Today In Court – Monday March 21, 2016

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“My son’s not breathing”

“My son’s not breathing”

It’s 9:24 pm on March 13th, 2012 and these are the words recorded on the first 911 call made by David Stephan. Carroll Moore, the 911 operator asks him whether he needs police, fire or ambulance. David is audibly desperate as he twice relays “my son is not breathing”, “my son is not breathing”. He tries to answer Ms. Moore’s questions, at the same time trying to help Colette with Ezekiel. The operator asks for their address, but its difficult to describe. “We’re in the small town of … well what used to be the town of … next to the old church … 4 miles west of…” We can hear David frantically searching for something that has their rural land address to give to the operator. He finds it and relays the lot and rural road numbers twice. She continues with questions about CPR, and then suddenly Ezekiel starts breathing on his own. David then says “you know what, I think we are just going to drive him into the hospital”. The operator isn’t certain that he is breathing, and his dad puts the phone next to his son. We all hear the croupy sounds as Ezekiel breaths and moans. The operator questions which hospital, and says, “If you need us – call back, ok?” The 3-½ minute call ends.

At 9:52 pm, David calls 911 again. Joel McDonald is the new operator who asks the same question with regard to police, fire or ambulance. This time dad is driving, and mom is in the back of their silver 2002 Chevy Trail Blazer en route to the hospital – emergency flashers on. David asks for an ambulance to meet them on Highway #2 north of Cardston. Joel is heard asking if they are performing CPR. They are, but he asks if Colette can hear him. David puts him on speaker and Joel begins coaching Colette on the number of compressions and breaths to give Ezekiel. Colette sounds very competent, and responds very well to Joel’s instructions. He counts aloud to mom: “27, 28, 29, 30. Ok, now two breaths, ok, now another 30 pumps”. This continues until the ambulance arrives approximately 11 ½ minutes from the start of this second 911 call. The paramedic takes Ezekiel from the vehicle into the ambulance to begin emergency treatment. How could mom and dad have known that the ambulance, regardless of its caring and competent paramedics, was not stocked with the life saving equipment necessary for a child Ezekiel’s age.

Both the prosecuting and defense counsels question these 911 operators with little to probe aside from the protocols handling calls and verifying the accuracy of the transcripts. The entire courtroom was emotional as we all wept along with David and Colette as this traumatic event is replayed. Will these parents ever be allowed to heal?

Note: The Crown Prosecution called the ER doctor and paramedic witnesses to the stand today before the 911 operators. However, todays report will be written in the sequence relative to the night of Ezekiel’s crisis, rather than the order they appeared in court.

Kenneth Cherniawsky is the Alberta Health Services paramedic that first responded to the scene on the side of the highway 4 kilometers north of Cardston 4 years ago. He gave testimony related to his observations during the entire treatment attempts and transportation of Ezekiel to the Cardston Hospital. Although there were several emergency medical personnel who assisted, Kenneth is the author of the report. He describes Ezekiel’s color as ashen, which means grey color with a blue tinge. He detailed for the court the Emergency Care Report as having a range of colors to select, from pink to mottling, from ashen to pale. Ezekiel was not at the extreme of pale. Ashen meant that he was in circulatory and respiratory distress. He wasn’t breathing and had no pulse or heartbeat.

At 10:03 pm, Kenneth did not think it appropriate to declare Ezekiel dead. The paramedics start BVM (Bag Valve Mask) attempts to establish an airway. They try several times over three minutes with no success. The BVM is not the right size for a child younger than 8-10 years old. Ezekiel is 18 months old. They could not get air into Ezekiel because the mask was too big. “No seal compliance”, is how Kenneth describes it. The air would blow past the mask, and his chest would not rise or fall. If you recall, an earlier witness taught, “If it isn’t rising, it isn’t working” in relation to proper oxygen in and CO2 out.

They next attempted to establish an airway with a LMA (Laryngeal Mask Airway). This is inserted into the mouth down into the throat. This too was the wrong size. Size 1 was too small, size 3 too big, and size 2 was incapable of sealing. Half sizes were destocked and not available in these ambulances. Five minutes are used up attempting this form of airway. Next, they try to intubate with an endotracheal tube. They use a special measuring tape and it indicates a #4 should be used. However, only a size 3 is available, so it is inserted and a poor but functioning airway is established. A total of 8 ½ minutes elapse where Ezekiel is without air. The one EMT must hold the tube in a specific way to even make it work en route to the hospital. While all of these airway attempts are being made, chest compressions did not cease. The EMT’s also insert an I.O. needle into Ezekiel’s lower leg to push a 200 ml bolus of normal saline. This is done for multiple reasons like hydration, but mostly to increase blood volume to assist with cardio recovery.

Once Ezekiel arrives at the hospital his color has improved to somewhere between ashen and pink (this is important to remember). He is not breathing on his own, nor is his heart spontaneously beating. They arrive at the hospital at 10:13 pm, 21 minutes from David’s second 911 call. The size 3 tube is switched immediately to the appropriate #4.5.

Dr. Lloyd Clarke was the attending physician when Ezekiel arrived at the Cardston Hospital. He called in Dr. Cunningham to assist (who testified last Wednesday), and the two met the ambulance and had Ezekiel moved into the ER. Now, Dr. Clarke is a bit of a contradiction in himself. Last Thursday he was called to be a witness for the Crown. He wasn’t at the stand long before he said two words that caused a two-day hiatus for the jury. They were asked to go home till Monday (today). This enabled the court to hear and give a ruling on an objection raised by defense concerning those two words that morning. Because of the publication ban, we cannot report on the contest before the court. What we can share is that when the jury commenced sitting this morning, they were charged by the judge to disregard the doctor’s two words: “extreme dehydration”. Can you imagine the prejudice this fiction may have caused with the jury with regard to the character of these parents? So here is the contradiction. When the EMT’s arrived at the hospital, Ezekiel’s color had improved. When Dr. Clarke was questioned during the preliminary inquiry last June, he said Ezekiel had no more mottling (better than ashen) and his color had improved and no mention of dehydration. However, when he gave testimony last Thursday morning, he broke into a less than convincing emotional observation of Ezekiel as “ghostly white” & “ghastly pale”, indicative of “extreme dehydration”. At no time in all of this process since investigation to trial has hydration ever been in question. It has never been commented on by any of the attendants or reported in their initial observations. What? Where, Dr. Clarke, did you come up with this entirely new rendition of the events of March 13th, 2012? And why did you contradict your earlier testimony and even your own ER report for that night. We question, “can a rat really be detected through smell”, as the saying goes? Many commented after Dr. Clarke’s faux pas led to an early recess that the doctor had been coached to his own embarrassment. One can only hope that the jury dismisses his testimony as easily as he dismissed the truth.

The errors of the Alberta Health Services (AHS) equipment transition and the refusal to respond to EMT/Paramedic requests for a full stock of equipment is no small matter in Ezekiel’s outcome and this trial. There has not been an internal inquiry or charges of negligence leveled against AHS for their failures. Why charge parents when your own actions are in question. Is there a cover up? Are these not double standards? Even the medical examiner, Dr. Adeagbo changed his testimony from what he stated in the preliminary inquiry to be the cause of Ezekiel’s brain injury. His Medical Examiner Report is now in question.

At one time the ambulances were stocked with neonatal, infant, toddler, child, and 8-10 year old sizes. These units were destocked due to government confusion when Cardston Emergency Medical Service was transitioned over to Alberta Health Services central control. The paramedic assured the court that he had tried numerous times to have adequate equipment in place, but was ignored by management. He also acknowledged that he served part-time in other ambulance centers where all of these items are well stocked in the “trucks”, as he calls them. Some additional things of interest arose during Kenneth’s testimony:

  1. One week after this incident with Ezekiel the necessary equipment that would have prevented his hypoxic injury was restocked in all the Cardston ambulances.
  2. Sometime later Kenneth required back surgery. While recovering in hospital he contracted meningitis. It was finally diagnosed after his wife insisted the doctors do further tests, because of the sickness and convulsions he was experiencing inconsistent with his recovery. When this information came out today, the Crown Prosecution strongly objected on relevance. The judge allowed the evidence. If doctors can miss meningitis, even when their patients are in their care in the hospital, how are parents expected to be held responsible if it is missed?
  3. Kenneth was strongly directed by his employer Alberta Health Services not to speak with defense counsel leading up to the preliminary inquiry.