Death Points Up System’s Flaws : It Takes 3 Calls to 911 to Get Ambulance--Too Late

When a 42-year-old Chatsworth woman suffered a heart attack several months ago, her family repeatedly dialed 911 to report life-threatening symptoms that emergency experts say should have immediately triggered red lights and sirens.

But instead of summoning an ambulance, dispatchers took various stabs at diagnosing her problem as the flu, food poisoning, or an anxiety attack. Medical treatment consisted of advice to breathe into a paper bag or to go see a doctor on her own.

The 911 dispatchers were “argumentative, condescending and cavalier” and their advice hastened the woman’s death, the family’s attorney, Marvyn Gordon of Beverly Hills, contends.

A tape-recording of the incident obtained by The Times shows the family of Ziporah Lam called for help three times during a harrowing 30-minute ordeal on Dec. 26. Never did the dispatchers ask the most basic questions--like the victim’s age or whether she was conscious and breathing.

Los Angeles Fire Chief Donald Manning, in charge of firefighters who rotate as 911 dispatchers, had no comment on the Lam case. But after mounting pressure over the years from paramedics, city officials, and emergency services experts, Manning is expected to announce at a Fire Commission meeting today that he will implement stricter dispatcher guidelines in July. One national emergency services expert, who has reviewed the Lam case, said, “ It’s as bad a case as I’ve seen. It gets an F.”

The president of the Los Angeles paramedics union, Fred Hurtado, called it a case of “dispatcher atrocity.”

Although a paramedic ambulance was available less than five minutes away from the Lam’s quiet suburban home, dispatchers did not send it until after Lam had suffered cardiac arrest and her distraught son called 911 for a third time.

The case, according to some health care experts, illustrates a critical point of vulnerability in otherwise sophisticated emergency response systems set up in many cities nationwide. In Los Angeles, critics have long maintained that firefighters answering 911 distress calls need better training and a specific protocol--or script--to follow in evaluating and screening medical problems. City reports dating back eight years have made these recommendations.

Serious Problems Noted

During the most recent management audit of the city’s paramedic services last month, Chief Administrative Analyst C. Edward Corser said investigators unearthed “serious mishandling of calls by dispatchers,” but he refused to elaborate because of the potential for litigation.

Fire Commission President Harold Kwalwasser, who has pushed for the stricter guidelines, said he expects the new protocol and training to “put some discipline into the (dispatcher) system.”

As for the Lam case, he said, “There’s no question from the tape that the dispatchers were not following a system of protocol.”

A multimillion-dollar claim accusing the city of negligence has been filed by Lam’s survivors: her husband, Seymour, a businessman; her son, David, who is a freshman at UCLA, and her daughter, who is a high school student.

Gordon, their attorney, has written Manning a letter accusing dispatchers of ignoring “more than sufficient information” indicating Lam’s severe cardiac distress. Furthermore, he says, they made “inaccurate, simplistic diagnoses” over the telephone and hastened the victim’s death by refusing to send an ambulance and instead prescribing harmful medical treatment.

The tape of the incident--which Gordon obtained from the Fire Department, sent to a private studio to be amplified and provided to The Times--shows that dispatchers repeatedly misdiagnosed her problem, apparently overlooking key symptoms of cardiac distress.

Initial Contact

Lam’s family first called 911 at 9:04 a.m., describing her as having back pain, stomach pain, pain all over, a chest problem, tingling arms and hands, coughing, faintness and vibrations in the chest.

But the dispatcher said he was certain Lam was simply hyperventilating due to an anxiety attack, and he refused to summon an ambulance.

At one point, he demanded that the victim personally come to the phone to answer his questions, and Lam’s husband interjected:

“Look, can you get a paramedic over here, my wife just isn’t feeling well.”

“Sir,” the dispatcher shot back, “we don’t come out for people that aren’t feeling well--O.K.?”

Lam herself finally went to the phone and personally denied the dispatcher’s assertion that she was breathing rapidly--the symptom that he had advanced as the basis for his belief that she was hyperventilating.

‘I’m not breathing rapidly. I’m having pains,” Lam said. “I’m having pains in my stomach and in my back, and my arms are really tingling.”

Finally, the dispatcher advised the family:

“There isn’t anything the paramedics can do for her. There isn’t anything a hospital can do for her. The thing she needs, is she needs to control her breathing.”

He told the family to place a bag over the victim’s nose and mouth for 15 minutes--a move that doctors say could be lethal for a heart attack victim struggling for oxygen. If there was no improvement, the dispatcher told the family, “You can take her over to the local hospital.”

Before hanging up, Lam’s son asked again about the dispatcher’s diagnosis of hyperventilation:

“You’re positive that’s what it is though,” the son asked.

“That’s what it is,” the dispatcher said.

“It’s not anything like a heart attack or anything?” the son said.

“No,” the dispatcher replied.

The paper bag remedy did not seem to be working well, and at 9:10 a.m. the victim’s husband called to report:

“Now she is throwing up. Is that part of hyperventilation?”

Suggestion of Flu

The dispatcher--a different one from the first--did not answer the question, suggesting instead that Lam might be suffering from the flu.

The husband explained that his wife’s pain had started in her stomach, gone up into her upper back, made her hands tingle, caused vibrations in her chest, throat and ears, and finally prompted her to vomit.

“Might be a touch of food poisoning,” the dispatcher surmised.

His recommendation: “I would just put her into the car and, you know, let her be seen by a doctor . . . because that’s all, that’s all the paramedics would do.”

It was the son’s third call to 911 at 9:26 that finally brought an ambulance at 9:33 a.m.

By that time, Lam had been forced to walk to the car, while experiencing “a severe heart attack with rhythm disorder,” according to Gordon. “She made it into the car, but arrested.”

In his final call to the dispatcher from a portable phone, Lam’s son said his mother was foaming at the mouth and choking. The dispatcher said he would send the paramedics, but then failed to stay on the line to describe what the family should do for the victim in the meantime.

Patient Dies

When the paramedics finally arrived, they reported finding her in cardiac arrest and were unable to revive her. Nor could the doctors at Nu-Med Regional Medical Center of Canoga Park, who pronounced her dead.

Dr. Keesag Baron, a cardiologist at Memorial Medical Center of Long Beach, who has reviewed the medical files for Gordon but never treated the victim, said that Lam eventually received expert attention from the paramedics, but it was too late.

Had she received prompt care, he said her chances of survival were favorable because she was relatively young, in good health, with no prior damage to the heart.

Hurtado, president of the United Paramedics of Los Angeles, said the dispatchers’ performance was “lethal.”

“One dispatcher made up his mind she (Lam) was anxious and hyperventilating which, in the face of the information provided, was nothing less than incredible,” Hurtado said. “The other gave advice that was equally bad. And the last dispatcher . . . did not stay on the line to give pre-arrival instructions” in how to care for the victim until the paramedics arrived.

Hurtado has long criticized the Fire Department’s emergency medical dispatch system for failing to formally adopt an emergency dispatch protocol that sets forth questions and follow-up questions for dispatchers to ask in order to determine the seriousness of an incident and to properly select the level of medical skills needed to respond to an incident.

Stalling Alleged

“This Lam case is just the latest in what’s happening all over Los Angeles,” Hurtado said. “In hundreds of cases each year, patients are put at risk by dispatch breakdowns.” He said that he has “a wheelbarrow” of documentation and that the real tragedy is that the Fire Department has stalled for 10 years in moving to address the problem.

As for the department’s intentions to implement new dispatch protocols in July, Hurtado was skeptical.

“What we expect, if history is any indicator, is passive resistance,” he said. “They will say, ‘Yes, we will do all these wonderful things,’ and then they won’t do them.”

He said fire officials have resisted adopting a formal protocol, mainly because of other consequences that flow from such a move--especially, a heavier reliance on firefighters rather than just paramedics to respond to medical emergencies.

“The problem is that the Fire Department does not want to use them (fire trucks and firefighters) for medical emergencies. They want to use them to fight fires, even though 80% of our calls are for medical emergencies, not fires.” Hurtado said.

The workload has stretched the city’s 350 paramedics so thin, Hurtado said, that 58% of paramedics responding to a recent union survey admitted to having made treatment errors caused by fatigue.

In essence, the adoption of a dispatch protocol could have the effect of redistributing the workload in the Fire Department by requiring dispatchers to send paramedics only to the most serious emergencies and relying to a much greater degree on firefighters with medical training to respond to lesser problems.

Two Issues Cited

Battalion Chief Dean Cathey said that labor and cost issues have been the main impediments to the department’s adopting a strict protocol for dispatchers.

“The challenge has been to find a means of more equitably distributing the EMS (emergency medical services) workload without severely negatively impacting the city’s fire protection system and accomplishing it in a cost-effective manner,” according to a Fire Department report that will be presented to the commission today.

Studies dating to 1980 by various city authorities have recommend better medical training and protocol for dispatchers and a tiered-response system whereby paramedics are sent on life-threatening calls and firefighters with medical training are sent on less urgent emergencies.

Attorney Gordon said that in addition to the Lam case, he is investigating two other incidents where he believes dispatchers failed to properly assess and respond to a 911 call.

He said that untrained dispatchers have been a problem in other cities, too, such as Dallas and Racine, Wis. Both cases received national media attention several years ago.

In the Dallas case, a man who called for an ambulance for his 60-year-old stepmother dying from a heart attack, instead got a sharp tongue-lashing from a dispatcher for swearing on the phone.

In the Wisconsin case, a woman who was having trouble breathing got a friend to call twice for help, but she died at home after a city dispatcher--instead of sending an ambulance--told her to breathe into a paper bag. The case is still in litigation.

Prevention Factor

Incidents like these could be prevented if more cities would adopt dispatch protocols that spell out what questions callers should be asked, according to Dr. Jeff Clawson, medical director f1869750388and in hundred of other cities, including Houston and Seattle.

It is Clawson’s protocol that Chief Manning plans to implement in Los Angeles on July 5. Clawson said that Los Angeles has “probably the best Fire Department in the country” and he is therefore puzzled why it has not moved more swiftly to implement the protocol.

Times staff writer John Kendall contributed to this story.