Rialto Paramedics’ Refusal To Treat Dying Heart Attack Victim Spotlighted Worldwide

The City of Rialto and its fire department find themselves the focus of local, state, national and international scorn as further details have emerged about how three Rialto firefighters, two of them paramedics, refused to administer aid to a 56-year-old man who had suffered a heart attack at an acute care facility 2.2 miles from the fire department’s headquarters and main fire station.
Joseph Angulo was pronounced dead less than an hour after the firemen, fearing exposure to the coronavirus if they were to enter the Rialto Post Acute Care Center, waited outside the facility’s entrance in accordance with what they said was department policy.
Only after a Rialto police officer arrived and pushed the wheel-less bed Angulo was in down a hallway and over the threshold of the acute care center’s entrance/exit did the fire department personnel begin their ministrations.
Fire department personnel and the union for the firefighters insist the paramedics conducted themselves properly.
Indications are, however, that the seven to nine minutes during which Angulo was not being properly attended to by the paramedics were critical and contributed to his death.
The department has initiated an internal investigation and audit of what occurred, over three minutes of which was captured on video by the bodyworn camera of Rialto Police Officer Ralph Ballew, who was dispatched to the Rialto Post Acute Care Center, located at 1471 South Riverside Avenue in Rialto at 7:51 p.m. on November 17.
That video footage and the officer’s matter-of-fact report of the incident has proven highly damaging to the reputation of a fire department that has already suffered from negative publicity relating to the union representing its firefighters engaging in surveillance of city council members in an effort to obtain leverage in contract negotiations.
At least two Rialto firefighters have been placed on paid leave while that investigation is ongoing. The Sentinel was told by a department member that both paramedics involved will be fully reinstated once the investigation runs its course, as both of them and another firefighter on the scene during the November 17 incident were adhering to written policy guidelines as well as the instructions of Sean Grayson, who had served as fire chief from 2014 until earlier this year. Grayson has since been replaced by Division Chief Brian Park, whose title has been changed to interim fire chief.
According to the written report Ballew made the night of November 17 incident, he arrived at the entrance to the facility where he encountered the fire department personnel waiting.
“I approached the door and stood by with fire personnel as I was unsure if they had already made contact with the staff of the location and [whether] arrangements for transport were being made. I was informed the facility was becoming problematic as [the] Rialto Fire [Department] was just here for an unrelated patient. After a few moments, an unknown employee of the location yelled out to fire personnel, ‘Please come help, he’s having cardiac arrest.’ Fire personnel responded by insisting the patient had to be brought outside the facility before they could provide any sort of treatment. I was informed due to an unspecified COVID-19 law, fire personnel [were] prohibited from entering the facility and the patient needed to be brought outside.”
According to Ballew’s report, a “frustrated employee yelled out to fire personnel pleading for help as they were provid[ing] CPR and could not move the patient and disrupt the rescue effort. Fire personnel replied ‘you are doing the same thing we would have to do if we went in, so hurry up and bring him out so we can help.’ The fire personnel to my immediate left then subtly stated it was a state law and if it was not appreciated staff could call their congressman.”
At that point, Ballew took it upon himself to go into the facility.
“Unsure of why fire personnel chose not to enter I decided to enter the location myself and determine how to assist staff in getting Angulo to fire personnel,” Ballew’s report continues. “As I walked toward Angulo’s room, I was passed by several distraught hospital employees pleading for help as Angulo was undergoing cardiac arrest. I informed staff fire personnel [were] not entering the location due to a law unfamiliar to me.”
Ballew continued to where Angulo, prone and unresponsive on a bed, was being administered cardiopulmonary resuscitation by one of the acute care center employees.
Ballew pushed the wheel-less bed from where he originally encountered it down the facility’s hallway toward the entrance, where paramedics were yet standing. The paramedics and other firefighters remained impervious to requests from the facility’s employees for assistance until the bed containing Angulo was outside the facility entrance.
“Despite being in their line of sight, fire personnel still insisted on Angulo being brought to them outside before they began life saving efforts and made no effort to assist me in getting Angulo outside,” Ballew’s report states.
Upon Angulo’s bed being pushed outside, there were four Rialto firefighters present. Once Angulo had cleared the exit/entrance, the paramedics, interacting with facility staff to ascertain what resuscitative efforts had already been made, undertook to assist Angulo.
With regard to the restriction preventing fire personnel from entering the acute care facility, Ballew’s report states “I was then told [after] the implementation of said law, Rialto Fire Personnel had not received any direction on how to proceed from their command.”
Angulo was transported to Arrowhead Regional Medical Center in Colton, the main campus of San Bernardino County’s public hospital system which is 1.75 miles away from the Rialto Post Acute Care Center. At Arrowhead Regional he was pronounced dead at 8:38 p.m.
The Rialto Fire Department is celebrated as being uncommonly advanced in its provision of first response emergency medical care, particularly with regard to the coronary emergencies. The city has gone to considerable effort and expense to allow its department to recruit and train paramedics as part of its firefighting personnel and has outfitted the department with state-of-the-art equipment intended to enhance the survivability of those suffering cardiac arrest if the fire department’s paramedic crew can get to them in a timely manner.
The department’s paramedic units are provided with an automated CPR device known as AutoPulse which offers continuous high-quality and precisely calibrated automated compressions by performing a circumferential squeeze of the thoracic region. Personnel are trained to augment the AutoPulse with apneic oxygenation, which is the practice of applying a nasal cannula providing oxygen at a rate of 15 liters per minute prior to intubation taking place. In addition, the paramedic units are equipped with an impedance threshold device, commercially known as an ResQPOD, positioned inline of the ventilation circuit providing apneic oxygenation. The impedance threshold device lowers intrathoracic pressure during the recoil phase of CPR by selectively restricting unnecessary airflow into the chest. This vacuum increases preload, lowers intracranial pressure, and improves blood flow to the brain and vital organs. In addition, the Rialto Fire Department’s paramedic personnel are provided with cardiac event victim life-sustaining training that is advanced of the medical industry standard, including what is referred to as “heads-up CPR” and defibrillation delaying techniques. Heads-up CPR is used in conjunction with automated CPR and is achieved by elevating the patient’s head and torso to a 30-degree angle, thus reducing venous pressure, allowing an increased blood flow to the heart from the brain. Heads-up CPR decreases intracranial pressure and increases coronary and cerebral perfusion pressures. This allows deoxygenated blood to return to the heart and oxygenated blood to be pumped to the brain. Rialto paramedics are further trained that when encountering cardiac arrest patients with prolonged downtime, ventricular fibrillation or an end tidal carbon dioxide level of less than 20mmHg, that defibrillation should be delayed prior to administering high quality CPR to increase perfusion and correct hypoxia and further resolve acidosis. Through delaying fibrillation until after efficient CPR is accomplished and increasing perfusion and reversing acidosis, the heart becomes more receptive to electrical therapy, increasing the probability for the return of spontaneous circulation and the resumption of a sustained heart rhythm.
Despite the high level of training and availability of advanced equipment that could have potentially kept Angulo alive, the refusal of the two paramedics on scene at the Rialto Post Acute Care Center on November 17 to enter the facility prevented that level of care being applied in a timely manner.
Footage of Ballew’s body-worn camera released by the city shows Ballew approaching the entrance of the Rialto Post Acute Care Center. Already in place are two paramedics, who are standing at either side of the automated side-sliding entrance into the Rialto Post Acute Care Center. At one point, when Ballew turns slightly, a third Rialto firefighter can be seen standing off to Ballew’s side. Ballew then engages in a brief but inaudible conversation with the two paramedics, after which he enters the building.
The video’s field of view, essentially from Ballew’s perspective, shows him progressing down a hallway toward a nursing station and then turning left into an adjoining hallway within the facility. A female employee in nurse’s decorative scrubs can be heard inquiring about the paramedics’ inaction, emphasizing, “It’s cardiac arrest!”
Ballew is heard responding, “They are not going to come in. They’re saying it’s a state law that they can’t come in.” He then makes a right turn into another hallway off of which the room where Angulo is being attended to is located. As Ballew approaches, a nurse can be heard hurriedly apprising him of the situation. “It’s cardiac arrest. We’re doing compression. You cannot move him while we’re doing compressions.”
Shortly thereafter, again from Ballew’s perspective, he can be seen pushing the bed onto which Angulo is sprawled down the hallways, while a nurse, who is kneeling on the bed to Angulo’s side frantically performs CPR on him. Ballew can be heard telling other nursing facility personnel that he can push the wheel-less bed on his own, but that he needs their help guiding it down the facility’s corridor. When the bed containing Angulo reaches the sliding door entrance/exit to the facility, the paramedics can be seen outside the door. Still, they remain on the other side of the door until the bed is pushed entirely outside of the facility.
There is no California law preventing paramedics or firefighters in general from entering acute care facilities, nursing homes or convalescent facilities. Nevertheless, in the aftermath of the COVID-19 pandemic, during the early and mid-stages of which there was a rash of deaths within nursing homes, there were directives made to public safety and public health personnel relating to precautionary measures to be taken with regard to operating at or near nursing homes and convalescent care facilities.
One of those was an April 2020 memo from the San Bernardino County Fire Chiefs Association stating that fire personnel should minimize the risk of their exposure to the coronavirus, particularly in settings where it was known to be flourishing. According to that memo, personnel should seek to render lifesaving assistance outside the confines of nursing homes and convalescent care facilities, and “all dispatch centers will be requesting the facilities to move patients to the door or outside the location.”
Nevertheless, the instructions in the memo do not expressly forbid all personnel from going into such settings. The memo stated that “if the patient cannot be transferred to [the] exit for or outside prior to arrival, one member of fire/EMS personnel should initially interact with the patient.”
Word of what had occurred at the Rialto Acute Care Facility and Angulo’s death spread quickly.
Articles detailing some of the particulars appeared in the San Bernardino Sun, the Inland Valley Daily Bulletin, the Los Angeles Times, the San Jose Mercury News, the Atlanta Black Star, the United Voice and the Daily Mail. In addition, the CBS affiliate in Los Angeles, the Los Angeles ABC affiliate and Fox News, both locally and nationally, covered the story. Multiple websites, including newskudo.com, YahooNews, planet-today.com, the worldnews.net, whitehousewire.com, newsbreak.com, nigerianlatestnews.com, the palmierireport.com, freedomrockradio.com, parrotnews247.com, patriotnewsusa.com, and newsfeeds.media latched on to the story.
In response, Rialto’s acting fire chief, Brian Park, placed the two paramedics who Ballew encountered at the entrance to the Rialto Post Acute Care Center on paid leave. It is not clear whether the suspension applied to a third firefighter present when Ballew arrived and a fourth firefighter known to have been present when he emerged from the facility on November 17.
Rialto Mayor Deborah Robertson publicly stated that an internal investigation being carried out into the matter “will focus on the conduct of the responding fire department personnel and the reasons those personnel did not enter the acute care facility immediately.”
Rialto spokesman Adan Ortega said the investigation will not be conducted in-house and will not whitewash what occurred. The city and its fire department, Ortega said, “hired a third-party law firm to conduct all the interviews because the city wants the chips to fall where they may at the conclusion of this investigation.”
Ortega’s statement went beyond what Robertson was willing to say. The mayor implied the city was interested only in determining why what had occurred happened. Ortega indicated the paramedics involved may either be disciplined or fired outright for not administering aid to Angulo under the circumstances.
That will not happen, department personnel and members of the Rialto Professional Firefighters Local #3688 told the Sentinel.
“They were just doing what they were supposed to do,” one of those firefighters said of the two paramedics. “The memo was in writing. That came from Chief Grayson and it was never rescinded, even now that Brian [Park] is the chief. If something went wrong, that’s on them. They can’t touch us.”

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