How Could Such A Thing Happen?
The emergency services are filled with heartbreaking stories. This is a “given,” given the nature of the work. That said, things usually go well and are made better. Good outcomes come to those wearing the uniforms and badges through consistent training, appropriate continuing education, accountability, and steadfast personal commitment to high standards. Then, when situations go badly, results can usually and justifiably be regarded as unavoidable.
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But sometimes there are factors in play when outcomes go “south” that highlight less-than-stellar public safety performance. No one wants that. The following story is one of the avoidably heartbreaking kind, but by telling it, my hope is that it can help prevent further preventable tragedies. (Alert: this is a difficult story.)
In April 2018, sixteen-year-old Kyle Plush was headed for a tennis match at his Seven Hills School in Madisonville, Ohio, in metropolitan Cincinnati. He was probably reaching for his gear when (according to a re-creation), he likely put a knee on the third-row bench seat while reaching over it into the rear well to grab his gear. The seat flipped and the force and weight of it, “trapped Plush upside down, head in the rear well and legs in the air against the minivan’s rear door” [Source #1].
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Plush was able to contact authorities by voice-activating his phone during two 911 calls that totaled six minutes. During the first one at 3:16 pm, the dispatcher had difficulty hearing, but got enough information to send a patrol car to the area. Two officers cruised the vicinity beginning at 3:26 for 11 minutes, and reported finding nothing. At 3:35 pm (while they were still nearby), Plush made his second call and was able to report that he was in a gold, 2004 Honda Odyssey. According to the Cincinnati Enquirer, “That information was never relayed to officers on the scene.” They went back into service at 3:37pm [source #2]. (A sheriff deputy directing traffic that afternoon also tried searching at 3:48, but found nothing.)
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Despite evidence that Kyle was screaming for help and pounding on the interior of the vehicle, “His father finally located him in the van when he went looking for his son after he didn’t return home from school” [source #3]. The cause of death was asphyxia due to chest compression. The family’s wrongful death lawsuit against the City of Cincinnati led to a $6 million settlement.
Multiple disturbing facts of the case came out in the lawsuit. Body camera video showed that the two law enforcement officers never left their patrol car during their “search” for the teen, at least not while the body cams were on. They only cruised through one of three parking lots at the school. The second dispatcher never relayed the make, model, or color of the vehicle. The officers were heard wondering if it was a prank call. The dispatch center was found to be woefully understaffed (and thus surely a stressful work setting).
Photo credit: Anna Shvets
There have been way too many unjustifiable outcomes in the headlines lately. It brings to mind an intriguing term: “normalization of deviance.” Coined by American sociologist Diane Vaughan it describes the process where unsafe or wrong deviations from correct or proper behavior become increasingly tolerated within an organization. Maybe it’s just easier to turn a blind eye, or not “buck” the embedded (and, sadly, often toxic) cultural system of a place. It might be that known best-practices are ignored, or maybe there is an absence of training. Whatever the “explanation,” actions by those who hold other lives in their hands fail to live up to reasonable, honorable expectations. When things go wrong, according to the FireFighters Close Calls source, it is usually after "a long incubation period [before a final disaster] with early warning signs that were either misinterpreted, ignored or missed completely." Think normalization of deviance. Think George Floyd. Breanna Taylor. Tyre Nichols. Others that presumably include at least a measure of normalization of deviance.
Over the years, I have worked for or visited hundreds of firehouses, EMS agencies, and law enforcement organizations. Each has its own unique institutional culture. Usually, as the public should fairly expect, our emergency providers deliver good-quality care. But sometimes, a cultural air of indifference and disinterest exists. Losing sight of the mandate can (and sadly, does) generate avoidable catastrophe. It hurts our own souls, and those we serve. Such normalization of deviance hurts everyone.
We can (and do) make mistakes in this business. As long as there are unceasing, honest and dedicated efforts to do the right thing, we are typically forgiven. No one wants press like the opening line from one of the Cincinnati Enquirer articles: “Three years ago, Cincinnati police and 911 center workers failed to rescue a teenager who died after becoming trapped in his car.” Ouch.
Normalization of deviance is a real thing. Like a weed, this sinister overtone and the latitude to act on it has to be yanked from organizations where it takes root. Hopefully, no one will ever show up at your door in such a frame of mind if (heaven forbid) you ever need emergency assistance.
The author of FireFighter Close Calls, Billy Feder, posted this column in the online webzine FireRescue1 shortly after I wrote this blog. it is a worthwhile add-on read: Federer: When Our Caring Stops
[Source #1: www.cincinnati.com/story/money/2018/04/12/honda-minivan-seven-hills-teens-death-may-have-been-subject-national-recall/510074002/ accessed August 4, 2023]
[Source #2: www.cincinnati.com/story/news/2021/05/19/ohio-teen-kyle-plush-died-three-years-ago-what-we-know/5171492001/ posted May 19, 2021, accessed August 4, 2023]
[Source #3: FireFighter Close Calls post dated 10/20/21]
