Pregnant with twins and bedridden, Vladimira Doran needed help fast. Her husband was at a park with their 3-year-old son and she was in the midst of a miscarriage.
The Mar Vista woman immediately called her doctor, who had been closely tracking her troubled, 16-week pregnancy. Doran was instructed to get to Cedars-Sinai Medical Center.
But in an action that has prompted investigations by Los Angeles city and county officials, a senior paramedic refused to take her to the Westside hospital. The paramedic, who has been disciplined, tried to persuade her to go to a closer emergency room.
With her husband now back from the park and by her side, the paramedics handed him the stillborn in a plastic container, helped Doran into the back of the family's small car and sent them on their way to Cedars. Still inside Doran was the second twin.
"I just thought someone would come and take me," said Doran, 39, crying as she remembered the events of May 27. "They said they have rules."
When Doran showed up in the emergency room at Cedars-Sinai Medical Center that Saturday afternoon, nurses and doctors were outraged that a pregnant woman in her condition had arrived without professional help.
An emergency room physician immediately complained to the Fire Department's medical advisor. A nursing supervisor, meanwhile, fired off an e-mail to the department and the county agency that regulates paramedic services.
"This is such a high-risk case legally and medically," the nursing supervisor wrote. "I don't think the paramedics understood the magnitude of what could have happened."
The incident is being investigated by county authorities to determine, among other things, if the paramedics violated local and state health policies. Preliminarily, they have concluded that the paramedics erred in leaving Doran.
"The bottom line here, from what I know, is these paramedics should have taken that woman to Cedars," said Virginia Price Hastings, director of the county Emergency Medical Services Agency.
The incident highlights yet another major gap in the city emergency medical network, which has been hit with dispatching problems, staffing shortages and record burnout rates among rescuers.
Doran's case underscores concerns about how rescuers handle some of their riskiest calls: those in which they do not take patients to hospitals.
Such cases account for about 40% of the city's 250,000 emergency medical incidents each year, officials say.
These cases pose the greatest liability to the city--and the greatest potential medical danger to patients--because serious problems can go untreated or even undetected, government medical experts agree.
The Fire Department says it does not have the staff to follow up on the outcomes of these cases. There is no system to track complaints lodged in connection with cases in which patients are not taken to hospitals.
At least a dozen legal claims--four of them involving patient deaths--have been filed against the city in the last five years after it was alleged that patients needed to be transported to emergency rooms but were not.
Several of the claims are pending and others have led to lawsuits, at least two of which the city recently won. It could not be determined if any settlements have been reached.
The principal worry, regulators say, is that there is no way to assess whether the right decisions are being made by paramedics when patients are not transported. The problem extends beyond the city to departments across the county.
"It's just an unknown area, [a} weakness in our monitoring process," Hastings said.
The Doran case came to light only because the emergency room workers complained. Experts say that in Doran's case, the consequences potentially were dire for two patients: the mother and the surviving twin.
A subsequent Fire Department investigation found that the senior paramedic in charge of the incident used "poor judgment" in deciding that Doran's request was unreasonable. He told investigators the trip to Cedars would have removed his ambulance from its assigned neighborhood. There is a 10- to 15-minute difference in traveling time between the two hospitals.
As it turned out, said the Fire Department, the emergency crew did not receive another call for 47 minutes after leaving Doran and her husband on their own.
The senior paramedic also failed to follow policies requiring rescuers to radio hospital supervisors for instructions in such an emergency, records and interviews show.
"There is no doubt in my mind [hospital supervisors] would have said, 'Take that woman where the doctor is,' " said county regulator Hastings. "It was not all the way across town."
The senior paramedic has been reprimanded and received other unspecified discipline, said a spokesman for Fire Chief William R. Bamattre.
The second rescuer escaped discipline because he disagreed with the supervising paramedic, said Battalion Chief Daryl C. Arbuthnott. He declined to elaborate, saying it was a personnel matter.
Doran and her doctor knew that a miscarriage was a possibility.
The physician had warned her that, should problems develop, city paramedics might try to take her to the closest hospital--an alternative the doctor did not favor. So Doran kept the number of a private ambulance service within easy reach.
But when she called, the ambulance company--as mandated by county medical policy--told Doran that her condition required that paramedics be sent. Her call was promptly transferred to a 911 operator, who switched it to a Fire Department dispatcher.
"I have a patient on the phone who's having a miscarriage," said the 911 operator.
Doran, after providing her address, calmly told the dispatcher: "The thing is, I want to go to my doctor. I just called my gynecologist and she told me that I have to go to Cedars-Sinai right away."
"Well, I don't know if the paramedics will be able to take you there," the dispatcher said.
"Do you have somebody to give you a ride?"
Doran said her husband was supposed to be back in 10 minutes.
"You wanna wait for him, or you want me to send the paramedics out there?" the fire dispatcher asked.
"If the paramedics come out, they gonna take me to . . . "
"I'm not sure. You'd have to talk with them when they get there. You want me to send them, just, uh . . . ?"
"OK. Send them just to see, because I think it's better if I lay in the bed there."
Before signing off, the dispatcher told Doran: "Just get in a position where you're most comfortable until we get there, OK?"
During the about three-minute call, the dispatcher did not ask a single question about Doran's medical condition, a crucial factor in determining the proper emergency response.
Dr. Samuel Stratton, who oversees paramedics countywide, said the dispatcher appeared to treat the call as if Doran "was calling for a taxi, rather than calling 911."
Stratton is heading a county investigation of the incident that could lead to discipline by the state agency that licenses paramedics. In Doran's case, he said a preliminary review has found that the dispatcher failed to follow procedures for eliciting medical information.
In fact, Fire Department records show that the paramedics were dispatched to a call involving "unknown problems."
A department spokesman said its probe focused on the paramedics' actions in the field, not how they were dispatched.
When paramedics arrived at Doran's home a few minutes later, they found her lying in bed. About that time, Doran's husband arrived.
The paramedics severed the stillborn's umbilical cord. They tried to persuade Doran to go to the emergency room at Daniel Freeman Hospital, about 10 minutes away. But she wouldn't budge from her doctor's orders. She also could not shake the memory of a friend treated in an unfamiliar hospital.
Several years earlier, Doran had taken the bleeding, cancer-stricken friend to a Las Vegas emergency room. There the woman languished, suffering while the hospital tried to reach her physician.
"I was terrified [by] what happened to my friend," Doran said, fearing that the same fate would befall her.
Doran said she was emotionally wrought and confused by the impasse over where she should go. The trip to Cedars would have added just a few extra minutes, she thought. What's the problem?
"It was a nightmare. . . . It's like you're out of your mind. You don't know what to do," said Doran, a Bulgarian immigrant.
She was troubled at the prospect of using her only other way of getting to Cedars: the family car. "I would still feel better if I lie down in an ambulance," she recalled telling the paramedics, who then handed her a legal form.
It said she was refusing to be transported against medical advice. Though she desperately wanted to be taken by ambulance to Cedars, not the closer emergency room, she signed.
But there are questions about whether she was properly informed of her options.
"This lady wasn't refusing transport," said county investigator Stratton, "just transport to a particular [medical] center."
When Doran arrived at Cedars, she was treated, seen by her doctor and released later in the day. She lost the second twin about a month after her ordeal.
Despite her experience, Doran said she had no reason to think that her well-being was not paramount to the paramedics, who treated her professionally and warmly. She believed they had no choice but to drive away.