Fire Dept. Plays It Safe by Responding to All 911 Calls : Health: Paramedics have dealt with headaches and heart attacks since a suit over a 1987 incident.

TIMES STAFF WRITER

While the Los Angeles City Fire Department struggles with budget cutbacks that have slashed staffing at fire stations, fire engines and rescue ambulances continue to respond daily to such ailments as sore throats, headaches, and cut fingers.

"I've gone out on hangnails, ingrown toenails and mosquito bites," said Ron Lingo, a Fire Department paramedic who responded a few months ago to a call from a young mother concerned because her "baby hadn't smiled for an hour."

Teletyped messages from the Fire Department's dispatch center show emergency crews have responded to complaints that include: "55-year-old male constipated," "36-year-old has pain in mouth after going to the dentist," and "been drinking since Super Bowl Sunday, doesn't feel good."

Until 1989, Fire Department dispatchers screened out calls that they believed were not genuine emergencies. Since then, in a move to simultaneously save lives and stave off lawsuits, the department has been responding to every medical complaint that callers make when dialing 911.

The new system was set up in the wake of outrage over the December, 1987, death of Ziporah Lam, a 42-year-old Chatsworth woman whose family called three times before dispatchers sent help.

Over the telephone, dispatchers variously diagnosed Lam as suffering from flu, food poisoning, hyperventilation and an anxiety attack. "Sir," one dispatcher told her husband over the telephone, "we don't come out for people that aren't feeling well--OK?" By the time help arrived 29 minutes after the first call, Lam was in full cardiac arrest.

A multimillion-dollar lawsuit over that case is pending.

"We're through second-guessing because we wound up in some of the city's worst lawsuits and I think we now have pretty close to the best system we could have," said Chief Terry Dickeson, a supervisor in the department's dispatch center deep in a sub-basement under City Hall East.

"But we have a tremendous amount of calls that are absolute 911 abuse. We get people who call here and their feet itch and they want an ambulance. If they say even the slightest thing that sounds medical, even if it's a cut finger, we respond--not always with sirens, but we respond. We have no 'no-send' category."

The new system was developed in conformance with a 1988 audit by the city administrative office. The audit recommended that the department adopt sophisticated written "protocols" to ensure that dispatchers give uniform responses based on medical research. Similar systems have been adopted by thousands of agencies nationwide.

Under the system, developed by Salt Lake City expert Dr. Jeff Clawson and refined by city officials, dispatchers read questions from standardized cards. Calls are divided into 32 categories depending on the type and severity of the problem. Dispatchers are monitored to ensure they follow the protocols.

First-aid complaints receive a crew of firefighters trained as emergency medical technicians. In critical cases, such as apparent heart attacks, fully trained paramedics and a fire engine or truck company are dispatched with sirens and red lights. Dispatchers read emergency instructions to callers to help them administer emergency aid while help is on the way.

However, some firefighters and paramedics are now worrying that since a 10% budget cut led to "rolling brownouts" at city fire stations, crews may be either "browned-out"--out of service--when emergencies occur or dispatched to first-aid complaints that dispatchers formerly categorized as "no-send."

Once the new system had been tested, a "no-send" category for apparently trivial complaints was supposed to be re-established. But that hasn't happened.

Fire officials said that under terms of Clawson's consulting contract, he was supposed to set standards for a "no-send" category and did not do so. Clawson, in an interview from Salt Lake City, said that he set up guidelines for a study that could lead to such a category, but that fire officials had dropped the ball.

In any event, conceded Dr. Gregory Palmer, the department's medical director, "It's been left hanging." He said the idea "was never a high priority" because under the best projections only 2% to 4% of calls the department receives could be screened out without risking lives or lawsuits.

More than 77% of the 250,000 emergency calls the department receives are medical complaints. Fewer than 9% are fires. The remaining 14% are miscellaneous incidents such as hazardous waste spills, rescues and bomb threats.

Fire Chief Donald O. Manning said in an interview last month that he still considers a no-send category "advisable." However, he said, he appreciates both the legal protection and the safety buffer the current system provides.

"It would be nice to fine-tune this and never go on any of those calls that appear to be ludicrous," he said. But, he pointed out, developing standards under which the department is comfortable refusing to send help is difficult and legally risky.

Taking the example of a "39-year-old female (who) swallowed her mouthwash," he said: "To you and I it may be green liquid in a bottle . . . but are you willing to gamble a little to accept that person's identification of what they swallowed and not send on it?"

Under the current system, he said, "we're protecting dispatchers, we're protecting the people who are delivering our services out there that they won't be criticized, that they won't have to appear in court."

Because there is no way to calculate the cost of potential lawsuits, it is conceivable that responding to so-called "Band-Aid" calls may be less costly than not responding at all.

After the Clawson protocols were adopted in 1989, the department asked dispatchers to keep track of those calls they would have screened out for "no response" under the old system. More than 700 such calls were logged during a 45-day period.

Clawson said the list confirmed that most of the calls dispatchers would have screened out did not appear to involve the sort of life-threatening emergencies for which 911 is designed. However, other calls that would have prompted no response under the old system were potentially so serious that they "scared the living heck out of us."

One example, he said, was "baby doesn't look right." Although on the surface the complaint seemed trivial, he said, "that is often a typical lay person's view of a critically ill child."

Nobody knows exactly how many non-emergency calls there are because the department does not computerize reports from the field, according to Battalion Chief Dean Cathey, a department spokesman.

Cathey said 9.2% of calls received during a recent 60-day period were initially listed as non-emergencies. However, some such calls turn out to be life-threatening. Conversely, others reported as life-and-death emergencies turn out to be calls for sympathy, reassurance or simply a ride to the hospital.

Some paramedics and firefighters in the field say the number of non-emergencies is far higher than statistics suggest.

"I'd guess a good 30% of the calls we go out on don't really need us," said paramedic Cindy Sweem. "Basically what we do is check their vital signs and see if they have means to go to a hospital by private auto. If so, we recommend they see their own doctor or emergency room."

Many calls come from onlookers who are not certain of a victim's condition, and from victims who are too frightened to adequately explain their maladies or who have no way of diagnosing what is wrong.

In the San Fernando Valley recently, a woman called 911 when she heard her neighbor scream, "My God! He's not breathing!" Fire crews arrived, sirens blaring, to find a German shepherd dog in respiratory distress.

Sorting out the life-threatening emergencies from mere crises is not easy.

The number of medical calls to 911 grows annually because of the closure of emergency rooms, the number of immigrants who do not speak English, increases in violent crime and cutbacks in numerous public services.

Many people relying on the 911 system for medical care have no doctors, no health insurance, and sometimes no cars to get to emergency rooms. Since the closure of many trauma centers, some call 911 because the alternative is a 12-hour wait at a county hospital emergency room. Some call 911 because, whatever the reason, the Fire Department is the only place they can call and know someone will come and at least tell them if something is wrong.

Battered women call days after their husbands beat them because they are afraid. Elderly people call because they need rides to the doctor. Pregnant women who can't afford hospitals wait until they're in labor to call. Immigrant parents, unable to get landlords to clean up insect infestations in slum buildings, call when their small children wake up in terror with cockroaches burrowing into their ears.

The busiest Fire Department station is No. 9 on Skid Row, where firefighters and paramedics respond frequently to calls about homeless people with multiple physical and mental maladies that no one else addresses.

On one recent Saturday night, a gas station attendant called 911 with a report of a "45-year-old woman in labor."

"Bet it's Dolores," one veteran firefighter said as he turned on the siren.

Sure enough, there was Dolores, a distraught, homeless woman with no teeth and a shiny new manicure lying next to a gas pump with all her worldly belongings, convinced that she was in labor. Once paramedics arrived, she seemed somehow reassured, and turned down transportation to a hospital. She was not pregnant and there was no medical emergency, but a problem was solved.

But paramedics say some of the most demanding callers are wage-earning citizens who complain that they are taxpayers who have a right to city ambulance service.

"Somebody called us in the middle of the night on what turned out to be a routine call," said Capt. Sidney Wilmot, who is based in North Hollywood.

"I asked, 'Why are you calling us now? Why don't you go to see the doctor?' And she said, 'Because I have Kaiser and if I call them, I'd have to wait.' In the meantime, we go out there with red light and siren, jeopardizing people on the street."

One fire chief said his station has responded to 78 calls at one apartment building in the Valley since 1989. He said the department receives regular calls from one building resident who genuinely needs emergency respiratory treatment--but only because he predictably runs out of his asthma medicine.

Firefighters and paramedics have taken to collecting some of the more seemingly humorous calls. One firefighter said a crew responding to an emergency from one woman was asked to "exorcise a ghost" from her house.

"We went on one today where it turned out a man had had a sore throat for two weeks," said firefighter Willie Thost. "There's nothing we can do. We take their vital signs, assure them they're not dying, and tell them, basically, go see your doctor."

Ed Corser, chief administrative analyst who supervised the audit that recommended the new protocols, was surprised to learn that the department had not yet developed a "no-send category."

"I just can't believe they'd send on this type of calls," Corser said. "This is what I would call aggressive over-compliance. . . . There was a clear understanding that once we had the protocols in place, we would re-establish a medically justified system with a no-send category."

Two other interesting recommendations in the report also have not been fully implemented. One was the establishment, in conjunction with local hospitals, of a county-supervised hot line to discuss symptoms so "minor medical problems would not have to become full-scale emergencies handled at great cost to the city and the patients alike."

That recommendation proved unfeasible because of the lack of funding and the coordination required with other agencies, Cathey said.

Another was a "comprehensive media campaign" to educate the public about proper use of 911. The city administrative office's report recommended that the media message read, "If your neighbor calls for EMS (emergency medical service) help on a cut finger, the rescue ambulance may not be available to respond as quickly on your heart attack!"

Cathey said that the department has conducted some media campaigns, but that the "Fire Commission was uncomfortable in deterring people from calling."

"We are bending over backwards to err on the side of people's health," said Fire Commissioner Aileen Adams.

"On the other hand, we don't want to waste resources, either. . . . Ultimately, what we'd like to have would be a definition of the kinds of things we should not be sending on, and provide those callers other resources to call."

Unlike such cities as Anaheim and Beverly Hills, Los Angeles does not charge treatment fees. Nor does the city charge a fee for "false alarms" in the belief that such fees might discourage people from calling when they need help.

Within the next week, however, a proposal is before the City Council which, if approved, would impose fees for anyone who receives treatment. The fees, which range from $75 to $173, are based on actual Fire Department cost, and would raise an estimated $13.5 million annually by fiscal 1992. Those patients who cannot afford to pay would not be turned away.

The Fire Department is also conducting a pilot study in the San Fernando Valley to determine whether people who merely need transportation to a hospital could be referred to private ambulances. Adams described the system as "evolving."

The Fire Department assumed responsibility for emergency medical service in 1970. Until then, medical emergencies were handled primarily by ambulances known as "brown bombers," dispatched when available from two hospitals in downtown Los Angeles.

At the time of the city administrative office's audit in 1988, the city's 49 paramedic ambulances were responding to virtually all routine medical calls--200,000 a year--while firefighters at the city's 103 stations stood by for fires and major medical emergencies.

The audit recommended that by using firefighters to respond to medical incidents, the department could double the number of units available for medical problems, cut response time, and reduce the overload on paramedics.

Since then, all firefighters have received training as emergency medical technicians, and the closest fire company is immediately sent on medical calls, freeing the more highly trained paramedics for more critical calls.

One dispatcher asked a reporter to clarify that there is, in fact, one sort of call firefighters screen out.

"Please tell people we don't go out on cats in trees," he said. "People call us any time they see a cat in a tree, and we're sitting here with people's lives at stake. What you want to say is, 'Ma'am, have you ever seen a cat skeleton in a tree?' But that's a little cavalier.' So I just say, 'Sorry.' "

A Sampler of Calls

When the Los Angeles Fire Department implemented a new dispatch system in 1989 and began sending emergency crews to everybody who called with a medical complaint, dispatchers were asked to note which calls they would have refused under the old system. Some were considered by medical experts to be genuine emergencies dispatchers would have missed, while others were clearly non-emergencies ranging from the mundane to the preposterous and heart-rending.

Here is a sample of verbatim Teletypes sent to fire stations from dispatchers: * 17-year-old female cut foot while trimming calluses

* Person has arm stuck in ready teller machine

* 18-year-old male can't get any rest at home . . . wants ride to the hospital

* 15-year-old orphan arm hurts and no one will take responsibility as guardian

* Lady from New York has been drinking, feels ill, spent all her money on jerks

* Told to quit smoking--feels weak and nervous

* Quadriplegic bleeding from her catheter

* Lady's baby died. Now she can't sleep

* Lady got hit in the head with a belt buckle a couple of days ago. Now she's styling her hair and it's bleeding. Wants us to put bandage on it

* Man in blue cowboy hat and yellow pants has swollen feet

* 13-year-old stubbed her toe on a stereo speaker

* 61-year-old worried her stomach is not growling

* A lady sat on her hand earlier this morning and broke her finger

* Person answered no to question are you conscious?

* Baby-sitter says baby cries when you put him down

* Lady has headache for four days. Husband has no money for aspirin

* Patient's finger is numb from carrying grocery bags

* Lady has blisters on her feet from walking for three days at the Taco Bell

* Splinter in finger

* This guy is inside Humphrey Medical Center. Says the people inside are not helping him fast enough so he called (fire department)

* Bee stuck in child's nostril

* Out of breath from 'running from the police'

* Daughter says mom is acting weird

* Man was shot two months ago. Now he feels dizzy

* Paralyzed lady with toothpick in her throat

* Woman says her boyfriend threw her off porch last Saturday. Now her side hurts

* Man shot one year ago--says the bullet and his intestines are coming out now

* Person fell off bike

* 69-year-old male needs checkup

* Penile implant causing pain

* Slept wrong on neck

* Left testicle bigger than right testicle

* 17-year-old upset after a funeral

* Husband claims wife is mentally unstable

* Got punched in the eye the other day

* Tree branch in leg

* This person has been hiccuping for four days

* Lady says man is screaming that wife is dying

* 22-year-old says half of his face is asleep

* Help overweight lady out of the tub

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