Policy Called Outdated : Paramedic Dispatch Rule--Sick, Injured Pay Price

It was 4.8 miles through heavy traffic from Los Angeles Fire Department Station 68 in West Los Angeles to the retirement complex just off Crenshaw Boulevard. When alarmed bystanders first called for help, the elderly woman who had collapsed on the lobby floor was still breathing. When the paramedic ambulance arrived, she wasn’t.

“We started getting a lot of harassment from the people there,” recalled David Heard, the paramedic who pronounced the woman dead at the scene. The assistant manager of the complex told Heard he had called the Fire Department four times seeking help. But help, he said, took more than 30 minutes to get there.

“This was a predominantly black area,” Heard said. “Their comment to us was, ‘There’s white men’s medicine and there’s black men’s medicine, and this is black men’s medicine.’ ”

In a city that was the birthplace of pre-hospital emergency care in the 1970s, incidents like the one Nov. 15 at the retirement complex have become focal points in a debate over the level of resources Los Angeles has devoted to emergency medical care.

Los Angeles, with 49 paramedic ambulances assigned to cover a city of 3 million, has one of the lowest ratios of paramedic ambulance service per capita of any city in the nation.

Moreover, the Fire Department’s policies for dispatching paramedics, criticized as outdated by many experts, often mean the sick or injured must wait for paramedic ambulances from miles away when they may be only blocks from one of the city’s 110 fire stations and at least basic first-aid resources.

The city’s present dispatching policies have come under attack by paramedics and physicians because only in certain instances--if someone is shot, stabbed, hit by a car, having a heart attack or breathing difficulty or is more than five miles away from a paramedic ambulance--is the closest available emergency resource automatically dispatched.

The result, paramedics say, is that people suffering a variety of life-threatening problems, reports of which are called in simply as “sick” or “person down” by the dozens each day, often do not receive help in time.

Even when nearby fire trucks were dispatched quickly to accident scenes, more than 20% of the city’s medical aid recipients last year had to wait longer than eight minutes for a paramedic ambulance, according to a review of the city’s emergency response data prepared for The Times.

“On Jan. 26, an ambulance that is based in the Sunland-Tujunga area was dispatched as the closest available paramedic resource to a call in downtown L.A.,” said Fred Hurtado, president of United Paramedics of Los Angeles, which is pushing for additional paramedic resources in the city.

‘All Tied Up on Calls’

“On the last shift I worked, an ambulance from East L.A. was dispatched as the closest ambulance to a call in South-Central,” Hurtado said.

“On a frequent basis--weekly--there are times when there is not a single ambulance available anywhere in the city. They’re all tied up on calls. And the cost for not effectively addressing this issue has been lost lives, unnecessarily jeopardized lives, and bewildered, anxious, angry paramedics.”

Paramedic Paul Medina said one of the longest rides he ever took was the trip last summer from Lincoln Heights to 77th Street and Central Avenue in rush-hour traffic. Even with emergency lights and sirens, it took 32 minutes.

At the other end of the trip was a critical gunshot victim.

“When we got there, the guy was pretty bad. He was barely conscious,” Medina recalled.

Although firefighters with limited medical training had arrived much sooner, they could do little more for the heavily bleeding man than administer oxygen.

The trip to the designated trauma center at Los Angeles County-USC Medical Center was another 20 minutes. The man was still alive when they arrived, but only barely.

“What should be a five-minute response, we get there in 20, 25 minutes, and if it’s a critical situation, that’s too late,” Medina complained in a recent interview.

In the Nov. 15 incident at the nursing home, bystanders said they telephoned four times before a paramedic ambulance arrived, an estimated 35 to 40 minutes after the woman’s collapse.

Heard said his ambulance took 11 minutes to drive from a station nearly five miles distant when first-aid-trained firefighters were just two blocks away. If the woman had shown any signs of life, the firefighters, if summoned, might have been able to administer cardiopulmonary resuscitation until paramedics arrived, he said.

The dispatcher told Heard that because paramedics were 4.8 miles away, the incident did not meet the five-mile criterion for automatically dispatching nearby firefighters.

“He also stated they sounded real ignorant on the phone, like they were illiterate,” Heard recalled. “I asked him, ‘Shouldn’t it have caused you a little bit of concern when they called back three times?’

‘Didn’t Do Anything Wrong’

“The captain said the dispatcher didn’t do anything wrong, he’s not going to do anything, and if these people have a complaint, they’re going to have to do it in writing,” Heard said.

Joe Jackson, assistant manager of the Baldwin Villa Plaza where the incident occurred, said dispatchers did not seem to be heeding his pleas for help.

“We called, and they ask you how old is the person. What is the trouble? Is she breathing?” Jackson recalled. “The lady’s lying on the floor, and they’re going to ask me, ‘Is she breathing?’ Do they want me to leave her lying there so I can go look in my files and see how old she is?”

Jackson said the Fire Department sent a supervisor out to investigate the incident as a result of his complaints. He said he was told that if the paramedics had responded when first called they could have saved the woman’s life. “I don’t know why it took them so long to get here. We’re right around the corner from the Fire Department.”

A recent issue of the paramedics’ newsletter tells of a September case in which a foreign exchange student found his 69-year-old American sponsor on the kitchen floor and called for help. A paramedic unit responded 17 minutes later, having passed two fire stations on the way.

Paramedics called for an engine company to assist them, but could only administer basic CPR until firefighters arrived to take over CPR and free them to begin administering medications and attempting to restart the man’s heart.

Too Late by Then

By then, it was too too late to save the man’s life, according to paramedic Chris Dale, who wrote about the incident. “Variations on this story occur hundreds of times each year,” Dale said. “Who is the culprit in this story? Is the dispatcher to blame? Why was the incident dispatched as a ‘person down’? Why wasn’t the closest emergency resource sent?

“The real culprit is the outdated medical dispatch criteria which the Los Angeles City Fire Department still clings to. These criteria contribute to citizen deaths.”

The city “tends to send paramedics on everything and emergency medical technicians (firefighters with limited medical training, also called EMTs) with them either on everything or only on certain specific things like . . . cardiac arrest,” said Dr. Steve Rottman, director of pre-hospital care at UCLA.

“This actually is 180 degrees of what we probably should be doing. We probably should be sending the EMT-level responders on everything . . . and then we should selectively dispatch paramedics to those types of complaints that are highly likely to need paramedic-level intervention.”

“You can’t send out (paramedics) on every call, because if you do, you don’t have (paramedic response) when you really need it,” said Jerald Birt, medical services administrator for Seattle, recognized as one of the leaders in pre-hospital care in the nation.

Seattle always dispatches the nearest fire truck staffed with emergency medical technicians, not only to get help to the scene more quickly, but because it is recognized that a pair of paramedics are not equipped to handle a major medical emergency without help, Birt added.

“We will never send a paramedic unit alone. Never. There will either be an engine company or an aid car (staffed by emergency medical technicians) or both,” he said.

The paramedics’ union has urged the department to hire medically trained dispatchers who are able to gather important medical information from callers through a carefully prepared series of questions, such as, “Is the person breathing?” or “Does he have a pulse?” that automatically appear on the dispatcher’s computer screen.

With that information, dispatchers can then determine which calls are truly life-threatening, deserving immediate response from the nearest engine company and paramedic ambulance, and which calls may not even be worth sending an ambulance--one way of reducing the paramedics’ growing caseload.

Such modern “dispatch criteria,” first developed in Salt Lake City, are already successfully in use in nearly 100 cities across the country.

Caution From Doctors

But while a number of physicians have urged the department to consider such criteria, some in the medical community also caution against the potential hazards of “telephone triage,” the risk that the caller turned away as not serious enough for a dispatch may be the next coroner’s statistic.

Another risk, they caution, is that the dispatcher may waste valuable time asking questions when an ambulance should be on its way.

Los Angeles Fire Chief Donald O. Manning said the department, in addition to seeking money for additional paramedic ambulances, has asked for money in next year’s budget to begin training dispatchers.

But he questioned the practicality of sending engine companies out ahead of, or instead of, paramedics more frequently than the department does already.

Firefighters in some of the busiest stations are already making as many calls as the paramedics, he said, “and where I’m now rolling out two people (in an ambulance), I’m going to roll out four (in an engine company). And where I roll out a $30,000 piece of equipment, I’m going to roll out a $130,000 piece of equipment.

“I’m not sure that makes a lot of sense, particularly if when (the firefighters) get there and I’ve got a heart attack,” Manning said.

“Now they’re going to have to call for (a paramedic) to work on me, and without any defibrillator (equipment which firefighters are not certified to use which administers electrical shocks to the heart) I’m going to die. All we’ve done is allowed the paramedics to maybe not go out on some calls, and some people have died that don’t need to die.”

Paramedics and some physicians say the department’s own response times point to the need for change.

Severe trauma victims, such as those bleeding heavily, probably need help at the scene within two minutes. Medical experts generally agree that heart attack victims should receive basic life support, such as CPR administered by bystanders or firefighters, within four minutes, and the more advanced care provided by paramedics should be available no later than eight minutes after the attack.

Response Time Goal

Manning said the department’s goal is to achieve a five-minute response time throughout the city. The national average for paramedic responses in major metropolitan areas is comparable to that of Los Angeles, four to six minutes.

Yet paramedics say that average response times can be misleading. A detailed analysis of paramedic responses in 1986 conducted by the paramedics union shows that only 55% of the department’s individual responses met the five-minute goal.

While responses in the busiest areas of the city are usually comfortably under five minutes, 21% of all ambulance runs arrived later than eight minutes after dispatch. In some of the more remote areas of the city, such as the area along Mulholland Drive, responses were longer than eight minutes 41% of the time.

The Fire Department’s community liaison officer, Dean Cathey, said it is important to remember that those numbers represent only the amount of time it took for a paramedic ambulance to arrive. In nearly all cases, an engine company arrived much sooner, he said.

Paramedic responses in the most critical kinds of cases--heart attacks and breathing difficulties--took longer than eight minutes only 10% to 13% of the time, Cathey said.

Moreover, the city’s response times compare favorably with those of the Los Angeles County Fire Department, which operates paramedic services in much of the area outside the city limits.

County paramedics took longer than eight minutes on 69% of their responses--a figure that county officials attribute to the traffic congestion that plagues the entire Los Angeles area.

But in all of those cases the county also dispatched the nearest emergency medical technicians, who probably arrived sooner, officials said. The city Fire Department dispatched the nearest engine company only 38% of the time.

A 1982 study by the Fire Department concluded that it would take an additional 116 ambulances to bring all of the city’s emergency medical responses to five minutes or less under present dispatching policies. It would take only about 15 new units, however, to guarantee a five-minute response citywide if nearby engine companies are factored in, the study found.

“The reality is that there are certain situations where if you don’t get a paramedic there in five minutes, they’re likely not to be much use when they do get there,” said Dr. Eric Alcouloumre, a member of the Los Angeles County Emergency Medical Services Commission who recently headed the pre-hospital care program at Los Angeles County/USC Medical Center.

The most recent study of how well cardiac arrest patients fare under Los Angeles’ emergency medical system was conducted in 1983 by the department’s medical director, Dr. Gregory Palmer.

In a look at 494 patients in West Los Angeles and the San Fernando Valley whose hearts and breathing had stopped by the time paramedics arrived, Palmer found that 9.8% left the hospital alive, compared to a national average of 15% to 20%.

Response Times’ Role

Response times clearly played a key role in the results, Palmer said. In those cases where paramedics arrived in three minutes or less, 15% of the patients survived.

“Nobody survived following eight minutes,” he said.

Dr. Douglas Arterberry, director of Northridge Hospital’s emergency department, participated in a similar study a year earlier.

The study, he said, found that the number of patients who suffered no long-term health effects after their heart attack--a measure, in part, of how long they were without oxygen before help arrived--was even lower than the overall survival rate: about one in 50.

“I think it gave us a snapshot of the system at the time, and it was not a very reassuring snapshot,” Arterberry said. “It’s our slow response time that gave us the poor statistics. We’re looking at some eight to 10 minutes in some areas.

“I feel we have problems, and these problems are adversely affecting our ability to function. But I would also like to say that before Los Angeles had paramedics, we used to have a lot of DOAs (dead on arrivals) brought in the hospital. Now, we’ve had very few people come in who didn’t at least have a fighting chance.”

Chief Manning discounts the results of survival studies because it is so difficult to measure how much is attributable to the paramedic’s response and how much should be counted against the patient’s condition when paramedics arrived and how he was handled at the hospital after paramedics dropped him off.

But department officials said they may be able to improve survival rates with a plan to train firefighter engine companies in the use of computerized defibrillators, a plan that would allow nearby engine companies to be dispatched quickly to critically ill patients and provide them with the most important kind of help they can receive short of a hospital emergency room.

Last week, the department deployed three new part-time ambulances in some of the busiest areas of the city--in South-Central Los Angeles, the Wilshire district and Baldwin Hills--that will operate during the peak hours of the day, between 8 a.m. and 10 p.m., staffed by paramedics working voluntary overtime or emergency medical technicians.

Manning said he is also looking at hiring private ambulances or volunteers to handle less-critical medical aid calls.

Those last two options, he acknowledged, “will be expensive and probably won’t help the paramedic workload condition right now.”

“Even if it helps 10%,” he added, “it still isn’t going to do what needs to be done to the system, to get the issues that need addressing down to some reasonable level.”