Critical Conditions : Emergency Room Shutdowns Are Hitting Home as Patients, Paramedics Scramble to Cope

The family of Luz Hermengildo, an 83-year-old woman with a history of diabetes and hypertension, discovered her lying unconscious on the floor of her East Los Angeles apartment at 6:25 Friday night. Under the anxious eyes of half a dozen family members crowded into a tiny living room, Los Angeles County Fire Department paramedic Pete Murrieta, one of several members of the rescue squad that responded to the emergency call, grabbed the telephone and called his base station, County-USC Medical Center.

What hospital could he take her to?

His first choice, Santa Marta Hospital, was only five minutes away. But the voice on the other end of the line told him it was overloaded with emergency patients and temporarily closed to rescue ambulances.

“How about Monterey Park (Hospital), ETA 6 minutes?” Murrieta asked next.

Closed.

“How about East L.A. Doctors (Hospital), ETA 6 minutes?”

Closed.

“The next closest,” he said, “would be you guys.” But County-USC, 10 minutes away, also was too jammed with critical patients to accept her.

So Murrieta asked the status of White Memorial Medical Center, the fifth closest emergency room. And at last he got the response he’d been waiting for: It had room for Hermengildo. But now they had to wait another 10 minutes for the ambulance which, because most of the nearby emergency rooms were filled to capacity, had been forced to make its last run to a hospital some distance away.

Hermengildo was treated and released, but for Murrieta it was just another incident in an ongoing crisis. “It’s frustrating,” he said with a slight shake of his head. “But there’s nothing we can do.”

Later that night, in a small, coolly lit office tucked inside County-USC Medical Center’s bustling emergency ward, Walter Johnson hung up a telephone and walked briskly to a bulletin board covered with two long columns of hospital names. With a thick red marking pen, he added “Cedars ER” to the list.

It was 10:55 and Cedars-Sinai Medical Center in West Los Angeles was so swamped it was shutting its 20-bed emergency department to public ambulances until further notice--a sober fact that Johnson duly noted on the “status board” maintained in the Medical Alert Center, the throbbing heart of the county’s fragile emergency service system, where all rescue ambulance traffic is coordinated.

Cedars was the 12th hospital in Los Angeles County to declare its emergency room temporarily closed on this night.

To Johnson, an emergency patient-transfer coordinator, it was not a dramatic moment. In a crisis spurred by funding cuts, the growing use of emergency facilities, and permanent closures of some, rashes of emergency rooms are filling to capacity and closing all at the same time, triggering a state of “medical gridlock.”

But to paramedics out in the field--and to the people they would rescue--it can mean adding critical minutes to the time it would take to transport a patient to a hospital that is open to emergency cases.

And, with each temporary closure, emergency room experts say, the pressure shifts to the next closest hospital, rippling out across the county’s network of 94 hospitals that are authorized to receive rescue ambulance traffic.

Paramedic units “are literally sitting at the scene (of a rescue call) and not turning their wheels” because of emergency room jam-ups, said Alan Cowan, chief of paramedics for the Los Angeles City Fire Department, which responds to more than 600 rescue calls a day. “Our entire system has had a cardiac arrest.”

It is so bad, he said, that every day paramedics on rescue calls have to run down a list of three, four or five hospitals to find one that is open, or arrive at a hospital only to find their ambulance is the fourth or fifth in line outside the emergency room door and that the hospital has run out of empty gurneys.

Experts say medical gridlock was once a problem experienced primarily in the inner city, where the scarcity of hospitals and the poor health and indigence of many area residents combined years ago to push emergency facilities to their limit. But now the congestion is spreading out to hospitals in middle-class and affluent communities of the county, straining an increasingly overtaxed emergency service network.

“One year ago I would have said the inner-city working poor are being hurt the most,” said David Langness of the Hospital Council of Southern California. “Today, that isn’t true anymore. Today, it’s anyone who gets in an accident, suffers a traumatic injury or life-threatening illness, such as a heart attack. And it’s not just the downtown hospitals anymore. The ripples are now reaching out to Brotman (Hospital in Culver City), Cedars-Sinai and hospitals in the San Fernando Valley and Glendale and Pasadena where the affluent in our area live.”

“People think, ‘I have insurance, so (the closures) don’t affect me,’ ” said Virginia Price-Hastings, director of the county’s paramedic and trauma hospital programs. “The hospitals don’t just close to poor people. When they’re closed, they’re closed to anyone. You can be the richest man in the world, checked into a suite at the Bonaventure, and if you have a heart attack, you’re going to the same crowded hospital and wait along with everybody else.”

Eight of the original 23 trauma centers that opened in 1983 have closed their doors permanently over the last three years, largely because of the exorbitant costs of providing specialized emergency care and the large number of patients too poor to pay for the service, according to Price-Hastings. Other hospitals, such as French Hospital in Chinatown and Linda Vista Hospital in Boyle Heights, have shuttered their emergency departments for good. And, in the latest shock to the countywide system, Queen of Angels, which handled more than 400 rescue calls a month, folded its entire facility to merge with the Hollywood-Presbyterian Medical Center.

As a result, Price-Hastings said, the 94 remaining emergency rooms licensed to accept rescue ambulances are under enormous pressure to pick up the slack. Periodically over the past several weeks, more than half of the hospitals “were on some kind of diversion,” she said, temporarily refusing all emergency cases except the most serious. In such cases, county health department policies dictate that if every emergency room within 10 minutes of a rescue call is closed, paramedics will take the patient to the nearest facility anyway, she added.

Dr. Don Thomas, director of emergency services at Huntington-Memorial Hospital in Pasadena, said Huntington’s emergency room has been so swamped that on four occasions this month it had to turn away rescue ambulances for periods stretching from an hour to a day and a half. Its trauma center, the only one in the San Gabriel Valley, closed down nine times for as long as 48 hours, a hospital spokesman said.

Such frequent shutdowns in the emergency room “almost never happened to us” before, Thomas said. But in recent weeks, “we’ve had every bed filled and extra gurneys in the hallway for people waiting for a bed to open up upstairs. It’s like a dam clogging up all the tributaries,” the physician said, “and the flow still keeps coming in.”

County regulations allow hospitals to divert paramedic runs to other facilities if they become too crowded. But in such cases they actually are “closed” only to rescue calls made by county or city paramedics. Under state law, they are required to accept patients who arrive on their own, either by walking in or through private transportation.

In either case, Thomas and other emergency room doctors who were interviewed said the public should not fear that they won’t receive hospital treatment in an emergency if they need it. “They are not going to come to our emergency department and find the door closed,” Thomas said.

But be prepared for long waits, especially for injuries or illnesses that are not life-threatening, such as a lacerated hand or an earache, he said.

“There have been days when it’s been embarrassing,” Thomas acknowledged, when patients in pain have sat for two or three hours “before we could do anything for them. We’re not going to let people die. But I guess people should be alarmed. Care is being slowed down because of forces beyond our control.”

Dr. Joel Geiderman, an emergency room physician at Cedars-Sinai, said the gridlock conditions mean that patients may have to wait on a gurney for longer than they or the hospital would like. “It gets hard in here sometimes to meet basic needs, like giving (a patient) a blanket. We get so overwhelmed,” particularly on weekends, he said.

The current crisis also means that patients cannot be transported to the hospital of their choice, unless they use private transportation, either car or private ambulance, said Dr. John McConnellogue, medical director of Northridge Hospital Medical Center’s emergency department.

“For people who require an emergency city ambulance . . . you might very well be brought to a hospital you don’t want to be taken to, one that is out of the normal area because of closures” of emergency rooms nearer by, he said.

At least one large downtown company was so worried about emergency room gridlock that it has taken extraordinary steps to ensure quality hospital treatment for its employees. Atlantic-Richfield, which has 1,400 workers at its headquarters at Fifth and Flower, recently signed an agreement with the Hospital of the Good Samaritan’s heart institute to provide immediate care to any Arco employee who suffers a heart attack or other cardiovascular emergency, said Arco spokesman Al Greenstein. AT&T; has a similar arrangement with Good Samaritan covering 10,000 Southern California employees, although a company official said it was not prompted by the emergency room closures.

If more companies decide to strike up similar deals with private hospitals, “it would very much trouble me,” said the hospital council’s Langness. “A lot of downtown companies are very worried about this (emergency room closures). But what you would have then is a very fragmented system, a two-tiered health care system. And that is the worst thing that can happen.”

In the view of Cowan, the city paramedics chief, the consequences of the epidemic of closures could become more severe.

He said he knows of one case, reported in The Times in 1987, in which a patient died because closures of the four emergency rooms nearest to his South-Central Los Angeles home forced him to wait too long for hospital treatment.

“The question is, how many (deaths) do I not know about?” Cowan said. “People who, because of delays, wound up dying three days later?”

Asked what, if anything, can be done to avoid getting caught in the gridlock, he was blunt:

“My advice unofficially is, don’t get hurt right now in L.A. We’ll get you there (to a hospital), but where will that hospital be? And how long will you wait once you get there?”