Special Reports

Questions surround paramedics' response to head trauma victim

At 9:31 p.m. the night before Halloween, a Beaufort County ambulance rolled up to a house in greater Bluffton. Two paramedics, responding to a 911 call about a severely beaten man with a head injury, got out.

Inside the house on the living room floor lay Brian Lanese, 33, bleeding profusely from the right side of his forehead, speaking incoherently and behaving combatively -- often signs of severe head trauma.

What happened in the next 20 minutes has raised questions -- not only about the two paramedics' actions, but also about how the county's Emergency Medical Services handles trauma cases:

• Did the two paramedics under-react to Lanese's injuries? They didn't take standard equipment for head trauma cases into the house, according to a witness. And one of the paramedics assessed Lanese's head injury as "moderate." Yet it turned out to be so severe that he ended up in an intensive care unit for nearly two weeks.



• Why did the paramedics suspect Lanese was drunk or overdosing on drugs? His wife, Tracy, repeatedly told them he had only iced tea to drink. Later tests confirmed that, she said. Still, one of the paramedics reported that he had been "heavily drinking."



• Why did the paramedics initially head toward Hilton Head Hospital with Lanese? The hospital is not staffed or equipped for head trauma cases; a hospital in Savannah that routinely handles such cases is only few minutes farther away than the island hospital.



• Do county paramedics have to handle so many calls that they can't afford the time to take seriously injured patients to Savannah? On average last year, the two county ambulances that serve most of southern Beaufort County's mainland handled 4.5 times as many calls as the seven ambulances that serve Hilton Head Island.



• Why wasn't LifeStar, the emergency medical helicopter, called to get Lanese to the hospital faster?



• Why did paramedics spend nearly 20 minutes at the Lanese house -- during which he received little medical care. Beaufort County protocol recommends spending no more than 15 minutes.



• Why did Lanese's wife and a neighbor have to carry him to the ambulance -- without a backboard or neck collar and with no help from the paramedics?



The neighbor who helped carry Lanese happened to be an award-winning paramedic for Hilton Head Island who lived across the street. He was already at Lanese's side when the county's paramedics arrived, and was so upset by what he observed that he wrote a letter to Beaufort County administrator Gary Kubic. It prompted an investigation by the S.C. Department of Health and Environmental Control. Findings are expected soon.

"I am thankful that Brian is still alive but feel utterly disgusted about the care he received from the paramedics," the neighbor, Adam Hoffman, wrote in his Nov. 7 letter.

THE ATTACK

Brian Lanese, a landscape architect and father of 2-year-old twin boys, was grilling steaks with a friend, Jeffery Wooten, when three masked assailants rushed them at about 9:15 p.m.

Two of the invaders beat Lanese with their fists and one of the two rammed the stock of a pellet rifle into Lanese's forehead. The third assailant beat Wooten before all three ran into the woods.

Dazed but not seriously hurt, Wooten ran inside and called 911 as Lanese stumbled in. Tracy Lanese tried to calm her husband, who had blood gushing from a 4-inch gash across the right temple. Blood would soak through a big beach towel by the time paramedics arrived.

Tracy's sister ran to get Hoffman, a paramedic who received the Town of Hilton Head Island Fire and Rescue Division "Star of Life" award last year from the Hilton Head Department for "exceptional critical thinking or ability" that saves a life.

Hoffman found Lanese "thrashing around and speaking incomprehensible words" -- typically signs of severe head trauma, according to state EMS protocols. Of the 12 indicators typically displayed by trauma patients, Lanese exhibited two: "penetrating trauma to the head, neck, torso" and "potential head injury."

Beaufort County dispatched an ambulance with two paramedics a minute after Wooten's call. Four minutes later, paramedics Shayna Orsen and Jeffery Knieling, were parked down the street from the Lanese house, waiting in their ambulance for sheriff's deputies to make sure the attackers were gone -- standard operating procedure.

While the paramedics waited, Hoffman -- already in the house -- explained to the dispatcher that Lanese had a serious head injury and was combative, according to a recording of the call. Hoffman said Lanese's injuries were so severe that LifeStar, the medical helicopter, should be called. The request was automatic for Hoffman: His employer, Town of Hilton Head Island Fire and Rescue Division, puts LifeStar on standby for all potentially life-threatening injuries.

Hoffman also tried to help Tracy Lanese calm her husband. A deputy who was on the scene began shouting at Lanese, saying, "If you don't stop moving, I'm going to put cuffs on you," according to Hoffman's letter.

The deputy "got on top of Brian" and placed a cuff on his right hand. She had trouble cuffing Lanese's left hand, though, because "he was shaking and thrashing around. The officer then proceeded to punch his right arm trying to make a patient with a head injury comply," the letter said.

Hoffman asked the deputy, who is not named in any reports, to move aside so that he could restrain Lanese. Hoffman managed to get Lanese's hands behind his back, allowing the deputy to finish cuffing him.

Sheriff P.J. Tanner declined comment about the deputy's actions pending the results of the state's investigation.

PARAMEDICS ARRIVE

With the Laneses' home secured by deputies, the county's paramedics arrived at 9:31 p.m. They moved "with no sense of urgency," according to Hoffman's wife, who watched from across the street. She said Orsen and Knieling spent a few seconds opening and closing doors and compartments on the ambulance and chatted briefly before entering the house.

The paramedics brought no medical equipment inside with them -- no stretcher, backboard, cervical collar or oxygen, according to Tracy Lanese and the Hoffmans. The county's "EMS Standing Orders" for trauma patients recommend that "immobilization equipment and any necessary supplies should be taken to the patient on initial approach" so time isn't wasted if they're needed later.

Asked why no equipment would have been taken into the house, the paramedics' boss, Beaufort County EMS Director Rusty Hollingsworth, declined comment.

When the paramedics walked into the living room, Hoffman and Tracy Lanese were holding Lanese down on the living room floor. Hoffman identified himself as an off-duty paramedic and said Lanese's combativeness was unusual for the usually mild-mannered man, according to Hoffman's letter.

Hoffman asked Knieling, one of the county paramedics, if LifeStar would be called to take Lanese to a trauma hospital in Savannah. Knieling answered that LifeStar wouldn't pick up a combative patient, Hoffman's letter said.

Responding to the paramedics' questions, Tracy Lanese said her husband had had no alcohol that evening -- just sweet tea. Hoffman also told them that neither drugs or alcohol were involved. But the paramedics were skeptical, Tracy Lanese said in an interview.

In fact, a follow-up report written by Orsen and signed by both paramedics stated that family members acknowledged Lanese had been drinking: "While on scene, family reported the PT (patient) had been 'heavily drinking,' " that report stated.

Tracy Lanese emphatically denied ever making such a statement and says that drug and alcohol tests later performed at the hospital came back negative.

Knieling did not return calls from a Packet reporter. Orsen declined comment, directing questions to Hollingsworth, the county EMS director. Hollingsworth said neither Orsen nor Knieling could talk, citing the DHEC investigation and legal concerns.

Orsen has been with the department for about six years. Knieling was first hired more than 12 years ago. Neither have had complaints filed against them during that time, according to records obtained by the Packet.

'I'M NOT TOUCHING HIM'

The two paramedics spent "about 15 minutes trying to move the patient onto the stretcher and into the ambulance," according to the report the paramedics signed.

Hoffman, however, said in his letter that the paramedics gave Lanese little attention.

"... Orsen looked at the patient with her arms crossed and stated, 'I'm not touching him until he stops moving,' " the letter said.

Hoffman asked Knieling where they planned to take Lanese.

Hilton Head Hospital, Knieling replied.

Once again, Hoffman urged that Lanese be taken to Savannah. But Orsen told Hoffman he had no say in the matter because he was "not on Hilton Head anymore," Hoffman's letter states. And, according to her own written account, Orsen said "beggars can't be choosers" as she walked out the front door.

Angered, Hoffman shouted at Orsen, asking for her name. Then, because the paramedics "refused to touch" Lanese, Hoffman and Tracy Lanese picked him up from the living room floor and carried him outside to the ambulance by themselves, according to Hoffman's letter and interviews.

"Brian's wife and I picked Brian up and carried him to the stretcher with no help from either BCSO (the Sheriff's Office) or EMS 6 (Beaufort County paramedics)," Hoffman wrote.

Each held one side of Lanese's body and carried him -- face-down with his hands cuffed behind his back -- from the living room to the street, where a stretcher was waiting next to the ambulance. As they took him out the front door, Lanese kicked out one of his legs, catching it on the frame.

TO SAVANNAH OR HILTON HEAD?

Once Lanese was on the stretcher, Tracy Lanese straddled him, holding his shoulders down while someone else tied his legs down, she said. Each of his arms was handcuffed to a side of the stretcher.

When Hoffman asked a third time if Lanese would be taken to Savannah, Knieling said no, because "the patient was not that serious," Hoffman's letter said.

At that, Tracy Lanese grabbed a phone and called county dispatchers.

"My husband has a severe head trauma and he needs to go to Savannah and they (the paramedics) said they have to transport him to Hilton Head," according to a 911 recording. "He's incoherent. He doesn't know his name. His eyes are swelling. His facial frontal lobe is swelling. I need him to be transported to Savannah."

The dispatcher said she couldn't order the ambulance to Savannah -- only the emergency room doctor at Hilton Head Hospital could do so. Hoffman called Hilton Head Hospital's emergency room and spoke to Dr. Van Gauby, who said he would divert the ambulance to Savannah.

Apparently irritated about Hoffman's call to the hospital, Knieling asked a deputy to arrest Hoffman if he "interfered with this (incident) any further," Hoffman's letter stated.

"I stood back and watched helplessly with Brian's wife as the paramedics did nothing but tie Brian to the stretcher as time ticked by," Hoffman wrote. "Brian still had an open head wound that was bleeding and had not been controlled. Not a single vital sign or rapid trauma exam had been done."

Knieling stated in a follow-up report that Hoffman had been "irate and verbally abusive." Knieling said he told Hoffman that the paramedics couldn't take Lanese to Savannah without an order from the Hilton Head Hospital emergency room.

But paramedics don't need permission to divert to another hospital, Hollingsworth said. County protocol says that paramedics should alert the hospital they're going to -- not the one they're diverting from, he said.

DISPUTED COMA SCORE

Orsen first took Lanese's vital signs at about 9:50 p.m., moments before the ambulance departed, according to her report. She noted his level of consciousness as "alert."

She also gave him a Glasgow Coma Score, a simple test that rates the severity of head trauma based on eye, verbal and motor responses to stimuli.

On the test's 15-point scale -- 15 is a normal, uninjured person -- Orsen rated Lanese as a 12. Scores from nine to 12 reflect "moderate head injury."

Though she reported that Lanese's eyes were swollen shut, the score she reported for his eyes on the coma score reflects normal eye function.

In a statement prepared for the DHEC investigator, Hoffman said he would have given Lanese a score of only six. A score of eight or less signifies "severe head injury."

U-TURN TO SAVANNAH

The paramedics spent 20 minutes at the Laneses' home before heading to the hospital -- five minutes longer that prescribed by the county's standing orders: on-the-scene time with trauma patients should be "no more than 15 minutes," the orders say.

With Knieling driving, the ambulance headed toward U.S. 278 for the trip to the island hospital. Moments later -- because of Hoffman's call to Dr. Gauby in the emergency room -- the ambulance turned around and headed for Savannah.

"...Dr. Gauby gave orders to divert to Savannah Memorial hospital because the PT (patient) needed neurosugery . . .," Orsen wrote in a statement.

Orsen gave Lanese an IV 15 minutes before arriving at the Savannah hospital. She reported that she tried at least twice to bandage his head, but couldn't. He was still bleeding after arriving at the hospital 35 minutes after leaving his home, reports said.

Emergency room doctors quickly moved Lanese to the trauma operating room, where neurosurgeons performed the first of several life-saving surgeries, hospital reports said.

After spending nearly a month in Savannah Memorial, including several weeks in intensive care, Lanese went back home to his family in Bluffton. He's back at work now, but still goes to Savannah for checkups to make sure his brain is OK. His family and doctors never thought he'd recover completely.

It had been a trying night for paramedics Orsen and Knieling, the county paramedics. In a conversation with a dispatcher just before midnight as they drove back to Bluffton, Orsen described the call to the Lanese house as the "lovely run on Sugaree Drive that just royally kicked our butts."

Island Packet staff writer Daniel Brownstein contributed to this story.






Letter from Adam Hoffman



This is a letter written on Nov. 7, 2008, by Adam Hoffman to Beaufort County Administrator Gary Kubic. Hoffman, a neighbor of the Lanese family, is an award-winning paramedic for Hilton Head Island’s Fire and Rescue Division. On the night Brian Lanese was attacked, Hoffman helped Lanese until Beaufort County paramedics arrived, then observed their handling of the incident.






Statement from Jeff Knieling



This is a statement by Jeff Knieling, the senior of the two Beaufort County paramedics who responded to the Lanese home. Knieling wrote the statement for state officials who are investigating whether the paramedics handled the case properly.






Statement from Shayna Orsen



This is a statement by Shayna Orsen, one of the two Beaufort County paramedics who responded to the Lanese home. Orsen wrote the statement for state officials who are investigating whether the paramedics handled the case properly.








Calls for Beaufort County Emergency Medical Service



This document shows the calls for Beaufort County Emergency Medical Service on Oct. 30, 2008. The chart shows the number of calls each EMS unit responded to as well as the crew members involved. EMS-6 was the unit that responded to the Lanese home. It responded to six calls during its shift — more than any other crew.








DHEC Trauma Field Triage Scheme



The S.C. Department of Health and Environmental Control approved a new Trauma Field Triage Decision Scheme in April 2008. It is a protocol intended to help emergency responders make better decisions as to when air transport should be requested as well as which level trauma center is most appropriate for a patient. These documents include a letter from DHEC to all EMS providers announcing the new protocol and the decision scheme. The protocol says patients with head injuries should be taken to the closest designated trauma center.








Beaufort County's "Standing Orders for Emergency Medical Service"



Beaufort County’s “Standing Orders for Emergency Medical Service” provide instructions on how paramedics should respond to patients with specific needs. These three pages show the guidelines for patients with multiple kinds of trauma, how patients classify as trauma and the criteria for air transport.








State Trauma Centers



This document identifies all trauma centers in the state and what’s available at each. It also outlines how hospitals are designated as trauma centers. The state trauma program establishes standards for the kind of hospitals that are designated as trauma centers. There are three levels of trauma centers. The higher the level, the more specialists and medical equipment is available to treat trauma patients.








Audio: Adam Hoffman requests LifeStar standby and notifies of head trauma






Audio: Tracy Lanese requests transfer to Savannah and number to hospital






Audio: Shayna Orsen requests that the family be notified that Lanese is going to Savannah for treatment






Audio: Jeff Knieling calls to determine the amount of time EMS-6 spent at the Lanese home






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