33 Minutes To 34 Right

A CALL7 Investigation Uncovers Denver's Broken Ambulance System

When Continental Flight 1404 went off the runway in December, it was a perfect real-life test of Denver’s emergency response system.

But instead of prompting a well-coordinated response to a major airline accident, the crash exposed major flaws in the way Denver Health Medical Center reacts to emergencies, a three-month CALL7 investigation found.

Presented in a half-hour special, the investigation exposed problems with communication and a lack of resources to cover both the city and its distant airport. CALL7 investigators also found the hospital had no policy to respond to plane crashes and failed to meet national standards in the response.

All of those problems led to a 33-minute ambulance response to the crash site of Runway 3-4 Right and led experts to the conclusion that Denver’s ambulance system is broken.

“It’s purely unacceptable that you’re talking about … that length of time,” said Jeff Lindsey, an assistant professor of emergency health services at George Washington University in Washington, D.C., who spent more than 20 years as a paramedic and fire chief.

James Sideras, a nationally recognized expert who spent more than 25 years in emergency services where he coordinated the response to a major mass-casualty incident, agreed.

“When you look at a plane crash or any type of disaster, the first few minutes are critical to saving lives,” Sideras said. “Those patients had a right to expect more, and I don’t think they got it.”

Flight 1404, filled with 115 passengers and crew, was scheduled for a two-hour flight from Denver to Houston on Dec. 20, 2008. It crashed at 6:18 p.m. while taxing for takeoff on runway 3-4 Right.

Denver Health administrators initially said they were proud of their response to the crash, pointing out no one had died.

"To say that no one died and you're proud of your response is really to stick your head in the sand and say a problem doesn't exist," Sideras said.

Later, after reviewing information uncovered by 7News, Denver Health administrators conceded that there were mistakes made.

“Personally, and I know I speak for a number of people …, (I) will never be satisfied or say this is acceptable,” said Dr. Christopher Colwell, the medical director who oversees the paramedic division. “It has to be better.”

The CALL7 investigation found a stark contrast between the response of Denver firefighters, who are stationed on the air field, and Denver Health ambulances, many of which are dispatched from downtown Denver.

“When a red alert comes in, it’s an automatic response,” said Denver Fire Chief Nick Nuanes. “We just want to make sure that we send enough help in case we need it. We’d rather have it there than have to call it in.”

Nuanes’ firefighters responded within seconds, sending more than a dozen trucks and engines from the airport and all over the city.

“I just look at it as a real fire fight,” said Assistant Fire Chief Bill Davis. “One of the rare firefights with an occupied plane … The guys just drove the equipment straight into the fire and put out the fire.”

All the passengers and crew escaped the burning jet, but there were injuries and no ambulances on the way to take people to area hospitals.

Five minutes after the crash, Denver Health’s records show “Denver EMS dispatchers have not yet been notified” even though they sit less than 30-feet from the fire dispatchers. The first call about the crash came in at 6:23 p.m.

“We have a red alert crash,” a Denver International Airport dispatcher said.

“Okay, on where?” asked a Denver Health dispatcher.

“Runway 3-4 Right. It’s going to be a 737. Confirming flames and smoke,” the DIA dispatcher said.

And that wasn’t the only notice Denver Health received that a commercial passenger jet had crashed at DIA.

Flight 1404 passenger Valdir Alves called 911 after exiting the burning wreckage.

“I say something to her -- they have an aircraft crash at Denver Airport,” Alves recalled. “She asked me twice where, where, I said Denver Airport.”

But despite the two emergency calls of a fiery airplane disaster, Denver Health dispatchers gave Alves’ call the lowest priority.

“Non-emergency … monitor only,” a dispatch report said.

When 7News showed Alves Denver Health’s response to his call, he was amazed.

“I believe when somebody says there is a plane crash, you don’t have to say anything more -- it’s clear,” he said.

But it must not have been clear to Denver Health dispatchers because their response was anything but urgent, records show.

It took four minutes until the first ambulance was dispatched from Interstate 70 and Colorado Boulevard, which is 19 miles away. That ambulance was dispatched Code 9 -- a non-emergency designation where the paramedics drive at normal speeds without turning on lights or sirens.

“There’s no reason that I can conceive of that a response to a confirmed crash of a commercial airliner, that the initial response would be non-emergency for transport ambulances,” said Bob Petre, a long-time Denver Health paramedic, who is president of the union. “It’s unbelievable.”

Sideras, who, along with Lindsey, reviewed documents obtained by the CALL7 investigators, said Denver’s Ambulance system is “broken.”

“There was a true failure in the system,” Sideras said.

In fact, records show it took 12 minutes after the crash for the first ambulance to be dispatched Code 10 – the city’s emergency designation.

“Did Denver Health pass the test,” CALL7 Investigator Tony Kovaleski asked Petre.

“I would have to say no,” Petre said. “I’m very troubled about the transport ambulance response, especially how long it took to assign those units and how long it took to get them to the airport.”

At 6:30 p.m., 12 minutes after the crash, passengers – some injured – were walking to the closest fire house on the airfield. Firefighters and paramedics who were stationed at the airport treated patients and determined the ones who needed the most urgent care.

At that time, Denver Health dispatchers receive information that there are “lots of injuries” and it is “unknown if everyone got out,” but the first ambulance was still 10 miles away, records obtained by 7News show.

An unidentified passenger calls a minute later, saying that people are injured and the passenger “sees no help,” according to records of the call reviewed by CALL7 investigators.

At this point, Denver Health dispatchers are looking for help from private ambulance companies and have found four available transport ambulances.

But instead of sending them to the crash, a Denver Health paramedic captain puts the ambulances on hold.

“I’ve already checked on all my privates, and I’ve got them ready,” says a dispatch lieutenant in a radio call. “You want me to start moving them?”

“Well, no. No, that’s good,” the captain says.

There were 12 ambulances available at the time, and Denver Health did not immediately send any of them, 7News has confirmed.

“Is that what the public should expect?” Kovaleski asked Petre.

“No. They should expect a much better response than that, and they should certainly expect more than one ambulance,” Petre said.

Records show it took that one ambulance until 6:45 p.m. -- or 28 minutes after the crash -- to arrive at Gate One at DIA.

“The 28 minutes says to me, essentially, it’s too long,” Lindsey said. “It’s unacceptable for an EMS service or any emergency service to be delayed, whatever the case may be, for a 28 minute period.”

Sideras agreed.

“When you are looking at 28 minutes to get one ambulance on site when you have 30-40 patients … that just doesn’t meet the national standards,” he said.

And those 28 minutes did not mean the ambulance was ready to transport patients. It took another three minutes to get an escort at the airport gate and two minutes to get to the scene. In total, it took 33 minutes for the first transport ambulance to arrive at the crash scene of Runway 3-4 Right.

And that first ambulance was just one ambulance for more than 100 passengers and crew.

The CALL7 investigation found the delays continued during the first, critical hour. Three ambulances were at DIA 40 minutes after the crash and five ambulances were there 50 minutes after the accident. It took a full hour for just 10 ambulances to arrive at DIA.

And the 7News analysis shows that it took an average of 17 minutes for each ambulance to arrive from when it was dispatched -- that is nearly twice the national standard of responding to an emergency in less than nine minutes.

In addition, two medical helicopters were available but never called in. Sources with the National Transportation Safety Board, DIA and Denver Fire were critical of that decision.

“Paramedic dispatchers were reluctant to send ambulances?” Kovaleski asked Petre.

“They are trying to conserve resources they have which are inadequate to do the job,” Petre said.

Other cities that experienced similar accidents had significantly better responses.

Case in point is an August 2005 accident in Toronto where a large aircraft slid off the runway. Like DIA, everyone survived the crash, but unlike Flight 1404 the first Toronto ambulance arrived to transport survivors within six minutes of the accident.

The EMS experts say Denver Health administrators have to fix the ambulance response times.

“It’s not the medics on the street,” Sideras said. “It’s not the supervisors in those rigs because they only have so many resources available to them. It has to be at the senior level of that organization.”

And the senior administrators at Denver Health have known for months that there was a problem with their ambulance response.

A series of CALL7 investigations last year brought attention to problems with ambulance response run by the hospital, which contracts ambulance service with the city to respond to Denver residents' calls.

“We’re understaffed,” said one paramedic who declined to be identified for fear of losing his job. “We have half as many ambulances as our next closest city.”

The investigation found that 12 percent of the time Denver Health ambulances exceeded the national-response standard.

A review of two months of calls also found that 88 calls exceeded 20 minutes and some patients waited more than 30 minutes.

Managers also failed to address the problem of so-called “frequent fliers” -- patients who repeatedly clogged the ambulance system with fabricated emergencies.

“It happens every single day,” said another paramedic who also declined to be named. “I’ve seen some people hundreds of times. We probably take six to 12 people to the hospital every single night just because they know the right things to say.”

After the initial investigation, CALL7 investigators found a long response that turned deadly.

Mark Elgin was returning home from a business trip in July 2008 when he felt ill. Paramedics stationed at DIA knew Elgin had to get to the hospital as fast as possible, but the closest ambulance was 26 miles away at Denver Health Medical Center.

The ambulance took more than 30 minutes to arrive, and Mark Elgin died of a pulmonary embolism at DIA’s Gate B36, records show.

Elgin’s wife, Vicki, is troubled by the ambulance response and was upset that Denver Health hadn’t fixed the problem six months later when the plane crashed.

“My biggest area of deep sadness is knowing he knew he needed help and knowing it wasn’t coming,” Vicki Elgin said. “It’s too late for me … Too late for my husband’s family … but if I can prevent someone else from going through this tremendous pain and hardship then that to me is something me and my family can do.”

After Mark Elgin died, 7News discovered that DIA was the only one of the five busiest airports not to have an ambulance stationed on site and that in 10 percent of airport calls Denver Health dispatchers had to send an ambulance that was at least 20 miles away.

Responding to the CALL7 investigations and pressure from city and airport officials, Denver Health agreed to station an ambulance at DIA. That ambulance had not yet been put in place on the night of the plane crash.

“Denver knew from the day they dug that airport … the challenges associated with getting ambulances there,” Vicki Elgin said.

But even after all the evidence of problems uncovered by CALL7 investigators, Denver Health officials still defended their response to the crash of Flight 1404.

“We did mobilize 18 ambulances and transport 38 patients in a relatively short period of time – in the time frame you would expect from a mass casualty event,” said Patricia Gabow, Denver Health’s chief executive officer. “Paramedics at the scene did a great job.”

Despite their justifications, Denver Health leaders and city officials now vow to improve the ambulance response system.

City officials set up a meeting with paramedics, airport managers and 7News to respond to the investigation. City and airport officials did not agree with Gabow’s assessment of the hospital's response to the plane crash.

“Twenty-eight minutes for the first ambulance after a plane crash to get to your airport -- 33 minutes before it actually got to the plane -- is that acceptable from your position?” Kovaleski asked DIA manager Kim Day.

“It’s not,” she answered. “It’s not and it’s something we will work to improve.”

That sentiment was echoed by Mayor John Hickenlooper.

“Denver Health … said we’re proud of this response. Are you proud of it as the mayor of Denver,” Kovaleski asked Hickenlooper.

“No, I am not proud of the response,” he answered. "Denver Health is one of the best big city hospitals in America, ... but they're not perfect and certainly the communications system within that call center needs improving."

Hickenlooper promised policy changes and better communication to improve ambulance responses to Denver residents for emergencies big and small.

“When you’ve got a red alert, you still need to send the resources immediately that that situation is going to need,” Hickenlooper said. “It’s unacceptable. You can’t have from the moment the crash happens, an ambulance there in 33 minutes. That will never happen again.”

If the video links on the right don't work, please view the program in four segments by clicking on these links:

  • "33 Minutes To 34 Right - Part 1"
  • "33 Minutes To 34 Right - Part 2"
  • "33 Minutes To 34 Right - Part 3"
  • "33 Minutes To 34 Right - Part 4"

    CALL7 Investigators special "33 Minutes to 3-4 Right: Denver's Broken Ambulance System" premiered March 14 at 6 p.m. The special reaired March 14 at 10:30 p.m. and again on March 15 at 4 p.m.

    In response to interest from the public, DVDs of the special investigation are available for $50. If interested, please e-mail producer Arthur Kane for more information or mail a check made out to KMGH-TV to Art Kane c/o KMGH-TV, 123 Speer Blvd., Denver, CO 80203. Please include your return address.

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