WORCESTER, Mass. -- When Lauren Chang crumpled to the floor that Sunday evening, the medic assigned to the cheerleading competition was away from the action, restocking her supplies after treating three earlier injuries, according to the private ambulance company she worked for.
As she gathered more icepacks nearby, coaches and spectators rushed the mat, where Chang's team had just finished performing a 2 1/2-minute routine.
Amid the chaos of questioning voices and blaring music at Worcester's DCU Center, two registered nurses, both of them mothers attending the event, and several others checked Chang's pulse, listened to her heartbeat, and forced air into her lungs using a breathing bag that one of the rescuers found in a bag of medical supplies nearby. The panicked cheerleader fought her rescuers as she struggled to breath and at one point vomited blood, the nurses said.
A spokesman for American Medical Response, the private ambulance company contracted by the DCU Center, said its medic responded quickly to help treat Chang. But 20-year-old Lauren Chang died a day later. An autopsy showed her lungs had collapsed.
There would be still one more cheerleading injury that evening, during a competition that spectators later would say was filled with a freakish spate of accidents.
The death of Chang, Newton North High School graduate, has parents and others scouring their memories of April 13, questioning the safety of the event and whether the medic on hand had been overtaxed.
By the time Chang went down at 7:20 p.m., the EMT already had already dealt with an asthma attack or fainting on stage, and a neck or back injury suffered in a fall during a stunt performed in the warm-up area, according to several witnesses.
In total that day, she treated five people, including Chang and three others who went to the hospital, said Doug Moore, a spokesman for the ambulance company. He declined to comment on the nature of the injuries suffered that day or whether his medic was overtaxed, citing a federal health information privacy law.
"That event was hexed," said Joe Hennessey, whose 12-year old daughter was competing. "I've never been to an event like that where there was so much confusion and mishap after mishap, and time delay. Whether it was poorly run or poorly planned, I'd hate to speculate, but [there were] definitely some issues with it."
As part of her team's performance that night, Chang had done some gymnastic tumbling and had been responsible for catching the head and shoulders of a teammate thrown in the air for a stunt. When or how she was injured, no one is certain.
But a 911 tape and several witness interviews suggested the chaos that ensued as Chang tried to run off stage, but instead fell just feet from the stairs that would have taken her down from the performance area.
The 911 callers seemed unable to explain exactly where the competition was taking place, and the paramedic dispatcher appeared confused by the treatment Chang seemed to be getting.
"It looks like she got kicked or, um, hit in the throat. Her face is all swollen. They're trying to get her air, um ... they're trying to trach her," a male caller told dispatchers, referring to the method of placing a tube in a patient's trachea to provide oxygen.
"They're trying to trach her right now?!" the paramedic dispatcher replied. Later in the call, the dispatcher radioed another person, stating: "Cheerleader unresponsive. Reportedly tubed at this time. By who, I don't know."
Few noticed the EMT who came to help Chang.
Five witnesses interviewed by the Globe said they did not see a uniformed medic immediately after the accident. Because of that, Robin Raynes, a registered nurse whose daughter was competing in the event, ran to Chang's side. A few minutes later, another parent who is also a registered nurse arrived.
"It was very, I guess - you know, there were a lot of people trying to do a lot of things," said Raynes, who works on a combination pediatric and surgical floor of the Wentworth-Douglass Hospital in Dover, N.H. "There were a lot of people trying to give directions. There were a lot of people talking, yelling."
Hennessey, whose 12-year-old had competed earlier in the day, watched Chang go down.
"I saw her frantically grabbing her throat," he recalled. "There were a few people yelling, `Somebody help her, somebody help her,' and there weren't any EMTs available."
Irene Horgan said she could not remember seeing a medic at Chang's side, either.
"Honestly, that competition that day, she was like the third person to go out in an ambulance," recalled Horgan, who was there watching her 16-year-old compete. "I know that the EMTs, in my opinion, they had left earlier with the two others girls that went out."
Mooresaid the EMT on duty came quickly to Chang's aid and that his company sent an ambulance within five minutes.
An ambulance from American Medical Response took Chang to Saint Vincent Hospital. Her family, which was not at the competition, arrived as Chang was taken to the larger UMass Memorial Medical Center. Siblings said she was already in a coma at that point.
In the days since her death, Chang's family and others are trying to determine what the appropriate safety standard is for cheering events like the Minuteman Cheerleading Championships, where Chang collapsed.
Her family is working with state Representative Peter Koutoujian to bring about changes.
They are considering whether to seek legislation regulating cheerleading, a call for increased medical personnel at events, and a public education campaign about the sport.
Since its widely recognized start in 1898, cheerleading has grown from simple rah-rahing at college games into a competitive sport filled with acrobatics and airborne stunts that can put athletes at risk for serious injury.
From 1982 to 2006, 10 female athletes have died from injuries sustained, directly or indirectly, during cheerleading stunts performed at the high school and college level, according to the National Center for Catastrophic Sports Injury Research, which is based at the University of North Carolina at Chapel Hill.
Injuries tallied by the center included paralysis, ruptured spleens, cracked skulls, and broken and dislocated vertebrae.
Yet organizations such as the Massachusetts Secondary School Administrators' Association still label cheering as an activity akin to student council. There are some safety regulations, but they vary among the different groups that oversee the sport at high school, college, and All Star levels.
According to the standards set by the US All Star Federation for Cheer and Dance Teams, it appears the Minuteman competition followed the necessary safety procedures that govern All Star events.
The federation, which certifies cheerleading coaches and trainers, requires medical personnel to be at USASF events. Acceptable medical personnel is listed as a doctor, EMT, paramedic, certified athletic trainer, or nurse.
In comparison, USA Gymnastics, the governing body for gymnastics in this country, has a mandatory safety certification for all professional members, offers classes for coaches and others, and provides a first aid class and a handbook that reviews injury prevention, recognition, and emergency treatment.
The gymnastic organization's medical staff requirements appear similar to those set by the USASF.
Spirit Cheer, the Florida-based company that organized the Minuteman event, is listed as an international member of the USASF.
However, the event was not named on the federation's website as a sanctioned competition.
Still, Spirit Cheer president Mike Pare said that proper safety precautions were in place and that when Chang was injured, the 16 Spirit Cheer staff in attendance quickly implemented an emergency plan to notify paramedics and guide them into the building.
"Short of me being a doctor and being involved right when Lauren went down, as an event producer I don't know what else I could be doing or should be doing," Pare said.
Erin Ailworth can be reached at firstname.lastname@example.org