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  • Andrew Westling Medical Report by Richard O. Cummins, M.D.

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    Andy Hobbs
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    Dr. Richard O. Cummins, professor of medicine at the University of Washington Medical Center, provided a detailed report of Andrew Westling’s medical records and autopsy at the request of the Budge’s law firm.

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    Andrew Westling medical report by Richard O. Cummins, M.D.

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    Dr. Richard O. Cummins, professor of medicine at the University of Washington Medical Center, provided a detailed report of Andrew Westling’s medical records and autopsy at the request of the Budge’s law firm.

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    12K tayangan39 halaman

    Andrew Westling Medical Report by Richard O. Cummins, M.D.

    Diunggah oleh

    Andy Hobbs
    Dr. Richard O. Cummins, professor of medicine at the University of Washington Medical Center, provided a detailed report of Andrew Westling’s medical records and autopsy at the request of the Budge’s law firm.

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    © All Rights Reserved
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    Report of Richard O. Cummins And Curriculum Vitae The Estate of Andrew James Westling (deceased) REPORT SEPTEMBER 20, 2016 Richard O. Cummins, MD, MPH, MSc Professor of Medicine Attending Physician, Emergency Medical Services University of Washington Medical Center ‘esting, Andrew: Cummins Report Tape QUALIFICATIONS AND EXPERIENC! 1, Richard Cummins, M.D., M.P.H., M.Sc., provide this report in the matter of the Estate of Andrew James Westling, Lam a physivian licensed to practice medicine in the State of Washington. | attended the University of North Carolina in Chapel Hill, as a John Motley Morehead Scholar, graduating Phi Beta Kappa, in 1968. I attended medical school at Case Westem Reserve in Cleveland, Ohio, graduating Alpha Omega Alpha, in 1972. I received three years of post-graduate training in Medicine and Pediatrics at the University of Virginia in Charlottesville, Virginia, For two years I served in the U.S. Public Health Service in a medically indigent community in rural Virginia. In 1977 I was awarded a Robert Wood Johnson Fellowship to the University of Washington School of Public Health where | obtained graduate training in Epidemiology, and a Master's in Public Health Degree. In 1979, 1 was awarded a Milbank Memorial Fund Fellowship to study for two years at the University of London in England (obtaining a Master's, of Science degree) and one year doing research at the Royal Free Hospital in London, In 1981, joined the faculty of the Department of Medicine at the University of Washington. 1 was promoted to the rank of full Professor in 1993. I am double-board certified in both Internal Medicine and in Emergency Medicine. A copy of my curriculum vitae detailing my professional qualifications and experience is attached hereto as “Exhibit 1”. Ihave served as the co-director of the Center for Evaluation of Emergency Medical Services, and as the Medical Director of the Early Defibrillation Programs in the Seattle-King County EMS Division. My research activities have been in epidemiology and the treatment of sudden cardiac death, including long-term survival, automatic extemal defibrillation, transcutancous pacing, and the pharmacology of resuscitation. [ have written and published more than 150 peer- reviewed articles, scientific publications, editorials, and book chapters about emergency cardiac care and related topics. Ihave served as the Chair of the American Heart Association's National ACLS Subcommittee, the National ECC Committee, and co-founder and co-chair of the Intemational Liaison Committee on Resuscitation (ILCOR). For five years [ served as one of two Senior Science Editors with the AHA’s ECC programs. In this position | helped develop ACLS guidelines, instructor manuals, provider manuals, handbooks and textbooks. | have been the co-editor for 3 editions of the ACLS Textbook, 2 editions of the ACLS Instructors Manual, and 6 editions of the ECC Handbook. I co-originated the ACLS for Experienced Providers Course and co-authored the Instructors Manual and Toolkit. In 2005 | was one of five individuals awarded the Giants of Resuscitation award given every five years by the American Heart Association and the ILCOR. ‘Asan active member of the Division of Emergency Medicine at the University of Washington, have worked continuously as an attending physician in the UWMC Emergency Department since 1981, more than 35 years. There I have provided direct patient care, and supervised and taught hundreds of residents and medical students in training, I have seen and evaluated many Page patients presenting with cardiac arrhythmias, and supra-ventricular tachycardias such as that experienced by Andrew Westling at Nisqually Correctional Facility on April 11-12, 2016. SUMMARY: THE CASE OF ANDREW WESTLING Andrew Westling was an 19-year-old man who died April 12, 2016 while incarcerated at the Nisqually Corrections Center (jy e.nisialltat gov indent aninistation Wib-sercices pubic safetvideparinenteaieeiiots), He had a history of a familiar, readily recognized, and easily treatable heart condition called Paroxysmal Supraventricular Tachycardia or PSVT. During his approximately 24-hour confinement at the Nisqually Corrections Center he began to experience symptoms from this condition. When he first reported his heart condition and his symptoms to correctional officers they simply transferred him to a different cell for supposed better “observation.” He reported his increasing distress a second time, approximately | and !4 hours later, However, no physical assessment, vital sign review, or even a pulse check was performed by a CO. No assessment was performed locally by the Correctional Center's nursing, or on-call medical staff. No request was made for an evaluation by Emergency Medical Services personnel, such as EMTS or paramedics. And no decision was made to have him evaluated and treated at a local hospital's emergency department. In fact, no medical provider of any kind was contacted by the COs and Andrew never received any kind of medical evaluation or treatment. After suffering for more than six hours from his PSVT, this 19 year-old man died, alone in his cell.This young man’s death was completely unnecessary and totally preventable, If it were not for the unreasonable neglect of the staff of the Nisqually Corrections Center, Andrew Westling ‘would be alive today and would very likely enjoy a normal life span, Page RECORDS REVIEWED Thad access to and reviewed the following documents related to Andrew Westling: * Records of Tenino Family Practice; Yelm, Washington. Included in these records are an electrocardiogram, an event monitor report, and an echocardiogram, ‘+ Multiple Emergeney Department Visits to Providence St. Peter Hospital; Olympia, Washington + The following documents from Nisqually Corrections: © Initial Medical Screening © Incident Report © Segregation Referral * Thurston County Medic One Incident Report + Thurston County Coroner's Report, and In-Custody Death Incident Investigation Report, prepared by Karen Peek, Deputy Coroner, and co-signed by Gary Warhock, Thurston County Coroner ‘+ Thurston County Coroner's Autopsy Report, with autopsy performed by Gina M. Fino, MD. ‘* Transcripts of taped interviews by Detective Mason of the Lacey Police Department conducted between April 12 and April 15, 2016, of the following officers of the Nisqually Police Department: ° ° ° ° ° Michael Althauser Mareo Garay Keenan Kalama Edna David Arron Robertson Michael Pino Tully Bailey PAST MEDICAL HISTORY ‘The following summary of past medical history confirms Andrew Westling’s diagnosis of the heart condition, PSVT. June 22, 2010. Visit to Leyton E. Jump at Tenino Family Practice. At this outpatient visit ‘Andrew Westling was 14 years old. ‘+ He complained of dizziness, light-headedness and near syncope. He had a queasy feeling hile shopping at Walmart, with vertigo, and “palpitations at ~100/min.” This episode improved with sitting down, and lasted about 1-2 min. ‘© Dr. Jump noted normal vital signs, cardiac examination, and thyroid function. A 12-lead ECG was over-read by a cardiologist as showing “youthful, fit heart.” Dr. Jump’s final assessment was “palpitations.” June 19, 2012. Visit to Karen Carlson, ARNP at Tenino Family Practice. Two years later, at age 16, Andrew retums to Tenino Family Practice ‘* On this visit he is again complaining of episodes of heart racing and palpitations. He tells, Nurse Practitioner Carlson that he had been experiencing episodes of lightheadedness, syncope, weakness. His palpitations had occurred with exertion at a friend’s house when he had an attack of some sort. The attack was associated with lightheadedness, chest tightness, and eye symptoms. + He reported several previous episodes of heart racing with activity. His worst episode followed 15 minutes of jump roping when his heart was pounding. He had to lay down, ‘When he got back up he felt his heart stop, then start to beat slowly again, and then retumed to normal ‘* Nurse Practitioner Carlson noted normal vital signs, normal cardiac examination, and fairly high level of caffeine intake. A 12-lead EKG was largely unchanged from the EKG of June 22, 2010; but showed possible pre-excitation, a short PR-interval, and a delta wave in several leads that raised a possibility of WPW syndrome (Wolf-Parkinson-White), a cardiac abnormality often associated with PSVT. + NP Carlson refers Andrew for a King-of-Hearts event monitor, and to see a Cardiologist for further evaluation and treatment, Three days later, on June 25, 2012, the King-of-Hearts monitor unit transmits a single tracing which demonstrated a sinus rhythm at 60-75 beats per minute, and no ventricular or supraventricular arthythmias, December 28, 2012. re by Paramedics at a local fire station in Olympia, with subsequent evaluation at St. Peter Medical Center ED, Olympia. Jonathan Babbitt, MD, ‘working in the St, Peter ED documented another episode of PSVT. * Andrew reported that he was just texting on his phone with his symptoms kicked in, making him feel lightheaded and di ‘He went to a nearby fire station, and paramedics were summoned, The medies made a diagnosis of PSVT on their monitor and started an IV. They followed standard field- protocols for PSV'T, administered two doses of adenosine 12 mg IV, followed by two doses of the calcium-channel blocker, diltiazem IV. These medications did not pharmacologically convert Andrew to normal sinus thythm, so the medics decided, appropriately, to proceed to electrical cardioversion, After sedation with versed Smg IV, they delivered a synchronized shock of 100 joules from their defibrillator. This successfully converted Andrew to normal sinus rhythm. ‘© He was then transported to St. Peter's ED for further evaluation and stabilization. There Dr. Babbitt decided Andrew was stable and could be discharged to close follow-up with the cardiology clinic and with his primary care provider, Leyton Jump, MD. January 7, 2013. Visit to Leyton Jump, MD at Tenino Family Practice. A week and a half later, Andrew followed up with Dr. Jump. * Dr. Jump reviewed the above December 28, 2012 episode, and gathered additional past ‘medical history. Andrew reported tachycardia bouts since about the third grade, and that they were happening more often. The episodes produced symptoms of lightheadedness, syncope, chest tightness and weakness. Andrew had learned that he could stop a bout of tachycardia with what are called “vagal maneuvers”, such as a Valsalva action, or by stimulating a dive reflex with ice water. The use of ice-water on one’s face or head, and other physical maneuvers (“vagal maneuvers”) are appropriately taught to patients, as they will often easily and quickly reverse an episode of tachycardia without the need for the patient to seek medical assistance or even use medication. Medication is sometimes prescribed as well, either to suppress the PSVT or for the patient to have as a backup if the patient’s self-administered maneuvers do not work. * Dr. Jump discussed starting the medication diltiazem to take on a daily basis to suppress the frequency of the PSVT episodes. Alternatively, Andrew could try the “pill-in-the-pocket" approach, in which he would a take a medication, such as the beta-blocker metoprolol, at the onset of a PSVT episode. Andrew chose to try the “pill-in-the-pocket” approach, and Dr. Jump wrote him a prescription for metoprolol 100 mg, to take “when heart is going fast.” © Dr. Jump ordered an echocardiogram for Andrew, and referred him to Cardiology for long- term management. January 14, 2013. Visit to Olympia Multispecialty Clinic for echocardiogram. The echocardiogram study concluded that Andrew had “normal systolic left ventricular function with an excellent ejection fraction of 67%: normal aortic valve and right ventricular function; trace mitral, pulmonic and tricuspid valve regurgitation; and mild bi-atrial enlargement with 10 evidence of pulmonary hypertension. A normal echocardiogram would be expected in a patient with PSVT. = ‘Westling, Andrew Cam SENTINAL EVENTS: NISQUALLY CORRECTION CENTER Monday, April 11, 2016; @ 00:39. Andrew Westling, 19 years old, had been arrested by the Yelm, Washington PD on misdemeanor charges of 4" degree assault and being a minor in possession of alcohol ‘The arresting ofticer from the Yelm Police Department, Chris Davis, informed Karen Pee Deputy Coroner, that Andrew was intoxicated at the time of his arrest. Mr. Westling was not medically assessed, and a breathalyzer test was not conducted * Inthe early morning hours of April 11, 2016, Andrew was booked into Nisqually Corrections. He completed the Nisqually Corrections Initial Medical Screening form. On this form, he checked that his physical condition was “good”; that he was not currently taking. medications; and that he had no history of heart disease. He checked “no” to a question about whether he was currently having shortness of breath or chest pain. He also checked “no” to a question about whether he had any other medical problems that the Correction Center should know about. Later, however, Andrew made multiple medical complaints to jail aff (see below). * Approximately twenty-four hours later Andrew Westling was pronounced dead in his holding cell Monday, April 11, 2016 @ 1800 hours: first episode of door-pounding. According to correction officers’ interviews, Andrew became anxious and upset at some point in the afternoon of April 11, 2016. This occurred after a telephone conversation with the judge who would be ruling on his case. ‘© The Incident Report completed by CO Althauser at approximately 1800 hours stated that Andrew began to bang on his cell door. He was noted to be holding his neck. He told the corrections officer (Althauser) that he had a heart condition, and an abnormal heart beat. He informed the officer that a prior episode of his heart condition required resuscitation by an ambulance crew. An incident report completed by CO Althauser stated: On4/11/2016 at approximately 1800 I Officer Althauser was working House 2. I/M Westling, Andrew began to bang on the door, VM Westling was holding his neck. When [talked to UM Westling he mentioned his heart condition, and said the last, time that his heart acted up he had to be resssusitated (sic] in the ambulance. | called for an available officer to come to the housing unit so that VM Westling could go on medical watch until a doctor comes to check on him, He currently resides in Holding 3. © Andrew further told CO Althauser and CO Pino that he took a medication for his heart condition but he did not know the medication’s name. * CO's Althauser and Pino decided that Andrew “needed to go on medical watch for his heart condition.” Althauser, and Pino, moved Andrew to a “medical watch” holding cell, A simultaneous Segregation Referral, was completed by CO Althauser. This documented why Andrew was moved to a medical watch holding cell, and noted that Andrew was complaining about irregular heartbeats, and that he had a heart condition. It stated: “7M Westling, ‘Andrew was complaining about irregular heartbeats, mentioned his heart condition, placed in holding for medical watch.” + The corrections officers claim to have observed that Andrew failed to note the existence of a heart condition on his initial medical screening form, or that he was supposed to be taking a medication for it. They claim that Andrew informed them that he did not have the medication available because of lack of funds. * Despite the medical screening form, CO Althauser and Pino now knew that Andrew was having a recurrence of distressing symptoms from a significant heart condition. This condition had required emergency medical treatment in the past. They knew that he lacked an important medication previously prescribed for his heart condition. They knew he was experiencing and complaining of heart-related conditions for which he had had to be wuscitated” in the past. * CO Althauser and Pino, however, failed to respond appropriately to the information reported by Andrew at 18:00 hours. They did not arrange for him to be evaluated by a nurse or medic, even though he complained again of his abnormally beating heart to an additional CO (Kalama). He was told to relax, get some air and get some water. Monday, April 11, 2015 1800 to 1930 hours: change of shift. A change of shift occurred at 1800 hours. A new shift of correctional officers became responsible for Mr. Westling, + These correctional officers all had information as to why Andrew had been moved to the medical watch holding cell. Copies of the Segregation Referral documenting Andrew's heart condition and that he was complaining of irregular heartbeats had been copied and distributed according to CO Kalama. * None of these officers, however, took additional actions, they failed to request further nursing or medical evaluation, and they failed to eall for an EMS response. No medical professional of any kind was summoned, Monday, April 11, 2016 @ 1930 to 2000 hours: second episode of door-pounding. Between 1930 and 2000 hours, Officer Edna David reported a second episode of Andrew becoming medically distressed and symptomatic trom his rapid heartbeat. CO David reported that when she first saw Andrew he had already been moved into Holding 3, the medical observation holding cell. * She stated that she initially observed Andrew between 1930 and 2000 hours. She witnessed Andrew “pounding on the door and said that he was having heart skip, skipping beats and he was leaning over the toilet area with a wet towel draped over the hack of his head... later)... He was leaning over the toilet on his knees. He had the towel wrapped around him. The towel was drenched, but CO David was unaware of how the towel got drenched. * CO David looked through Andrew's file to se that “there’s nothing written on his medical, Phe had any medical conditions, and noted She stated she had not been briefed on Andrew. ee ne Andrew: Commins Report, Paget Monday, April 11, 2016: 20:00 hours to Tuesday, April 12, 201: what, ifany, “monitoring” was done while Andrew was on “medic: at all by the other COs, She understood that Andrew was just there for medical observation, and that no nurse or medic had been called to evaluate him. Nevertheless, she had now been told specifically by Andrew that he was experiencing cardiac symptoms, which were clearly persisting following Andrew's previous complaints to COs Althauser, Pino and Kalama. CO David claims it was her impression was that Andrew was detoxing “because he kept talking about his heart coming out of, or he felt like like his thumping was coming out of his skin.” She reported this episode to Arton Robertson, the CO in charge at the time. Despite this, second episode of obvious distress and the documented reason for the medical segregation, and the previous reports to the other officers, neither CO David nor CO Robertson took any further action. They failed to check his pulse or vital signs, failed to request a nursing or medical evaluation, failed to call for EMS response and failed to summon any medical provider. Indeed, at no point prior to his unresponsiveness more than six hours later was any ‘medical provider summoned or even called for consultation. 50-01:26, It is unclear ‘watch, According to the coroner's report. video shows Andrew's last movements in his cell to have occurred at approximately 00:11, which was more than 6 hours after his initial door- pounding and cardiac complaints, and more than 4-4 hours after his second door-pounding, and cardiac complaints, At approximately 00:50 hours, CO Kalama noticed that Andrew appeared unresponsive. This ‘was approximately 40 minutes after his last movements per the video. CO Kalama called for backup and activated a local emergency response. The officers started CPR in the holding area cell, and retrieved the unit's AED (automatic external defibrillator). When attached and turned on, the AED did not detect a shockable rhythm and no shocks were delivered. The officers continued CPR until Thurston County EMS units arrived ALO0:53 the 911 call from Nisqually Corrections was logged in at Thurston County Medic One. Medics were en-route 3 minutes later (00:56), arriving on scene to Andrew Westling U1 minutes after the 911 call at 01:04 hours. ‘The Medics found Andrew in a flatine chythm (asystole). They started an IV and administered resuscitation medications (epinephrine | mg x 4 doses, and sodium bicarbonate x1 dose. of death is listed on the EMS records as 01:26 hours. However, Andrew would have already been dead for quite some time, likely following his last movements at approximately 00:11 and well-prior to his “discovery” at 00:50 Westling Andrew: Cummins Report Pane AUTOPSY AND CORONER’S REPORT ‘The scene investigator from the coroner's office was Karen Peek. She noted “white foam” in Andrew Westling’s nostrils. This indicated that Andrew had developed acute pulmonary edema during the hours of his untreated rapid tachycardia from PSVT. This diagnosis was confirmed by Gina Fino, MD, the pathologist who performed the autopsy on Mr. Westling two days later on April 14, 2016: Respiratory system: the larynx and trachea contain white foamy fluid... The primary. secondary and tertiary bronchi also contain white foamy fluid... The cut surfaces show crepitant deep red parenchyma with marked edeme and congestion. * On microscopic sections of the lungs Dr. Fino found edema and congestion. Alveolar hemorrhage in areas of marked congestion. * On microscopic section of the brain Dr. Fino noted an additional diagnosis of brain edema and congestion. At autopsy the examination of Andrew Westling’s heart also found congenital coronary artery and myocardial anomalies: hypoplasia of the circumflex and right coronary artery; as well as myocardial bridging of the distal left anterior descending coronary artery. Commentary. It is important to point out that even though the diameters of the circumflex and right coronary artery were small (1 to 2 mm), both of these arteries were open and carrying blood. Neither of these arteries were blocked with a blood clot or thrombus that would have precipitated an acute myocardial infarction. The left main coronary artery was noted to be “within normal limits with a@ maximum diameter of 4 mm”. In other words, the circumflex and right coronary arteries, even though hypoplastic, were still up to one-quarter to one-half the diameter of the normal left main coronary artery. In my opinion the hypoplasia of the circumflex and right coronary arteries was an incidental finding. Those arteries did not generate Andrew Westling’s eardiac dysrhythmia, and should not have been listed as a cause of death. The myocardial bridging of the distal left anterior descending coronary artery was also an incidental autopsy finding, unrelated to Andrew Westling’s fatal cardiac dysrhythmia. This abnormality, present since birth, comprised only a small, Imm bridge of myocardial tissue, passing over the distal end of the left anterior descending coronary artery. This artery, also, was open and not thrombosed. Page SUMMARY MEDICAL OPINIONS 1, Andrew Westling had Paroxysmal Supra-Ventricular Tachycardia or PSVT. The most salient conclusion that emerged from my review of Mr. Westling’s past medical history was confirmation of this diagnosis.’ This is a cardiac condition in which the patient is predisposed to develop paroxysms (sudden, abrupt onset, with sudden, abrupt cessation) of very rapid heartbeats. During these paroxysms, which the individual feels in the chest as an uncomfortable, rapid pounding, the heart can beat so fast that it fails to fill with an adequate volume of blood. This can lead to a reduced blood pressure, which, in turn, causes the individual to experience dizziness, light-headedness, and near-fainting sensations. Definitive confirmation of this diagnosis comes from cardiae rhythm strips that demonstrate the diagnostic findings of the various types of SVT. PSVT, however, can also be a clinical diagnosis based on the paroxysmal nature of the symptoms of heart-pounding, rapid pulse, dizziness and light-headedness, all of which Andrew experienced. In particular, Andrew's PSVT was often responsive to classic “vagal maneuvers” of breath-holding, ice-water immersion, carotid-sinus massage (holding his neck as described in the Nisqually records). Left untreated for lengthy periods, symptomatic, rapid PSVT can eventually lead to acute congestive heart failure, pulmonary edema, shock, cardiovascular collapse, and cardiac death. ‘This is what happened to Andrew Westling in the Nisqually jail on April 11-12, 2016. Over the course of 6+ hours, his untreated, rapid PSVT led to pulmonary edema, cardiovascular collapse and cardiac death. 2. Andrew Westling’s April 11-12, 2016 episode of PSVT was eminently reversible and treatable. This young man’s death from this condition was a true tragedy that would not have occurred had medical attention been provided at virtually any point in the hours leading up to his death. People rarely die from PSVT. This is because PSVT is a relatively common condition, easily diagnosed from a cardiac rhythm strip, and then effectively treated. Many healthy people suffer periodic bouts of PSVT. All emergency providers are trained to recognize the condition, and they are familiar with multiple effective therapies that are available, This opinion is supported by the December 28, 2012 episode of PSVT treated in the field by Olympia paramedics. They immediately recognized the PSVT based on their cardiac ‘monitor. They initiated a standard sequence of medications and electrical therapy—if first one treatment fails to convert then move on to the next. They started with adenosine for two Since the 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care the clinical term “Paroxysmal” has been eliminated from discussions about the Supraventeicular Tachyeardias, i favor of more specific etiologic categories such as atrial utter or fibrillation, multifocal atrial tachycardia or atrioventricular reciprocating tachycardia (which, in my opinion, was Andrew Weslling's most likely diagnosis). 1 “wll use the term “paroxysmal” supraventricular tachycardia, or PSVT, because i matches perfectly with Andrew's clinical picture i ‘Westing Andrew: Cummins doses, diltiazem for two doses, and then electrical cardioversion that restored normal sinus rhythm, ‘The effectiveness of this treatment was subsequently confirmed by the follow-up evaluation in the Providence St. Peter Hospital's Emergency Department. In my opinion, Andrew Westling’s symptomatic PSV could have been rapidly and effectively treated at any time over many hours during his Nisqually Corrections incarceration. This interval started when he first began to communicate his symptoms to the Nisqually Correctional Officers at 18:00 hours on April 11, 2016. Up until his death, more than 6 hours later, his PSVT was imminently correctable and reversible. At any point until near the time of his death, basic standard-of-care assessment and treatment by a medical provider would have returned Andrew's heart to normal rhythm. His death would have been avoided and he would have had no lasting physical impact from his PSVT. The opportunity to correct Andrew’s heart rhythm and avoid his death existed for many hours. It was only because his PSVT was allowed to persist for such a long period without medical care that he died. 3. Andrew Westling experienced hours of pain and suffering during his untreated episode of PSVT on April 11-12, 2016. The Nisqually Corrections Center records and correctional officer interviews document two episodes of Andrew pounding on his cell or holding area door. He was experiencing the physical discomfort of heart palpitations, rapid beating and pounding in his chest. These symptoms started at 1800 hours when he first brought these symptoms to the attention of correction officers. Their only response was to move him to a medical observation holding cell. A second episode, witnessed by CO Edna Davis, occurred between 19:30 20:00 hours, when Andrew again pounded on his cell door with complaints of his tachycardia symptoms. His efforts at self-cardioversion were unsuccessful and his pain and suffering persisted. Prolonged PSVT is generally highly distressful to patients. At some point in these hours Andrew began to suffer further side effects of his sustained, untreated tachycardia. He began to go into the state of acute pulmonary edema that was well-documented by his autopsy. This would have produced symptoms of shortness of breath and air hunger. In emergency ‘medicine dyspnea (shortness of breath) and air hunger are well-known to be highly distressful. It is highly likely that Andrew experienced significant mental and emotional distress, fear, and anxiety caused by the prolonged, untreated cardiac symptoms he experienced. 4. The correction officers of the Nisqually Corrections Center demonstrated gross neglect by their lack of a meaningful response to Andrew Westling’s medical complaints The corrections officers failed to initiate an urgent evaluation of an inmate complaining multiple times of a heart problem. It is a major tenet of standard emergency care that all cardiac complaints be taken seriously and evaluated expeditiously. On at least two occasions Andrew orally communicated to the COs information that indicated he had a valid and urgent problem: he had a specific diagnosis (palpitations and tachycardia); he had experienced a Page tz trical and he was prior emergency that required advanced treatment with medications and el cardioversion; he had seen multiple care providers including cardiologist supposed to be taking a prescribed medication, It-was tragic that this oral history was ignored completely by the CO"s because, apparently, ‘Andrew had not mentioned his heart condition, or his medication on his intake medical questionnaire. His real-time complaints and verbal account of his prior history should have trumped the absence of a history on his medical screening form. The fact that the COs ignored his active complaints in the cell because he had not mentioned his condition on his screening form demonstrated a level of reckless indifference that strains credulity. A particular tragedy in this matter is that there were so many easy, effective and meaningful responses available to the COs. A simple pulse check or vital sign review by the correctional staff would have been alarmingly abnormal, leading a reasonably prudent CO to seck further help and evaluation. A call to the facility's contracted physician, available 24-7, could have provided valuable recommendations. A 911 call from the correctional staff would have brought the Thurston County Medics to the scene. The EMS providers would have, in my opinion, reprised the same effective treatment the Medics demonstrated on December 28, 2012. Finally, transferring Andrew Westling to the nearby hospital and emergency department in a timely fashion would have led to the same rapid sequence of diagnosis and treatment. S. The autopsy identification of congenital coronary artery anomalies (hypoplasia and myocardial bridging) were incidental findings, that played no role in his PSVT, no role in his death, and were unlikely to affect his life expectancy. | respectfully disagree with any conclusion that the fatal event in this case was due to congenital coronary artery anomalies. Rather, it is well established that PSVT is most often caused by aberrant conduction tissue pathways located in the atria or atrio-ventricular node. This is particularly true for the subtype of PSVT that Andrew had (atrioventricular reciprocating tachycardia). PSVT is not (or rarely) associated with either myocardial bridging or hypoplastic coronary arteries. While itis true that there is a risk of fatal dysrhythmia and sudden cardiac death in some individuals with congenital coronary artery anomalies and myocardial bridging, this risk is extremely low. In my opinion the relatively minor degree of hypoplasia, the distal location of the myocardial bridging, and the lack of thromboses in the coronary arteries makes it extremely unlikely that these incidental findings ‘on autopsy played any role in Andrew Westling’s death. Indeed, there is little evidence that these congenital anomalies are associated with a reduced life expectaney. It is very likely that Andrew would have experienced a normal life expectaney had he not died in the Nisqually jail, More often than not, patients who experience the relatively common condition of PSVT experience normal, active lives and manage their symptoms over the course of decades with self-administered vagal maneuvers, medication when necessary, and basic medical treatment when self-administered maneuvers and/or medication do not retum the heart to normal rhythm. rmmine Report Respectfully submitted, Sea 0 Ging Richard O. Cummins, MD, MPH, MSc ‘Westing, Andrews Cummins Report Tare lt CURRICULUM VITAE RICHARD 0. CUMMINS. se Universtry OF WASHINGTON Mepicat CENTER EMERGENCY MEDICINE SERVICE BIOGRAPHY and CURRICULUM VITAE Richard Oliver Cummins, M.D., M.P.H., M.Sc. Professor of Medicine University of Washington Medical Center Emergency Medical Services 1959 NE Pacific Street Seattle, Washington 98195 Phone: 206/548-4228 Fax: 206/325-9202 Internet: doce PAGE 10r 24 (CURRICULUAE VITAL RICHARD 0. CUMMINS Biographic Sketch mmins, MD, M University of Washington Richard O. Cummins grew up in eastern North Carolina, He attended the University of North Carolina in Chapel Hill, as a John Motley Morehead Scholar. He attended medical school at Case Western Reserve in Cleveland; and received post-graduate training in Medicine and Pediatrics at the University of Virginia in Charlottesville, For two years he served in the U.S. Public Health Service in a medically indigent community in rural Virginia, He was awarded a Robert Wood Johnson Fellowship to the University of Washington School of Public Health where he obtained graduate training in Epidemiology, and a Master's in Public Health Degree. He was awarded one of five National Milbank Memorial Fund Fellowships to study for two years at the London School of Hygiene and Tropical Medicine of the University of London in England (obtaining a Master’s of Science degree); and at the London Royal Free Hospital. He joined the faculty of the Department of Medicine at the University of Washington in 1981, and was promoted to the rank of full Professor in 1993. As a member of the Division of Emergency Medicine he works as an attending physician in the UWMC Emergency Department, providing clinical care, supervising medical students and residents in training, as well as providing direct patient care. Dr. Cummins is Board-certified in both Intemal Medicine and Emergency Medicine. He has served as the co-director of the Center for Evaluation of Emergency Medical Servics and as the Medical Director of the Early Defibrillation Programs in the Seattle-King County EMS Division, Dr. Cummins' research themes have been in epidemiology and treatment of sudden cardiac death including long-term survival, resuscitation, defibrillation, transcutaneous pacing, and the pharmacology of resuscitation. He has written and published more than 150 articles and book chapters on emergency cardiac care and related topics. Dr. Cummins has served as the Chair of the National ACLS Subcommittee; the National ECC Committee; and co-chair of the International Liaison Committee on Resuscitation (ILCOR). He has also served as a Senior Science Editor within the AHA's ECC programs. In this position Dr. ‘Cummins has helped develop ACLS guidelines, instructor manuals, provider manuals, handbooks, and textbooks. He has been the Editor for 3 editions of the ACLS Textbook; 2 ditions of the ACLS Instructors Manual; and 6 editions of the ECC Handbook. He originated the ACLS for Experienced Providers Course and wrote the Instructors Manual and Toolkit. He lives in Seattle, WA with a rescued black lab, an alpha cat, and his wife Jenny with whom he has observed, but not influenced, the growth and development of daughters Caroline and Elisabeth, and son David. His life changed dramatically with the birth of his first granddaughter, Adela, in 2006, to whom he devotes two full “Papa-Play-Dates” a week. His second and third granddaughters, Delphine and Sibyl made off with the rest of his heart in 2009 and 2012. Q. PAGE 20F 24 (ICULUM VITALS RICHARD O_ CUMMINS EDUCATION Richard O. Cummins, MD grew up in easter North Carolina, In high school he was awarded the John Motley Morehead Scholarship \o attend the University of North Carolina in Chapel Hill from which he graduated Phi Beta Kappa in 1968. He attended medical school at Case Western Reserve University Medical School in Cleveland, Ohio (1968-72); graduating with Alpha Omega Alpha honors in 1972. Post- sraduate, residency training in Medicine and Pediatrics took place at the University of Virginia in Charlottesville (1972-73; 75-77). For two years he served in the U. S. Public Health Service in a ‘medically indigent community in rural Virginia (1973-5). He was awarded a Robert Wood Johnson Fellowship to the University of Washington School of Public Health where he obtained graduate training in Epidemiology (obtaining a Master’s in Public Health Degree; 1977-79). He then competed for and was awarded one of five national Milbank Memorial Fund Fellowships to study at the University of London in England (obtaining a Master's of Science degree; 1979-81). ACADEMIC APPOINTMENTS He joined the facuity as an Instructor in the Department of Medicine at the University of Washington in 1981. By 1993 he rose to the rank of full Professor in the Department of Medicine. He is a member of the Division of Emergency Medicine at UWMC, and a member of the faculty of the Madigan Army Medical Center-University of Washington Affiliated Emergency Medicine Residency Program, He now works full-time clinically as an Emergency Medicine physician, in the UWMC Emergency Department, providing clinical care, supervising medical students and residents in training, as well as providing direct patient care himselt. BOARD CERTIFICATION Dr, Cummins is Board-certified in the specialties of Internal Medicine (1977) and Emergency Medicine.(1996). He obtained his 10-year recertification in Emergency Medicine in October, 2006 after, completing all of the recertification requirements of the American Board of Emergency Medicine. RESEARCH ACTIVITIES AND THEMES He has served as the co-director of a research-focused collaboration between the University of Washington and the Scattle-King County Public Health Department, called the Center for E} n of Emergency Medical Services. As a community service Dr. Cummins served as the Medical Director of the Early Defibrillation Programs in the Seattle-King County EMS Division. Dr. Cummins’ research themes have been multiple: the epidemiology and treatment of sudden cardiac death; long-term survival and quality of life; techniques of initial resuscitation, early defibrillation, transcutancous pacing, and the pharmacology of resuscitation. He was one of the first researchers in the United States to evaluate the new technology of automated external defibrillation starting in the early 1980°s, He has consistently been a proponent o} AEDS as the key link in a community's chain of survival. His publication list includes more than 150 articles and book chapters on emergency cardiac care and related topics. PAGE 3 OF 4 NATIONAL AND INTERNATIONAL LEADERSHIP Dr. Cummins has risen to national and intemational prominence through volunteer work with the American Heart Association. He has played a number of leadership roles with the National AHA, including the following: Chairman, National ACLS Subcommittee; Viee-Chair, National ECC ‘Committee; Chair, National ECC Committee; founder and co-chair of the International Liaison Committee on Resuscitation (ILCOR). In these positions, Dr. Cummins has served as the lead Editor of the 1992, 1997 and 2003 Editions of the Textbook of ACLS, and for 5 editions of the Handbook of ECC and CPR. Under his editorship there were, at one time, more copies of the Textbook of ACLS distributed to readers than any other medical textbook in the World. As the co-leader of ILCOR, Dr. Cummins initiated the development of a series of “Utstein Style” guidelines on out-of-hospital, pediatric, and in-hospital resuscitation, resulting in more than 12 publications. AMERICAN HEART ASSOCIATION: SENIOR SCIENCE EDITOR (December, 1977 to July, 2003) From December, 1997 to July, 2003, Dr. Cummins served as Senior Science Co-Editor of the AHA's ECC programs (with Mary Fran Hazinski, RN as Senior Science co-editor). He received funding from the AHA to support a 50% commitment to this work. In this position Dr. Cummins had overall responsibility for the development of all of the AHA’s scientific publications on CPR and ECC. On August 22, 2000 the 2000 Guidelines on CPR and ECC was published as an entire issue of CIRCULATION with Dr. ‘Curmmins as the senior co-editor. ‘This was followed by these books edited by Dr. Cummins: 2002 ACLS Provider Manual, 2002 ACLS Instructors Manual, 2000 and 2003 Handbooks of ECC and CPR: 2000 ACLS Manual for Experienced Providers, the 2000 ACLS-Experienced Providers Instructor Manual, and, published in May, 2003 the 2-volume 2003 ACLS Textbook: ACLS—the Reference ‘Textbook: volume 1-ACLS Principles and Practice; and volume 2: ACLS for Experienced Providers. He is co-author of ACLS Scenarios : core concepts for Case-based teaching (1996), and co- author of 1998 Heartsaver-AED Textbook. HONORS AND AWARDS In 1994 Dr. Cummins received the National Award of Meritorious Service from the AHA, as well as the Time, Feeling and Focus Award. In 1995 he received the National AHA Volunteer of the Year Award, In September, 2002 he was presented with the Hans Dahll Award from the Citizen CPR Foundation for significant and outstanding contributions to research and education in ECC and CPR. In January, 2005 he was honored at the American Heart Association Intemational Guidelines Conference as a “Gian of Resuscitation”, an award given every five years or a career of outstanding contributions to the field of resuscitation. (Citation from Award Ceremony on following page.) PAGE 4 orm mice 0. CUMBIINS 2005 HONOREES Richard ©. Cummins, MD, MPH, MSc Cummins agian in all aspocts of ressitation Washington, He bas taughn PAGES OF 24 cunmemun auoo CUMIN ORIGINAL CONTRIBUTIONS Dr. Cummins, along with a number of fellow experts for each topic, has been given eredit for making unique and original contributions to the field of resuscitation. Perhaps more accurately he has frequently added to others’ original ideas by a more concise and defined conceptualization, and by articulating in publications extensions of the original ideas. This applies to the following concepts and principles: = the principle of early defibrillation by first responding healthcare providers, adding to documentation of the value of early CPR and early defibrillation, original formulation of the Chain of Survival Concept, articulating the principle of public access defibrillation, adding to documentation of the accuracy and effectiveness of automated external defibrillators, adding to documentation of the reality of sudden cardiac death during commercial air travel and gencration of the idea of using AEDs for in-flight cardiac arrest; = documentation of the ineffectiveness of transcutaneous pacing for asystole = documentation of the ineffectiveness of high-dose epinephrine in out-of-hospital arrest * implementation of intemational uniform recommendations for reporting cardiac arrests (the “Utstein Guidelines * recognition that there were too many causes of cardiac emergencies that went unrecognized and untreated, because of the lack of AHA guidelines (leading to the ACLS for Experienced Provider course; and new editions of the ECC Handbook) ‘+ implementation of the “S-Quadrads” approach to ACLS education by ereating the ACLS for Experienced Providers Course * bringing a more formal epidemiological and evidence-based approach to the development of CPR and ECC Guidelines. fostering the principles of “zero-risk therapeutics” in ECC and CPR guidelines * initiating and leading a new “scientific outreach effort” to make guideline development an “intemational consensus on Science’ installing the principles of evidence-based medicine into the daily work of guideline development and consensus PAGE 60K CCURKICLLENEVEEAE BILAL CURRICULUM VITAE Richard Oliver Cummins, M.D., M.P.H., M.Sc. Emergency Medical Services 1959 NE Pacific Street Seattle, Washington 98195 Phone: 206/548-4228 Internet:

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