The tragic death of logger Bill Bennett last fall was bad enough.
But it's been made far worse by nagging doubts that his rescuers may not have done everything in their power to at least try to bring him out of the woods alive.
His injuries were severe and possibly no efforts, no matter how
Herculean, could have saved him. That's something we'll never know.
But a tardy and rather milquetoast report on the incident by Kern County Emergency Medical Services (EMS) Director Ross Elliott is no help.
It only dances around the edges of some very core problems with helicopter rescues. And it is flat out wrong in letting Hall Ambulance off the hook for abandoning efforts to get medical aid to Bennett because a paramedic was "too physically tired" to make the half mile hike. (More on that in a minute.)
Bennett was working in rugged terrain south of Tehachapi last September when the upper portion of a tree fell on him about 9 a.m. His co-workers found him about an hour later and called 911.
Bennett was badly injured but at first he was conscious, breathing and even talking, according to dispatch transcripts of the incident and what co-workers told Bennett's brother-in-law John Hayes.
Hayes, by the way, is a retired battalion chief from the Kern County Fire Department. He's well versed in how medical aid operations should run and after reviewing what happened to Bennett, it was Hayes who fired off a complaint to EMS days after the incident.
The EMS investigation was completed only last week.
Elliott told me it took so long partly because he had to arrange interviews and partly because "there was no urgency from a global perspective."
That's not acceptable. If there's a chance a man died because agencies performed poorly or the system needs tweaking, I the taxpayer want that fixed pronto before any more harm is caused.
But even if the report had been timely, it doesn't do much, if anything, to illuminate what went wrong with the Bennett rescue.
First the helicopter rescue.
It took an hour from the time the Sheriff's Department helicopter, Air 5, located the patient to when they hoisted him out.
That's an awful long time and there has been considerable grumbling that the Fire Department could have done it in less than half that time.
The two agencies have been at odds over hoist rescues for several years since the Sheriff's Department bought a helicopter capable of doing them.
As I said, Elliott dances around this issue in his report noting that each agency has its own training protocols for hoist rescues and while neither one is better than the other, they should train together to make sure they understand each other's procedures.
No. Not good enough.
Elliott sets the emergency response standards for this county. It's up to him to settle this long festering dispute.
Does Fire do hoist rescues better? Elliott needs to look at both agencies' past 25 or 50 rescues and make that determination.
Then the better training protocol must be adopted by both agencies, including all the same standards from staffing to the type of litter basket used.
Elliott's job is to advocate for public safety. Not placate the agencies he's supposed to be overseeing.
If Elliott doesn't have the power to make that happen, then the Board of Supervisors needs to step up.
To their credit, both the Sheriff's and Fire departments agreed with Elliott's suggestions in his report that they do more joint training. In the last year, relations between the agencies on air ops has thawed considerably and they had begun doing some training together.
"Our relationship with Fire is the best it's ever been," Sheriff Donny Youngblood told me. Kern County Fire said the same.
OK, I'm glad.
But the residents of Kern County need to be assured they're getting top shelf service, no matter whose insignia is on the helicopter hovering over them.
The Sheriff's Department took me to task on that, saying there's no indication Bennett's rescue took any longer than necessary. Elliott's report backs that up, saying "erratic winds" made the rescue difficult and risky.
However, in the Sheriff's incident report, hoist operator Sgt. John McAdoo doesn't say deputies were hampered by winds of any kind, only that the dense woods made extraction difficult and Bennett had to be moved down-slope.
In a separate report by Kern Fire Capt. Jason Nava, who was at the scene, the Air 5 rescue appears anything but textbook. Nava reports that Air 5 made three tries before getting its rescuer on the ground and two more tries before it got the medical gear down. He also notes the Sheriff's rescuer "was not proficient in CPR and the use of his medical equipment."
I don't want to lob bombs when everyone's getting along so well, but I think both agencies need to do a much closer and more honest assessment of the Bennett rescue.
Now, on to Hall Ambulance.
This is the most disturbing part of this story and also where Elliott's report falls way short.
Hall Ambulance Unit 375 arrived at the remote dirt road that was nearest to Bennett just minutes after Fire Capt. Nava and another firefighter.
From there it was about a half-mile trek to Bennett. Rescuers faced a very steep incline of 10 yards or so, then the bulk of the trail was across a hillside.
Nava was a short ways up the steep part of the trail when the Hall crew arrived. He shouted at the paramedic and tech to "grab your gear and follow us."
Because Hall was there, Nava chose to take only a chainsaw rather than his medical kit, according to Elliott's report.
While Nava hoofed it up to Bennett, the firefighter with him and other logging company employees stayed closer to Hall's personnel.
Each Hall employee had about 30 pounds of gear. They started up the hill at about 10:50 a.m., according to Elliott's report.
Just 16 minutes later, at 11:06 a.m., they were already back in their ambulance having abandoned the hike. They gave it no more than an 8- or 9-minute try.
They refused to attempt the hike again even though they must have known, based on radio traffic in their ambulance, that it wasn't too far because Nava had made it to Bennett's side in 13 minutes.
And even though their ambulance radio had the ability to contact Fire's dispatch, or even Nava himself, the Hall employees chose to only tell their own dispatcher they weren't walking in to Bennett.
Their dispatch didn't relay that crucial information until 11:41 a.m.
That's when Bennett went into full cardiac arrest and Nava got on the radio beseeching Hall to hurry to the scene.
"Ambulance dispatch is advising that their employees cannot walk the 'dozer line to the patient," Fire's dispatch informed him at 11:43 a.m.
Elliott's report accepts and gives credence to every one of the excuses the Hall employees gave for their decision to leave Bennett and Nava in the lurch.
I do not.
It was unconscionable and immoral.
Hall spokesman Scott Allen would not give me the names of the two employees nor comment on the report, which Hall had not yet seen.
Here's the employees' reasoning for giving up, according to what the Hall paramedic told Elliott.
He "assumed," based on overhearing radio traffic, that Bennett wasn't hurt that badly and besides, Air 5 was on scene, he told Elliott.
The hike was too steep, he was thirsty and he just couldn't physically make it, he said.
"They did not make a heroic effort to reach the patient," Elliott writes in his report with unwitting understatement. "But heroism is not part of the training; personal safety is."
Come on now, a half mile walk is hardly "a heroic effort." These guys are stationed in the mountains, it's not outside the realm of expectation that they might have to do more than walk up someone's driveway on occasion.
Elliott concludes that Hall's actions did not constitute a failure to respond or patient abandonment.
It doesn't matter if they didn't make it to Bennett in time. But they had to at least try.
Of their myriad excuses, a few stood out.
At one point, a logger offered to drive the Hall guys and their equipment to the site on a skidder, a type of 'dozer.
They declined because Hall has a policy against its employees riding in non-Hall vehicles, not even county fire engines or helicopters. When getting to the scene means life or death, that policy makes zero sense to me.
And Hall issues its ambulances portable radios that can't communicate with other agencies because they use the wrong frequency, UHF instead of VHF.
Elliott suggests Hall should look into those issues.
I say EMS should order Hall to get the right equipment and revamp its vehicle policies.
If Harvey Hall, owner of the ambulance company, wants to maintain his near monopoly for "serving" the people of Kern County and charging his exorbitant rates, he ought to have proper equipment and policies that allow employees to do their jobs.
Because, when you think about it, it would have been better if Hall had never shown up. That way no one would have relied on them for help -- help which they were unable and unwilling to give.
Either way, I think it's time to reopen discussions of having firefighter/paramedics assigned to every outlying fire station in the county.
Finally, Elliott's report commends each agency for acting by the book, according to their own policies and those of EMS. But what about acting in concert?
That's where they dropped the ball.
As I said at the beginning, who knows if a more seamless, truly gutsy effort would have saved Bennett's life, or even given him enough time to hold his wife, Hollie's, hand one last time.
But the bumps in this effort made it far from seamless. It should serve as a signpost that we all vow to learn from, no matter how painful the lessons.
Opinions expressed in this column are those of Lois Henry, not The Bakersfield Californian. Her column appears Wednesdays and Sundays. Comment at http://www.bakersfield.com, call her at 395-7373 or e-mail email@example.com