By Kathleen Foody
Gannett Wisconsin Media Investigative Team
Feb. 17, 2013

Database of ambulance inspections

If you were injured in Adams County on Jan. 5, 2011 and ended up in any one of the ambulances serving the town of Friendship, the vehicle carrying you to the hospital either had faulty emergency brakes or tires that needed to be replaced.

How do we know? When the state’s lone ambulance inspector reviewed the vehicles the next day, he recorded those violations — among others — and gave the owner, Curtis Universal Ambulance Service, 10 days to fix the problems.

Such problems aren’t all that unusual. A Gannett Wisconsin Media review of state inspection reports obtained under open-records law found 23 percent of the ambulances in Wisconsin violated at least one state requirement during the last two years, even though inspections typically are announced to emergency providers a week in advance.

Those inspections are conducted by one State Patrol employee who is responsible for reviewing every ambulance in Wisconsin, traveling full-time in a cycle that brings him to each county every two years.

The most common violations are easily fixed with a new light bulb, but more serious problems regularly go unchecked until the state inspection.

In 1,062 inspections performed during the last two years, seven ambulances have been ordered to stay off the road until crews fixed violations revealed during inspections. One provider’s license was suspended after the company failed to fix the problems.

History has proven that the inspections are vital safeguards for patients and to the EMTs or paramedics working inside ambulances. Imperfect equipment can lead to tragedy, as in the case of an EMT left paralyzed by a 2003 crash, or leave a community searching for an ambulance provider, as the city of Waupun was forced to after the state shut down a private company last year.

It’s up to inspector Paul Schilling to prevent those scenarios — and penalize violators — as he makes his rounds every year.

How it works

On a January morning, Schilling sat at the front of an ambulance’s patient compartment, adopting a paramedic’s pose with his legs on either side of the bright yellow stretcher. No patient lay on the thin mattress covered in a hospital-green sheet, just one ordinary-looking duffel bag after another, stocked with the drugs and medical equipment that could save a life in an emergency.

Two paramedics hovered near the ambulance, one of two kept at the Oshkosh Fire Department’s main office. Battalion Chief Jim Austad assisted Schilling inside the vehicle.

In this scene, the ambulance is the closest thing to a patient.

Almost all of Schilling’s inspections are scheduled in advance. Other state inspections of restaurants, pools and businesses mix unannounced and scheduled inspections, depending on the owner’s schedule and whether inspectors discovered serious problems during previous visits.

One former ambulance inspector said notifying emergency medical services ahead of time was necessary, especially for those staffed by volunteers who don’t keep regular hours at a garage or station.

“I felt that it was better off telling them when to expect me, so if they knew they had things to get done, they’d get done,” Dee Evans, who inspected ambulances for the State Patrol from 2001 to 2003, said. “Now, that only happened once every two years. So what was going on the rest of the time that I wasn’t there, well, you have to wonder.”

Ambulance crews are supposed to conduct their own regular checks when the inspector isn’t in town. At the busiest departments, this is a daily and weekly task. In Oshkosh, for example, a binder packed with forms to complete every week and once a month is assigned to each ambulance in the city. Austad said crews also restock medical equipment and other supplies every morning, giving them another chance to catch problems.

At volunteer departments, that rhythm is tougher to establish. Evans, who started his career at a volunteer department, said volunteer EMTs returning from a call at 2 a.m. might not have the time to replace everything.

“When I started, we had a monthly check,” Evans said. “We went through the rig: clean it, sanitize it, restock, make sure everything was working.”

Inspectors can drop in unannounced, and Schilling said he typically does if someone complains about an EMS provider. But he’s skeptical that conditions are much different without an inspection on the horizon.

“I guess I have the mindset that my family could be in the back of that ambulance just like their family, and I think a lot of them realize that,” Schilling said. “So I hope they’re ready.”

Putting it to the test

Schilling, who started his career with the State Patrol 18 years ago but has been inspecting ambulances for seven, started his inspection in Oshkosh by opening a hard gray suitcase, full of gauges for testing oxygen tanks and other equipment on the vehicle.

He scooted to the edge of the seat facing toward the open rear doors. He methodically pawed through each color-coded bag in the ambulance — red for medications, blue for standard emergency tubing and masks, black for a defibrillator — turning small pieces of medical equipment over in his hands.

Everything has a designated place to help paramedics move as quickly as possible while treating a patient. Even an ordinary-looking stuffed bear, engineered to deliver oxygen when kids hug the toy close, has a cabinet.

Watching Schilling, it’s hard to tell which items he’s inspecting most closely. But the reports he has completed during 2011 and 2012 reveal repeat problem areas for ambulance providers in all parts of the state.

During that two-year span, Schilling found expired medications, ranging from the sugary gel used for patients with low blood sugar to the epinephrine used to treat serious allergic reactions, in dozens of ambulances.

Oxygen systems were flagged for having pressure that was too high or too low. Tires, a barometer for an ambulance company’s maintenance routine, are generally well-maintained. Any fewer than 10 violations and the state inspector can allow an ambulance to stay on the road. More than 10 serious violations means the ambulance has to be repaired before carrying patients.

Schilling remembers taking only one company’s ambulances off the road because of problems he found during a surprise inspection. On April 23, Schilling barred Brooks Ambulance in Waupun from using either of its vehicles.

In the first ambulance, he found more than a dozen violations of state rules including problems with the oxygen system and no heat in the back of the ambulance. In the second, he found 16 violations, including cracked tires, expired medical equipment and problems with the oxygen and heating systems.
Schilling gave the company 10 days to fix the problems, but got no proof of repairs and pulled Brooks’ license on June 14.

By then, city of Waupun officials had found a replacement for Brooks Ambulance. One of the company’s owners publicly charged that city officials orchestrated the state inspection as retaliation for a dispute over annual charges.

Efforts to reach the former co-owners of Brooks Ambulance this month were unsuccessful. Waupun City Administrator Kyle Clark directed a reporter to previous media coverage and declined comment beyond an e-mail statement.

“(The) Brooks family provided a tremendous public service over many years in the city of Waupun and surrounding communities,” Clark wrote.

Taking pride

The State Patrol provided Gannett Wisconsin Media with handwritten reports for about 1,250 ambulances that Schilling inspected during 2011 and 2012.

Bernard Coxhead, the State Patrol’s investigation unit manager who oversees the ambulance inspection program, said the department is now using a web-based system, allowing the inspector to type results rather than write them on a paper form.

The program has a $90,000 budget, including Schilling’s $44,539 salary.

Schilling plans out his stops at the start of each two-year cycle and spends most weeks away from home. The lifestyle, Schilling suspects, is one reason he has become the longest-serving inspector in recent memory.

His regular schedule can get interrupted when departments buy new ambulances that have to be inspected before they are approved to carry patients, or an ambulance is involved in a crash.

Maintaining ambulances as vehicles that serve as traveling emergency rooms has to be a point of pride for anyone working in emergency medicine, Bert Nitzke, an emergency medicine instructor at Northcentral Technical College in Wausau, said. It takes 180 hours of training to become a basic-level emergency responder, and a large chunk of that time is devoted to instilling what Nitzke calls “pride in ownership.”

“Even if you have 30 calls a year, you still have to take that pride, ensuring you have the best, most up-to-date equipment and medication,” Nitzke said. “Because that patient may be a family member of yours or mine, especially in the rural areas where we all know each other.”

Classes are divided into groups and given assigned days to perform their own version of the inspection Schilling did in Oshkosh. They’re tested with medications, with instructors sneaking expired medication in among the good equipment.

Nitzke said he wants students to get in the habit of performing regular inspections and paying close attention to expiration dates, making it easier to keep that routine back at work.

Like other paramedic-level departments, the Oshkosh Fire Department has equipment far beyond the state’s requirements. Schilling checks only state-required items, searching for expiration dates, counting for the required number of bandages, and checking sizes on tubing and wires used to help patients breathe. If he’s satisfied, the equipment goes back into the appropriate bag or cabinet.

If he’s not, the offending piece of gear is pulled out and must be replaced, proven by an invoice or other documentation faxed to Schilling’s home office in Phillips. Ideally, a new light bulb is installed or more bandages are added right away.

But bigger fixes, and ones that can endanger patients and the people treating them, take time. Tires have to be ordered. Medication already in short supply has to be replaced.

The Oshkosh department’s first ambulance passed easily. Schilling closed his gray kit, perched near a rolling crate to enter the information on his laptop, then followed Austad outside.
They visited six more ambulances that day, a small share of the 1,200 plus Schilling will inspect during the next two years.

“It’s a tiny program, but a huge program,” Schilling said. “Yeah, there’s only one person doing it, but I’m responsible to every citizen in the state.”

How we did this report

When state ambulance inspector Paul Schilling visits an emergency medicine provider, he completes a checklist of 150 required items. Those checklists aren’t typically made public but were provided to Gannett Wisconsin Media in response to an open records request.

The records were used to create a database and also were checked against a list of ambulance providers to ensure every department or company was checked during 2011 and 2012 as required.

Interviews with current and former emergency medicine providers, state officials, patients and others connected to the field were used to complete this report. State statutes, studies performed by emergency medicine researchers and complaints about ambulance service filed with the state also provided background information.