt. Cario advised me that the scene had not been determined safe yet, and that it was still unknown if there was more than one shooter.
Sgt. Cario then shouted out to the parking lot in front of the school to the other responding Police personnel that were arriving on scene that we needed a vehicle to transport this little boy to an awaiting ambulance. While waiting for a vehicle to transport this little boy away from the school, I told him that his family loved him and that he was a hero for trying to protect his class. (Redacted).
Shortly thereafter a dark colored Police SUV arrived to the front of the school at which time Sgt. Cario picked this little boy up and placed him in the back seat. That prior to Sgt. Cario doing so, I advised him that he would need to place a blanket on the back seat before placing the little boy down in order to be transported away from the scene for further medical attention.
Book 6 – 00002060 (Vanghele): I then noticed Officer Chapman running toward me with a little girl in his arms. (This may have occurred prior to me searching the cafeteria and the main office. My memory is unclear as to the order). I opened the front door of the school for Officer Chapman and ran with him through the parking lot of the school. I heard him saying “Come on sweetie, come on sweetie”. I at first thought the child had fainted and then noticed all of the blood on her. (Redacted.) We were running towards the ambulance that was near the back lot of the Sandy Hook Fire House.
The first rule of medicine is “Do No Harm.” This means that every precaution is taken to ensure a patient’s safety without incurring additional harm or damage to them. This includes not moving a patient who has not been properly assessed and protected (stabilized) unless there is a threat of imminent danger to them if they are not moved, such as a fire, a risk of something falling on them, hitting them, etc.
When a patient is struck by gunfire the bullets can either stay intact or they can fragment. And they can either pass completely through the body, or may remain in the body, or any combination of the above.
When a foreign object enters a body, it may or may not also sever arteries and enter organs. Knowing this, any undue movement without securing a patient may cause much more internal bleeding than if they were stabilized in place and secured on a gurney for transport to an ambulance. If a bullet or fragment remains inside a victim, undue movement can cause the fragment(s) to move into organs or sever arteries, causing even further damage and possibly much more severe damage than the original bullet strike.
In the case of pediatric patients, who have much less blood volume, the risk to the patient from (hypovolemia) blood loss increases dramatically. In most cases an IV infusion or even, in some cases, an interosseous infusion is begun even before transport to the ambulance. Hypovolemia (shock) is often cited as the leading cause of death in the pediatric population.
Keeping the patient as warm is also extremely important, to help prevent further shock. Carrying them out into the cold weather without blankets was absolutely contraindicated. In the Sandy Hook shooting case, because there was supposedly ‘a possible second shooter’ on the loose, the officers apparently decided to risk injuring the still living children further, and broke every rule of basic first aid medicine. Not only did they probably cause more harm (and possibly death) to the children by picking them up and running and/or driving with them not immobilized, cold, and dripping blood, they also put those children and themselves at high risk of being shot by that possible second shooter who may have been outside the school because the area was not yet secure.
2007 paramedic pediatric guidelines –
(Section 6 – Documentation)
In the medical field, there is a saying: “If it’s not documented, it didn’t happen.” Not only is documentation needed for payments, but also for tracking the compliance and ability of the caregivers. It also gives statistical information about the success and failures of a given procedure or activity, which in turn is used to measure its effectiveness. In addition, documentation is also necessary, should any legal action arise from an incident.
Book 6 – 00002113 (Cassavechia) “Cassavechia stated that four separate patient assessments were made to guarantee no one was rescuscitatable…”
Book 6 – 00002358 (Reed) “He stated there were a substantial amount of casualties and they spent a significant amount of time assessing the victims. Reed stated they all understood that it is a crime scene, but was told by command staff to do what they needed to do. Reed stated they assessed all the victims that did not have apparent fatal injuries….”
….. Reed stated with each victim that they utilized the cardiac machine on they left the EKG printout from the machine on the triage tag of victim.
Book 6 – 00019275 (Meehan): “Meehan stated that an assessment of all of the other victims in that classroom revealed no survivors. Meehan stated that they then went to the two victims in the hallway who were both expired. Meehan stated that Dr. Broderick of Danbury Hospital Medical Control and Cassavechia decided a secondary triage would be performed on all victims with the cardiac monitor and the triage tags would be applied and that presumption protocol would be followed.”
Item #7 in the “Paramedics Guide to Determining Death”, says. “All seven items must be clearly documented in the EMS patient care report (PCR).”
The “Paramedics Guide to Determining Death” was written for adults in a non-mass casualty situation.
Unfortunately I was not able to find anything per-2012, other than the Triage protocol dealing with pediatrics. But regardless, documentation is extremely important. Medical documentation should always be precise and accurate, and as detailed as possible. In this case, at minimum, there should be documentation as what time each patient was checked, what four assessments were performed, and the results of any effort, and it should be recorded for each patient individually … not just lumping every one of them into a generalized statement like they had “obviously fatal injuries.”
Things that should have been documented were patient position, whether the airway was patent, breathing effort, pulses, patient’s color and blood pressure, and a general overview of their injuries. In addition, since a cardiac monitor was used, there should be cardiac strips. There was no mention anywhere, other than by Reed, of the EKG strips. Why weren’t they photocopied and attached to the report to prove that murders actually happened there? Names could either be redacted or the victims could be referred to as Victim 1, Victim 2, etc.) HIPAA laws are very specific as to what personal and medical information can be released but the identifiers recorded on those strips, like so much else in the report, could have been redacted. There is a possibility that there is documentation that is unpublished, but in that case, there should be a reference to where that documentation is located since it would be considered part of the murder investigation.
In the Statewide Trauma System document, it gives specific information about what should be recorded (Data collection – page 5-6)
(Section 7 – Cardiac Monitoring)
There are several kinds of portable cardiac machines. Some do simple monitoring of the heartbeat by providing a visual of the heart at work, some have the ability to communicate (send EKG waveforms) with hospital facilities, while others are multifunctional, designed to also shock the heart (defibrillate) should it be necessary.
1200705354 – Sec. 8 (Autopsy Report and Images of Nancy Lanza) says: “Clothing Description:
Victoria Secret brand pink long sleeve button down pajama top and matching elastic/draw string pants with black dot pattern…..” and
**************************************************************************************************************** My comments:
“Evidence of Medical Intervention: AED adhesive pads located on the left posterior forearm and lower anterior abdomen.”
The electrodes placed on a patient to pick to up the heart’s waveform are small, usually about 1-2” and are placed on specific parts of body, usually placed on the right and left side of the chest and a ground lead which can be placed on the abdomen or on the patient’s limbs. There can be anywhere from 3 leads (electrodes) up to 12 (or more) used. These small electrodes are not referred to as ‘pads’
An Automated External Defibrillator (AED) can also monitor the heart rate and rhythm, but can also be used to deliver a shock to the heart when it is beating but out of rhythm (ventricular tachycardia or ventricular fibrillation.) In order to be effective, it requires two large electrode pads to be placed in specific areas, one on the right side of the chest and the other on the lower left side of the rib cage, or on the person’s back (usually used for children.) Although the AED machines themselves can be fairly small, the pads are generally quite large (adult size is usually 3”x4” or larger) and must fit snugly against the skin… there cannot be gaps. Incorrect placement (on an arm) not only would do no good at all if a shock was needed, it could be fatal to the patient.
First one must wonder why an electrode ‘pad’ was found on Nancy’s forearm? If an AED pad was found, as described, then it should have been attached to her chest. A forearm is absolutely contradictory to any medical process known. If however, it was an electrode found on her forearm, the report should not have specified that, and not said it was an AED pad.
(Section 8 – Patient Transportation)
In a mass casualty situation, providing transportation in a timely manner, with competent medical personnel, is extremely important. For critically injured patients, transport by helicopter, when available, is usually the preferred method. Air transport provides the shortest route between the victim and the receiving hospital. Air flight also avoids delays that may be caused by traffic, road construction, detours, etc. In addition, air flight, in good weather, is much smoother because it avoids things like bumpy roads, pot holes, etc.
In this abstract, published online in June, 2012, it discusses Connecticut’s mass-casualty helicopter transport system, established in 1985.
“Since 1985, the state of Connecticut has been served by a hospital-based, advanced life support (ALS) helicopter air medical service. The service is stationed at a 1,000-bed, Level I, trauma center that is responsible for its operation. Connecticut statute requires the hospital to file operations reports with the Office of Emergency Medical Services, which reports to the Connecticut Department of Public Health. Operations include response to requests for transportation of severely ill or injured patients from the scene of an incident, and patient transport from one hospital to a higher level, definitive-care hospital. This service also was charged to develop a disaster response plan to be integrated into the overall state plan for disaster responses……”
Certainly the qualifications of the transporting caregivers is a consideration. Life flight attendants are highly trained in critical care emergency procedures while ambulance crews may have lesser trained crew members. In a life-threatening situation, the expertise and qualifications of the caregivers should always be in favor of the most qualified.
LIFE STAR – Flight Crew
“The LIFE STAR flight crew consists of a flight nurse/paramedic, flight respiratory therapist/paramedic, pilot, EMS communication specialists and mechanics. Both LIFE STAR helicopters are staffed 24 hours a day, seven days a week. The LIFE STAR flight crew works collaboratively to function as a high performance team for the transport of the critically ill and injured patients.”
One of the main issues at Sandy Hook was the jamming up of the streets. Cars were apparently abandoned on both sides of the road and in some cases, they completely blocked traffic. Ambulances would not have easily been able to get to the school (if they had been allowed to) and then also would have difficulty getting back into the street to transport the patients. One patient (Natalie Hammond) was removed from the school by being wheeled on a chair, then loaded into a car and driven to the firehouse where she was placed in an ambulance. In the case of the two children who were transported to the hospital, both were carried to the ambulances (which may have caused much more damage than we will ever know.) Once there, the girl was transported by squad to Danbury Hospital. The boy was taken to the same ambulance as Natalie so she was (according to one story – 00019274) forced to move off the stretcher and ride in the front seat of the ambulance. If Natalie was well enough to ride sitting upright in the front seat, then she was probably well enough to have waited a bit for another ambulance, to be transported properly. Both were taken to Danbury Hospital.
Life Flight helicopters are stationed a Hartford Hospital, which is 38 miles to the northeast of Sandy Hook School. The flight team is always on stand-by, so the response to the helicopter is very rapid. The helicopters fly at about, or over, 150mph (2.5 miles per minute.) To travel 38 miles would take about 15 minutes + the amount of time it takes to get the crew loaded (because they are always on stand-by, it would be likely less than 3 minutes.) They could have landed on the school grounds, near the school. Time spent transporting patients from the school to Danbury Hospital would have been about 4 minutes. Total flight time would have been about 19 minutes. To fly them to Yale – New Haven Hospital in New Haven, would have taken an additional 4 minutes.
Danbury Hospital, traveling by expressway, is located approximately 10 miles from the school. An ambulance could have traveled at speeds of 80-90mph (1.3-1.5 miles per minute.). Under ideal conditions (no traffic jams) the time taken to transport a patient from the firehouse to Danbury hospital would have taken about 7 minutes. However, as seen in the police dash cams, there were traffic jams. And the ambulances were not able to park at the school; they parked about .2 miles away, at the firehouse. The time lost maneuvering around traffic, and then transporting victims from the school to the firehouse, certainly would have taken more time than if helicopter(s) had landed at the school and flew the patients to a Level 1 trauma center.
Because the report is so poorly written, and so much information is completely redacted, or not recorded, we cannot know the exact amount of time it took for the children to arrive from the school to the ambulances, and then how much time it took for the ambulances to get them to the hospital. We can know for sure, according to the report, that teacher Deborah Pisani was made to walk the distance from the school to the firehouse, even though she had a bullet wound to her foot. Once at the firehouse, she can be seen sitting on a chair at the 2nd triage area, with her leg extended….
According to the report, for some reason, it took over an hour to get her into an ambulance. She was wheeled on a gurney from that triage area to an ambulance parked in the street in front of the firehouse. Because of the jam of cars, the ambulance apparently could not be brought to her. Other considerations for Life Flight transport are distance (which was already discussed,) ease of access of helicopter vs ground transport, i.e. if there is an area clear enough to accept a landing helicopter, and finally, is it a safe environment to land in.
Sandy Hook was located on a triangular section of land. On the east side of Sandy Hook school was an open area and also a small baseball field. The field measured over 220 feet x 220 feet, so was well large enough for one or two helicopters to land in. Life flight helicopters require a minimum area of only 75’ x 85’ for landing.
The final consideration was safety. Was the site secure enough for a helicopter to land? Would a second shooter have put the flight crew in danger? If we step back and consider, the officers supposedly just evacuated 480+ students and approximately 90 adults out into the open and walked them up to the firehouse. There were armed officers surrounding the outside, and there were armed officers all over the inside of the school, even standing guard over the affected rooms, and there were news helicopters flying overheard.
Landing zones for Life Flight helicopters had been established before the 2012 incident; helicopters could have landed near the school in several locations away from potential gunfire; landing at the school itself was not necessary. Knowing these things, not summoning a life flight helicopter because of the possibility of a shooter, seems ludicrous.
Finally, in the report many officers stated that they saw many victims, very soon after making entry into the school. Of course no one knew what to expect, but they knew the number of victims was very high, and the officers should have known the capabilities of the immediate emergency teams. Besides the two ambulances from the Newtown area, 12 additional ambulances were summoned from nearby towns, ranging in distance from 10 to 15 miles away. When the calls went out to nearby towns for emergency assistance, why was Life Flight, who were prepared for mass casualty response, not summoned? That system should have been put into action immediately.
This is an excellent video reference to explain how mass-casualty events should be handled according to established guidelines, and explains why Life Flight helicopters should have been dispatched.
(Section 9 – The Patients are Loaded… Now Where Should We Take Them?)
Some considerations when determining the destination of the receiving hospital when transporting critical patients are
a) the level of care they can provide (trauma center versus non-trauma center) and
b) whether they accept pediatric trauma.
Danbury Hospital is the closest hospital. It is a Level II trauma care center but did not have a Pediatric Intensive Care Unit (PICU) in 2012. In addition, their Emergency Room was not specifically certified for pediatric patients at that time. Planning for a Pediatric Emergency Department began in earnest after the shooting, and is scheduled to open in 2014. So in 2012, those children with serious injuries could only be stabilized at Danbury Hospital and then must be transferred on to a children’s hospital. This causes extra movement of the child, less skilled caregivers tending to the patients, and further delay in the child’s care.
Following the established protocol for a mass casualty situation, a Life Flight helicopter would take the child directly to the nearest Level 1 Pediatric trauma center; in this case it would likely have been Yale – New Haven Hospital in New Haven, CT. which is just 20 miles away. Connecticut Children’s Hospital in Hartford, 38 miles away, is also a Level 1 pediatric trauma center. Danbury hospital at Level II, without a PICU, was a poor choice for any critically injured child.
Another factor is whether the receiving hospital can accept helicopters on their premises. All of the above hospitals have helicopter landing areas.
It is very important to realize that planning for mass casualty events has already been done long before the Sandy Hook event. There really was nothing the first responders (Newtown Police) and subsequent officers (Connecticut State Police) had to determine or decide, other than to declare a mass casualty event (see the video above) because the potential was there for multiple victims. If that had been done, everything else…. all those decisions about appropriate medical care…. were unnecessary because they would have already been predetermined.
(Section 10 – Could Noah Pozner Have Been Saved?)
In early 2014, Lenny Pozner published photos of several documents dealing with his son’s death. They included the Investigative Report performed by the Medical Examiner’s office, before the bodies were removed from the school, and page 2 of Noah’s 3-page autopsy report, which was performed in the ME office in Farmington, CT. Although Lenny has removed these documents, many people had copied and saved them.
The Medical Examiner, Louis Rinaldi, gave a short description of Noah’s body, at the scene. He described wounds to the face (mouth and chin) only. However, the autopsy report listed four separate wound areas…. to the face (jaw), thumb, and to the chest (and arm).
The CSP crime scene report specifically said that a cardiac monitor was applied to each of the victim’s at the scene. In order to do this monitoring, the bare chest had to be exposed. Then why didn’t Louis Rinaldi see and make note of the wounds to the chest and upper arm?
One thing I find curious in the Report of Investigation is that although it lists the time of death (apparently pronounced by some unnamed paramedic) there is no mention of how long the examiner estimated the body had been dead. There is nothing about lividity (pooling of blood) the body or coagulation around the facial wounds (remembering, of course, that it appeared the ME didn’t see the chest, arm or thumb wounds.)
The following is my personal opinion, after having helped deal with hundreds of pneumothorax and some hemothorax cases throughout my years as a Respiratory Therapist. A hemothorax is blood collecting in the lining of the lung, which compresses the lung, and in some cases, the heart. These are common in penetrating chest wounds. If the paramedic had revealed the bare chest to apply electrodes, he also should have seen Noah’s chest wound, and so should have suspected that there would be a hemothorax, and reacted.
The wounds to the face and thumb may not have been fatal. The wound to the chest, with a double hemothorax was most certainly deadly without treatment, BUT with rapid treatment, if the child was still viable, death may possibly have been preventable. Paramedics (everywhere, to my knowledge) are certified to perform needle aspirations to the chest, to withdraw air or blood. I would have expected that needle aspiration may have at least been attempted in an effort to restore breathing.
In summary of this document, I again contend:
a) That logic and professionalism were completely disregarded in caring for the proclaimed victims of this shooting.
b) That negligence by the first responders most likely delayed treatment and possibly contributed to further injury of the victims and
c) that the actions of some of the responders may actually have been responsible for the deaths of at least two of the children.
d) That either the paramedics failed to perform, or they redressed and repositioned the victims, or they lied. There are no other options.
To close, in my opinion, certain sections of this document prove that, at the minimum, a new investigation MUST be opened, not only into the shooting and its aftermath, but also into the investigative team, including Newtown Police Department, Connecticut State Police, and any state and federal agencies, who responded to this event. The medical aspects are only one small part of all the inconsistencies, improbabilities and conflicting statements in the official report.
Adam Lanza: Head Injury Makes Shooting Story Almost Impossible
I would like to thank Scott Anthony of youtube channel, “Flash News Network” for his critique and advice, especially concerning transport procedures and hospital determination protocols. I highly recommend his videos that deal with the medical information that he has gleaned from the official reports:
Diane Jakopovic is a retired respiratory therapist residing in Nebraska. She has certification in respiratory pediatric and neonatal care and is a registered polysomnography technician.