Charge of Diverting Emergency Patients Investigated

On a busy Saturday night this month, when ambulances were screaming around town delivering the sick and the wounded to various hospitals, officials at Daniel Freeman Memorial Hospital in Inglewood reported their emergency room was full and closed it to ambulance traffic.

But when Virginia Price Hastings from the county health department dropped by the hospital on an unannounced tour that night, she found the emergency room “literally empty.”

At a time when increasing numbers of emergency rooms are claiming to be overloaded and temporarily refusing to accept ambulance traffic, Hastings said her visit to the field on Dec. 5 left her with lingering questions about the legitimacy of some of the closures.

Unprofitable Cases

United Paramedics of Los Angeles President Fred Hurtado charged that in numerous instances, hospital officials have claimed their emergency rooms were full when they were not. To prevent paramedics from delivering certain unprofitable cases to their doorsteps, he said that the rules governing when hospitals must treat a patient in distress have been routinely violated.

The Hospital of the Good Samaritan in Los Angeles was cited by the county Monday for refusing to evaluate or treat a 3-year-old boy with an asthma attack on Nov. 22. Hospital officials declined to comment on “this particular case in question.”

Last week, the county Department of Health Services launched an investigation of charges by paramedics that Daniel Freeman Memorial Hospital has deliberately diverted patients from its emergency room for economic reasons.

The probe at Freeman is focusing on the case of Elray Wise, a man with a gunshot wound in the head who was refused treatment at Freeman’s emergency room on Oct. 26 and later died. The probe will also include a review of all cases involving Freeman during a one-month period, Hastings said, to determine the scope of any possible problem.

An emergency room physician at Daniel Freeman, Maxine Barrett, acknowledged that she has now determined that Wise was actually in life-threatening condition on Oct. 26 and therefore should not have been refused access to the emergency room. But she called the incident an isolated problem, not part of any conspiracy or economic decision to keep indigent patients away.

As for the the emergency room closure Dec. 5, Barrett said that hospital officials were just on the verge of reopening when Hastings came by. She said the emergency room was not empty but acknowledged that seven of the 12 beds in the emergency room were unoccupied.

Financial Strain

Freeman spokesman Christie Ciraulo said that about 60% of the patients treated in Freeman’s emergency room are unable to pay their bills, putting a tremendous financial strain on the hospital’s resources. To cut its losses, the hospital shut down its trauma center in June but continues to run an emergency room that accepts about 400 ambulance runs a month.

As part of its emergency service, the hospital operates a communications station where its nurses are linked by radio with nine paramedic units, controlling where the ambulances take a patient and dictating what medical treatment should be given en route.

There are about 30 hospitals that operate these dispatching stations, but Freeman’s is the third busiest in the county, receiving about 800 radio calls a month and accepting 50% of those patients, Ciraulo said.

In a 10-page memorandum, Los Angeles city paramedics charge that on Oct. 26, Freeman’s dispatcher willfully violated county rules that govern a patient’s destination. They also question how Freeman hospital dispatchers handled three other cases and call upon city fire and county health officials to conduct a full-fledged investigation “to determine the scope of various policy violations.”

The three cases dating back to July involve Freeman’s referral to other hospitals of a woman who was dumped half-naked out of a speeding car in South-Central Los Angeles, a four-month premature infant who was critically ill and an elderly man who was suffering severe chest pains.

Blocked Airway

In the Oct. 26 incident, Wise, a laborer, was shot above the left eyebrow about 4 p.m. in the 1500 block of West 58th Street. Police said Wise had offended some gang members by helping rescue a friend from their attack.

“He helped out somebody they were after, and then they came back to get him,” said a Los Angeles police lieutenant familiar with the case.

Shortly after paramedics arrived, the unconscious Wise began vomiting uncontrollably, which blocked his airway and put him in imminent danger of death. Under these circumstances, Hurtado said, county rules provide for such a patient to be taken to the closest emergency room, no matter how busy it is. In this case, it was Daniel Freeman.

But the tape recording of the radio conversation with the paramedics shows that the Freeman nurse repeatedly refused to allow paramedics to bring Wise to the Freeman emergency room, referring them instead to a more distant hospital and threatening to discipline them for balking at her commands.

The tape shows that paramedics repeatedly voiced their concern about the patient’s blocked airway, saying at one point:

“We’re unable to manage the airway on this patient. He keeps vomiting. We can’t hyperventilate the patient. . . . We need to go to the closest (hospital emergency room) and that would be you.”

Directed Elsewhere

On the way to another hospital, the paramedics continued to request permission to stop at Freeman. But Freeman’s nurse directed them to Centinela Hospital.

“We felt that once we advised of an unmanageable airway condition, the closest facility, Daniel Freeman, should have been the destination of choice, and not to bypass it to go another three to five minutes to the next closest facility,” the paramedics later reported in a memorandum to superiors.

Freeman’s spokeswoman said that “human error” accounted for the problem that day, with the nurse failing to understand the severity of Wise’s condition.

Hurtado said that the case illustrates a problem with the way paramedics are dispatched in Los Angeles County. The system is decentralized, virtually unmonitored and operated on the honor system by hospitals that have a vested interest in controlling ambulance traffic, he said.

Dispatcher Stations

“This is one of the most grievous examples, but it happens quite a lot,” Hurtado said. “It appears to us there is more than one (hospital dispatching) station taking advantage of its position to selectively reroute patients to other hospitals.”

Hastings, who is in charge of paramedic services for the health department, acknowledged that the system is too big to monitor closely and would be better managed with far fewer hospitals running paramedic dispatching stations. Even though it costs hundreds of thousands of dollars to staff, operate and equip paramedic dispatcher stations, she said that many hospitals apparently find the experience rewarding.

She said she does not know exactly “what they get out of it . . . but that obviously if you’re directing the paramedics, you have a little edge in controlling where the patients go.”

She noted that filling a hospital’s emergency room with patients who can pay their bills is a lot more profitable than filling it up with the growing number of people who have no health insurance or other means of paying their medical expenses.

A spokesman for the Hospital Council of Southern California, David Langness, said that up to 70% of emergency room patients have no method of payment, so that “the emergency room is where the financial bleeding is most profound in hospitals.”

“It’s the place where dollars flow out and indigent patients flow in,” he said.