L.A. County Trauma System Ailing : Officials Fear Breakdown in Emergency Room Care

The last time Altrus Hunter needed to be rushed to the hospital, paramedics came right away. But it was an hour and 10 minutes before the 60-year-old man with breathing difficulty finally arrived at a hospital that would treat him. And by then it was too late.

Hunter died Nov. 9, a day when all the emergency rooms at the four hospitals closest to his home in South-Central Los Angeles were reported to be full and unable to accept any more ambulances. Hunter was taken by paramedics to one of these hospitals--the county’s Martin Luther King Jr./Drew Medical Center--but the wait was so long there that the paramedics grew anxious and scrambled to line up care for him at a fifth hospital, Memorial Hospital of Gardena.

Hunter died soon after he arrived at Memorial, and the hospital’s administrator later reported to county health investigators that Hunter had not received “expeditious” care.

The case of “this unfortunate gentleman,” as a doctor at Memorial Hospital wrote later, is the tragedy of a man who might well be alive if he had received timely hospital care. It may be the worst in a series of recent incidents, including one on Nov. 22, when a 3-year-old boy with an asthma attack had to ride 48 minutes in an ambulance that was looking for an open emergency room to treat him.

Health officials fear that these cases may signal the looming breakdown of the system that provides emergency care in Los Angeles County. In the last year, several financially pinched trauma centers have shut down permanently, putting tremendous pressure on the 90 emergency rooms in the county that are licensed to accept ambulance traffic.

“Our trauma system is in great jeopardy,” said Chief Alan Cowan, who is in charge of the city Fire Department’s paramedics, who made more than 200,000 runs last year. “And now the problem is spreading to our emergency rooms, which are our front-line defense. . . . It’s like we’ve got a tire with multiple holes.”

More and more emergency rooms are routinely filling up and closing to ambulances, especially on weekends. This creates serious gaps in service, particularly in the inner-city area, fire officials said.

Records of hospital closures obtained by The Times show that emergency rooms at the four hospitals serving South-Central Los Angeles were closed to ambulances or accepting only certain types of cases about 54% of the time from September through October, the latest two-month period for which statistics are available.

The King/Drew Medical Center’s emergency room and trauma center--which is the bulwark of care in South-Central Los Angeles--was open without restriction only 35% of the time, and in some cases was closed because of “saturation” for days on end. Even County-USC Hospital, with the largest emergency room in the nation, became overwhelmed last month and closed for as long as an entire weekend--which is “mind boggling” said Dr. Gregory Palmer, the city Fire Department’s medical director.

The president of the United Paramedics of Los Angeles, Fred Hurtado, said there are about 10 emergency rooms serving the inner-city area. “If even one or two of these are closed, we got a problem. . . . The problem is compounded with each additional closure, and the risk to the public increases exponentially.”

Health care officials stress that emergency room closures have not compromised care for patients in the most dire medical straits--those who are in extremis, suffering from blocked airways and uncontrollable hemorrhages, for example. Even if an emergency room is closed, it must accept these patients, as well as all foot traffic.

The biggest impact of emergency room closures is on those patients traveling by ambulance who are not in imminent danger but are nevertheless in critical condition--suffering from heart attacks, gunshot wounds, strokes, spinal injuries and so on.

“What I dread,” said David Langness of the Southern California Hospital Council “is the first day that a patient dies being shuttled from one hospital to another.”

He said a catastrophe is bound to happen since emergency room closures have about doubled in the last year. “It used to be that 15 or 20 emergency rooms would close at some point during the weekend. Now it’s more like 30 to 40,” he said.

To those who tried to save him, Altrus Hunter appears to be a victim of a breakdown in emergency care.

A hospital source familiar with his case said: “There’s no reason for him to be dead. This didn’t have to happen.”

Hunter’s neighbors called the 911 emergency telephone number at 3:51 p.m. on Nov. 9, when Hunter, a widower who lived alone and suffered from emphysema, suddenly doubled over with a breathing attack.

The former truck driver, who was enrolled in the Cigna Health Plan, had been sick for years, said his daughter, Lynda Baker of Cleveland. He kept at least three portable oxygen tanks in his tiny apartment in the 700 block of E. 87th Place. He never removed the air hose from his nose, not even when he drove or slept, she recalled.

The paramedics took Hunter away about 4 p.m., noting that he was in “moderate respiratory distress.” But his neighbor, Edith Mosely, said she was terrified for him because he was heaving and his “chest was moving like an earthquake.”

Paramedics checked with their dispatcher, who, records show, reported that the emergency rooms at the four hospitals closest to Hunter’s home--King, St. Francis, Daniel Freeman in Inglewood and Centinela--were closed.

This is a very serious situation, said Virginia Hastings of the county Department of Health Services, but “not an unusual one.” County records show that, on a cumulative basis, these four emergency rooms were open without restriction only 46% of the time during September and October. About 25% of the time, they were closed because they were already full of critical patients. And about 29% of the time, they were not accepting certain kinds of medical, head or surgical injuries because beds in their intensive care units were full.

State law requires ambulances to take patients to the closest facility that is “staffed, equipped and prepared to handle the emergency.”

When all the emergency rooms near Hunter’s home were full on Nov. 9, the paramedics were directed by the dispatcher to take Hunter to the closest one, which is obliged under these circumstances to accept the patient. In this case, it was King.

The hospital’s emergency room is typically a busy place, but the week of Nov. 9 was a nightmare, doctors there recalled.

At about 4:30 p.m., when Hunter arrived, patients were already doubled up in stations designed for one. Ambulances were backed up. And there was not a single free gurney in the hospital or any spare oxygen, said hospital medical director James Houghton.

Paramedics reported that they were told that it might be two hours before Hunter could be treated and that, in the meantime, he would have to remain on the ambulance’s gurney. When paramedics objected, a doctor in the emergency room reportedly replied in irritation: “Then why don’t you put him on the floor somewhere?”

The paramedics stated that they refused and asked about leaving Hunter in a chair. But they said the doctor prohibited this, suggesting instead that the paramedics “go hunt some oxygen down and if you find any, put him on it.”

Dr. Houghton defended his staff, saying that it has never refused to treat any patient, even when the emergency room is full. He acknowledged, however that there was an incident Nov. 9 when an ambulance driver “became restless because we had their equipment tied up . . . and they wanted to get out of here.” He said the paramedics chose to take the patient to another hospital.

The paramedics stated that they were concerned about Hunter’s deteriorating condition and therefore decided to head for Memorial Hospital of Gardena. Fighting rush-hour traffic, they arrived about 5 p.m. By then Hunter was in “severe medical trouble,” said Seth Ellis, hospital administrator.

Medical records that Ellis released to Hunter’s daughter show that Hunter’s blood pressure on arrival at the hospital had hit a dangerous 232 over 120. A blood gas test showed that Hunter’s carbon dioxide level had risen to a point that is virtually incompatible with life. He was immediately “intubated”--with 100% oxygen pumped by tubes into his lungs.

But a medical source at the hospital said that Hunter had already languished too long “in the danger zone” and nothing short of a miracle could have saved him. He was pronounced dead of cardiac arrest at 5:58 p.m.

“What happened to Mr. Hunter,” Ellis said, “is just a symptom of the disease. I think that everybody wanted this man to get better . . . but it’s just become an overwhelming problem in terms of resources.”

Robert Gates, director of county health services, said emergency room closures are “not something that is desirable” and he has recently appointed a committee to look into the problem. He said that an expected $11-million allocation by the county Board of Supervisors should help by providing more funds to private hospitals and expanding the county’s own emergency room capacity.

Langness at the Hospital Council said the emergency care system in Los Angeles County is under tremendous strain, partly because of “a ripple effect” caused by fewer providers caring for a growing number of people, especially people who have no health insurance.

Seven of the 23 trauma centers in Los Angeles County are expected to close by the end of the year, Langness said, and eight emergency rooms have shut down permanently. Trauma centers provide round-the-clock teams of surgeons and other specialists and expensive hospital equipment to stabilize patients with wounds and injuries. But these centers are just an important part of the entire emergency care network. The backbone of the system are the dozens of hospital emergency rooms that treat both extremely serious as well as minor medical emergencies.

These emergency rooms, which Langness pointed out are big financial drains on hospitals, have been bombarded recently by patients from both ends of the medical spectrum. They have been forced to shoulder the load of critically injured victims who used to be treated at trauma centers that are now shut down.

And, at the same time, they have been swamped by growing numbers of medically uninsured people who tend to rely upon emergency rooms as their primary source of health care. Frequently they are people who lack the money or health insurance to go to a doctor about a pain or illness--which typically gets worse when left untreated, and finally leads the patient to the closest emergency room.

“You might look at these people and think they don’t belong in an emergency room,” said Daniel Higgins, co-director of the Los Angeles County Emergency Medical Directors Assn., “but in reality, this it the only place they can think of going.”

The overloading is the worst in South-Central Los Angeles and downtown because there are proportionately fewer hospitals there, said Hastings of the Health Department.

Hurtado, spokesman for the paramedics, said there are other problem as well. He said that in some cases, hospitals are not obeying the county guidelines that govern their closures.

Rules adopted by the county in 1981 define when a hospital can declare itself to be closed and require the hospital to inform the county’s Medical Alert Center. The center then advises paramedic dispatchers to divert ambulances.

Gates said he believes that, for the most part, hospitals are acting in good faith when they declare themselves to be closed. Possible violations are investigated by a unit in his department.

Hastings acknowledged problems with the reporting process, which is voluntary. She said that sometimes hospitals get busy and forget to report when they are closed or when they become open again. “There are probably some abuses,” she said, “but it’s very hard to prove.”