How an antiquated 911 system killed a woman

Two years ago in this space, I passed along Peter DeMarco’s open letter to the people who tried to save the life of his wife, Laura, who died after an asthma attack. He had written it for the New York Times.

It was dedicated to the nurses.

They asked me to leave the room for a moment, and when I returned, they had shifted Laura to the right side of her bed, leaving just enough room for me to crawl in with her one last time. I asked if they could give us one hour without a single interruption, and they nodded, closing the curtains and the doors, and shutting off the lights.

In the Boston Globe Magazine over the weekend, DeMarco tells the other side of the story.

Laura knew she was dying when she called 9-1-1 for help. She tried to tell the dispatcher where she was.

She was just outside her car, she said, on the street.

It took 10 minutes to find her. That’s long enough for her brain to die.

She wasn’t in some far-off parking lot, DeMarco reveals.

She was at the door of the hospital’s emergency room, which was locked.

In just 41 seconds, Laura managed to relate seemingly everything the operator needed to know. Laura said she was having an asthma attack, one so severe that she felt she was going to die; she said she was at Somerville Hospital, outside the emergency room, and that she couldn’t get in.

Laura was an amazing communicator — it was her profession — and, with her life on the line, she did not waste a single word.

Her cellphone call had been relayed to a regional operator 18 miles away. After explaining where she was, her call was sent to the local police department where she had to tell her story all over again.

By then, she could barely speak.

“She’s outside of the Somerville Hospital,” said the regional operator, jumping in while still on the line, DeMarco said in the Globe article, which includes audio of the call. “She’s having an asthma attack. She can’t get into the hospital there.”

How cracks and flaws in our health care system — communication errors, overburdened staffs, lack of fail-safes — snowballed into one woman’s unimaginable death. On the doorstep of a Boston-area hospital.

Posted by The Boston Globe on Saturday, November 3, 2018

A ping of her cellphone was inaccurate, he said. It showed her at the hospital’s mailing address, not at the ER’s front door.

While an Uber or Lyft driver seems to know where you’re standing, and marketers can track your every step via apps on your phone, the same often can’t be said for police and fire responders who receive 911 cellphone calls, because our nation’s 911 infrastructure hasn’t adapted nearly fast enough to our wireless world.

When you use an app involving your location, your phone constantly transmits where you are, in a way like a homing beacon. But when you make a 911 voice call, that doesn’t happen. Instead, a satellite must be pinged, and that information is integrated with other bits of data your carrier knows about your phone to trace where you’re calling from, a more complex Theand often inexact process.

Federal Communications Commission rules merely require carriers to locate 911 calls “generally to within 50 to 300 meters” of a 911 caller’s location. So potentially, a caller can be more than three football fields from the location of the ping, in any direction — a vast area for emergency responders to search for someone in trouble.

The fire department guessed where she might be; they guessed wrong. That took another minute. Nobody seemed to have a direct line to the ER, but a moment later, police reached a charge nurse inside.

The nurse, who didn’t think one of the door’s to the ER was locked, looked anyway and found it locked.

It’s the pivotal moment, as Laura has been unconscious less than three minutes. It has been possibly less than two minutes since her heart stopped beating. The odds were still strong she could have been saved, if only Nurse X walked a few feet to find Laura on that bench.

But Nurse X did not do that.

On the surveillance video, you see Nurse X take one step outside the ambulance-access door, going no further than an arm’s reach from it. In the predawn darkness, Nurse X cranes her neck a bit to see, but she doesn’t spot Laura on the bench, which is almost straight ahead of where she’s looking, albeit in a shadow.

There were only two entrances, within 100 feet of each other, that could have led to the emergency room.

But Nurse X never strayed from the sliding door, as if she were afraid it would close on her.

The nurse told police she didn’t see anybody outside the door. Three minutes later, retracing Laura’s steps, firefighters found her.

By then it was too late.

A police officer’s incident report says he ran to the ER for help.

“I ran inside and no one was at the security desk. I ran to the entrance of the Emergency Room and looked inside the windows and did not see anyone. I started to bang on the glass with my ring and from in the back I heard someone yell, ‘Relax’ in a very [annoyed] tone, and then as she turned the corner and saw me she said, ‘Take it easy’ in that same annoyed tone.

I was standing there in full uniform and could not believe the attitude on this woman. I said, ‘Are you kidding me, the firefighters are working on someone on the sidewalk and need help and a stretcher.’”

DeMarco writes that when he made it to the hospital, nobody told him the correct story of where his wife was found.

No one said anything days or even weeks later, after he’d penned his tribute to the nurses.

I am not going to sue the Somerville police or fire departments, or the State 911 Department — nor can I, as state laws grant them powerful immunity regarding 911 response errors. But the mistakes made in the transferring of information between emergency responders that morning also dictated Laura’s fate.

I hope emergency operators and dispatchers who read this story learn from those grave mistakes, make efforts to react with greater urgency to asthmatic callers, and establish protocols for reaching out not just to ambulance companies, but to the nearest possible source of help when that’s the best chance someone has of surviving.

  • Debby

    I started to read this and cannot bear to go on.

  • Guest

    When trying to define the word ANGUISH, this story should be included.

  • Guest

    Be aware, when apps “know” you are next to a store, they basically just know a customer is within X feet. It would take some work to put a name and history attached.

    Folks may choose to have their GPS and/or medical records available to the ambulance crew in upgraded 911 systems, but that would be spotty opt-in. A system has to be designed to work with as many as possible.

    Having the current system comes with flaws, but be aware there IS a trade off if we want government to know where each person is 24/7.

    • Brian Simon

      Um, no. If you have an app on your device & choose to let it know your location, they know exactly where you are, and whatever else you’ve told the app about yourself. If it’s facebook, and you’re a typical user, they’ll know your age, gender, relationship status (including cyber-flirting with the cutie across the office), phone number, what you look like (auo-tagging your pics!), companies you like, companies you don’t like, political affiliation, hobbies, well, lets just say the list goes on. So facebook has already done all that work to put a name and history atrached to that bit of location data – and their business model is to sell that data. That data is worth some money to people trying to sell you stuff. Ever wonder why facebook valuation is so high when they’re providing a free service to you? It’s because you’re not the customer – you’re the product.

      911, on the other hand, is a government run service. No customers, no revenue & fighting for every dime they can get in an environment where taxes can only be cut, with no consideration for the service cuts that go along with it.

      • Guest

        Ya, I guess I have to admit, the app knows what it is told about you. And Facebook is in the business of micro-slicing the market.

        It is almost as if James Bond was replaced by a free app that told where the shoes stores are 🙂

  • AL287

    I keep telling my son and his wife that they need to have a basic landline for emergency purposes since they now have a son going on 16 months.

    They tell me they are not worried. Ah! The folly and naivete of the young adult.

    It’s precisely why I have my landline because I live alone and I am not getting any younger.

    GPS can be off by as much as 10 city blocks and that distance is doubled or even tripled if you’re out in the middle of nowhere and have a medical emergency.

    The part of this story that angers me the most is not the loss of a talented woman and beloved wife, but that EMS has known about these location errors for years and have done nothing to correct the situation.

    It would cost money to upgrade the system. I guess people’s lives don’t fit into the budget.

    • Sasha Smith

      Where I live you can’t get landlines anymore. I tried to get one with Verizon and was told that they don’t give them to new customers and they’re trying to phase them out from the old customers.

  • jon

    911 location system is only active when you are calling 911, it is not a tracking system that tells the government where you are 24/7.

    GPS is the Global positioning system of satellites accuracy of this system can be as high as 3m in (about 10 ft) on handheld devices. (~4m for altitude as I recall)

    If your phone is reporting an accuracy of 300m on your location, odds are good that it’s not reporting via GPS which on my phone start a fix with an accuracy of about 50m, decreasing as it acquires more signals and corrects for atmospheric conditions.

    Your cell phone (not the 911 systems) can be set to acquire and send a GPS signal to a emergency service server in the event of an emergency call, however you’ll need to have a clear view of the sky to ensure satellite reception. (if you have the option turn this feature on, though I believe many newer phones don’t give an option, it’s just always on.) This is known as a E911 (enhanced 911) feature.

    If you do not have the E911 GPS feature enabled, or if your phone is unable to acquire a GPS signal the 911 system relies on a triangulation from cell phone towers… This method of location tracking normally has an accuracy of 100-500m, and is NOT as good as as GPS signal.

    Last cavate, is if you have a phone service that allows for calls over wifi networks, the system cannot triangulate your location, in theory there are database of wifi locations, but they are always out of date (as wifi networks pop up and are moved/removed) and have an accuracy of about 50m or so (100m depending on the accuracy of the wifi maps being used). If you are in an office building, with No GPS and making the call over wifi 911 operators get NO information about your location other than the address associated with your phone (usually your billing address).

    In this particular instance it sounds like the triangulation worked as expected, the E911 feature did not work (no GPS signal, or not enabled on the phone, or setup at the 911 operators side).
    If you have to call 911, and have the option, a clear view of the sky is best, it will help the gps get a lock and identify your location more accurately, and it will be easier for first responders to get to you if your not in a structure that needs to be searched for your location (or an entrance, etc.)

  • Al

    When I contemplate leaving government, it’s always, every single time, been due to frustration with technology. Not the lack of funding, not the derision we constantly weather from legislators and the public alike, the ANCIENT technology that no one seems to have the power, wherewithal, or motivation to change. Some days, I feel like the kid with his finger in the dike. Except that the dike broke a long time ago and now we’re just standing there in the rush of water wondering what the hell we do now.

    • betsy w

      It’s all part of the infrastructure which the pols don’t care about because it’s not getting them votes.

  • Jack

    This is why I have a land line at home and will always have a land line. When my spouse was having a heart attack (which progressed to cardiac arrest), I called from our unpublished land line and they had the exact address pull up.

    I consider the extra monthly expense to be insurance. It’s also the same reason I went ballistic when the neighbor’s contractor cut the underground cable and said nothing. It can be a matter of life and death.

    • Laurie K.

      A landline is a smart idea, however, it only works if you have a medical emergency at home. A landline would not have saved Laura. Not even being within feet of the hospital saved her.

      • Jack

        I completely agree.

        On a related note, I did renew the OnStar subscription on our GM vehicle for the same reason. Price of piece of mind is well worth it. Made sure that our plan included emergency services. Also made sure that my family was aware that it should be pressed in an emergency.

        Cell phones are still good to keep with you though. Rule at our house is to have it on you when outside the house – even if just working in the yard.

        Not having emergency personnel find the caller has always been my fear. What happened to the caller here is unforgivable- especially the hospital not looking harder for her. Wonder why the hospital locked the entrance instead of having security on site.

  • lusophone

    To me the biggest issue here is that the charge nurse was contacted by the police who told her that there was someone needing medical attention outside the entrance that was locked and when the nurse discovered that the door was locked, didn’t make the extra effort to locate the patient.