911 audio sheds light on collapse of Cody Sherrell

By Ray Legendre

Columbian staff writer

Two months after Cody Sherrell’s death, Clark Regional Emergency Services Agency refused to release the 911 call that chronicled his treatment inside the La Center Middle School gym on the grounds their dispatcher was a “health care provider.”

The Columbian received the 911 tape on March 22, eight days after questioning the legality of the organization’s refusal of its public records request. CRESA initially said it would not release the tape without written authorization from Cody’s parents because it contained “health care information.”

“Recordings of 911 calls are generally subject to disclosure under Washington’s Public Records Act,” said Eric Stahl, a Seattle-based attorney who represents The Columbian. “The agency’s initial claim that the dispatcher was a ‘health care provider’ isn’t supported by Washington law.”

Cody died Jan. 9 at Randall Children’s Hospital at Legacy Emanuel in Portland, six days after collapsing at the end of basketball practice.

The 911 call made by assistant coach Greg Hall shed light on why school officials did not use an automated external defibrillator on him.

The tape revealed the dispatcher told Cody’s caregivers on two separate occasions to continue CPR rather than use the AED, before instructing them to use the device. CPR should be performed for two minutes on prepubescent patients before an AED is applied, said Dr. Lynn Wittwer, the medical program director for the county’s emergency medical services.

The tape also revealed the people around Cody had difficulty finding the AED’s pads to shock him once the dispatcher gave the go-ahead to use the device. The reason is unclear.

As of Monday, the La Center School District had not received the transcript of the call, Superintendent Mark Mansell said.

CRESA refused the school district’s public records request on the same grounds it refused The Columbian’s request, Mansell added.

The 911 call has been public for nearly three weeks.

Wittwer asserted his organization had nothing to hide but merely sought to avoid violating health privacy laws. “CRESA’s not stonewalling,” he said, “because there is absolutely no reason to stonewall.”

Wittwer and Mansell agreed the tape could be a useful instructional tool for schools.

As Cody Sherrell, 14, suffered cardiac arrest in La Center Middle School’s gym Jan. 3, a device that could have shocked his heart back into rhythm went unused.

The reason has been a source of contention in the months since the teen died.

La Center school officials say the 911 dispatcher told Cody’s basketball coaches not to use an automated external defibrillator. Clark Regional Emergency Services Agency officials dispute this version of events, countering that a dispatcher gave instructions to perform CPR and then use the AED.

Paramedics used an AED once they arrived, more than nine minutes after assistant coach Greg Hall made the initial 911 call. However, Cody died six days after collapsing at the end of the first day of basketball tryouts.

A copy of the 911 call recently made public by CRESA proves that both school and EMS officials are correct, albeit with caveats, and illuminates the confusion and chaos that surrounded the traumatic incident.

The dispatcher told Hall to forgo using the AED twice during the 911 call, instead advising others on the scene to continue CPR. The dispatcher worked off a script, asking questions about Cody’s breathing and level of alertness to advise Hall on the next steps of care.

However, around six minutes into the call, the dispatcher advised Hall to tell Greg Morgan, the father of one of Cody’s teammates, and head basketball coach Tom Rice to open the school’s AED. Difficulty locating the device’s pads prevented the men from using it, according to the 911 tape.

“I would have liked to have seen the AED go on the patient before the first paramedics got there,” concluded Dr. Lynn Wittwer, medical program director for the county’s emergency medical services.

No one was to blame, Wittwer said. As if anticipating the next question, he added, “Whether it would have made any difference is anybody’s conjecture.”

Cody did not have a prediagnosed heart condition, school officials said. Whether he had a heart condition that would have rendered the AED moot is unknown.

The Multnomah County Medical Examiner’s Office did not perform an autopsy on Cody, officials there said. Legacy Health officials refused to say whether an autopsy had been performed at the hospital in Portland where Cody died, citing privacy laws.

Cody’s parents have not spoken publicly about his death, aside from a brief speech his father Brandon gave prior to La Center Middle’s Jan. 19 basketball opener. Attempts to contact them for this story were unsuccessful.

Sprained ankle

On the afternoon Cody suffered cardiac arrest, Morgan walked into La Center Middle School’s gym expecting to find his son, Dalton, nursing a sprained ankle. Parents waiting outside the gym to pick up their sons from the first day of eighth grade basketball tryouts told him a player had been injured.

Morgan assumed his son had suffered a minor injury, he recalled last month. To his dismay, he found Cody lying on his back on the gym floor. Morgan walked to Rice’s side and told him that he knew CPR, and offered to help.

Minutes earlier, Cody had participated in drills without showing signs of discomfort, coaches said in interviews days after his collapse.

As players and coaches gathered to adjourn practice, a player alerted coaches that Cody had collapsed.

“We’ve got a student-athlete who is on the court moaning on his back,” assistant coach Greg Hall told a dispatcher. Cody was either dehydrated or suffering a seizure, Hall said.

In the next two minutes, Hall relayed the dire nature of the situation to the dispatcher.

Cody’s breathing was sporadic and his eyes had rolled back. He had started to turn blue, Hall noted two minutes and 29 seconds into the call.

“Is there a defibrillator on scene?” the dispatcher asked.

Yes, Hall answered.

‘He is not breathing’

During cardiac arrest, most human brains can survive unscathed three to four minutes without intervention. Then damage rapidly occurs, Wittwer said.

Reports that Cody was breathing slowed CPR application. It is possible that what the coaches considered breathing was actually agonal respiration, a sign a person is dying, said Jason Royse, founder of Northwest Health and Safety, a company that contracts with Clark County schools on AED purchases.

Three minutes and 26 seconds into the call, Hall informed the dispatcher head coach Tom Rice planned to start CPR.

“Don’t start CPR if he’s breathing,” the dispatcher ordered.

“He is not breathing,” Hall responded.

Almost three-quarters of a minute elapsed before CPR began at the 4:20 mark.

“C’mon, Cody! C’mon, Cody!” a voice encouraged in the background.

Morgan grabbed the AED, as he was directed. He scanned the machine’s directions and took the pads in his hand, he recalled. Morgan waited for the command to shock Cody. Meanwhile, Rice continued mouth-to-mouth resuscitations and chest compressions.

A cardiac arrest patient’s chances of survival drop by 10 percent every minute without the defibrillator, Royse said. The goal is to use the defibrillator within 3 to 5 minutes of recognition of cardiac arrest, he added.

In Cody’s case, the AED could have been used at least 4 minutes before paramedics arrived.

Hall initially asked the dispatcher whether to use the AED at the 4:59 mark. Hall asked a second time 36 seconds later.

Each time, the dispatcher advised to continue CPR.

At the time Hall made his second request, CPR had been performed for around 73 seconds. CPR should be performed for two minutes on prepubescent children to get their heart primed for the AED, Wittwer and Royse agreed. It is unknown if Cody, 14, was prepubescent.

Hall did not argue with the dispatcher’s directive. Morgan noted that at that point everyone was focused on clearing Cody’s airway. The boy had vomited while Rice performed mouth-to-mouth, leading Morgan to take over CPR duties. When exactly the men switched roles is unclear.

“I had it all ready to go,” Morgan said of the AED. “At the time we were about ready to hook it up to Cody, Greg told me not to do it. He told me the dispatcher had told him not to use it.”

The three men’s stories have been consistent, La Center school Superintendent Mark Mansell said.

There was “a little bit of frustration as they started to determine Cody’s condition relative to the instruction they were getting from 911,” the superintendent added. As coaches, Morgan and Rice were trained to use the AEDs, per school district policy enacted Jan. 24, 2006, Mansell said.

‘We’re looking’

The dispatcher’s commands changed in the next minute. He asked Hall to relay to Rice and Morgan to put the defibrillator next to Cody, then later to remove his shirt.

Then around seven minutes into the call, he asked whether the pads were installed on the AED. They were not.

A minute passed. Confusion over finding the pads continued, even though Morgan had apparently had them earlier.

“If they’re not plugged in, they’re usually in a foil package or some sort of plastic package,” the dispatcher told Hall almost eight minutes into the call.

The dispatcher asked a half-minute later if they had them. “We’re looking,” Hall answered.

Morgan reiterated during the interview several times that he knew where the pads were. He had some confusion whether the “pediatric” or adult pads would go on Cody, but that was not the same thing as not knowing where the pads were, he said.

As fluids continued flowing from Cody’s mouth, paramedics arrived through the gym doors nine minutes and 20 seconds into the call.

Cody had no heartbeat, school officials and doctors said.

9:20 and beyond

In the aftermath of Cody’s death, Royse received calls from school officials across Clark County asking whether they should use AEDs if their students suffered cardiac arrest.

He sought more information from county emergency response officials.

“The one issue I can speak to is that events reported by the media pertaining to deployment of the AED did not accurately reflect events as they occurred during this case,” wrote Wittwer’s assistant, Marc Muhr, in an email to Royse. “The dispatcher provided pre-arrival instruction for CPR and AED use as per protocol.”

Mansell remains unconvinced. CRESA has rejected his request for a transcript of the 911 call on legal grounds, he noted.

“We don’t have any evidence to say we need to do anything differently with our AED policy,” Mansell said, noting that his district could not learn anything more from the situation without the transcript.

A sense of sadness lingers in Morgan’s mind about the day Cody suffered cardiac arrest. But the sadness has nothing to do with the care he and the two coaches provided to Cody.

“Everybody did their best with the situation,” Morgan said.

Ray Legendre: http://facebook.com/raylegend; http://twitter.com/#!/col_smallcities; ray.legendre@columbian.com; 360-735-4517.