Crowded ERs Put Patients on Hold

Overcrowding in Los Angeles County emergency rooms is forcing patients brought by ambulance to wait up to five hours in hospital hallways and lobbies, cared for by paramedics rather than doctors or nurses.

Paramedics and ambulance workers with six months or less of formal training often are the only ones watching over patients who are seriously ill or even dying--a task many say is far beyond their ability.

“People call 911 and they think if we bring them in, they’ll get seen by the doctor faster,” said Los Angeles Fire Department paramedic Orville Wright, who waited more than two hours last week with a respiratory patient at Martin Luther King Jr./Drew Medical Center. “That’s not the case.”

Hospital officials say the most critically ill patients are treated immediately. But paramedics and some emergency physicians say the congestion is endangering patients’ lives.

The danger extends beyond the ER. While paramedics are waiting for a bed to open up in the emergency room, ambulance responses are often delayed in the communities they cover. If an ambulance is taken out of commission, response times in its service area increase by four to five minutes on average, fire officials say.

Ambulance backups are worsening because more patients are seeking emergency-room care, even as hospitals are closing ERs. In the last decade, more than 20 ERs have shut down in Los Angeles County, narrowing treatment options in a sprawling region of 9.6 million people.

The waits are longest in downtown Los Angeles, South Los Angeles and the Antelope Valley. Among recent examples:

* Two patients have died since December while waiting with paramedics at Good Samaritan Hospital in downtown Los Angeles. In response, Dr. Marc Eckstein, medical director of the Los Angeles Fire Department, sent a letter expressing “grave concern” to the hospital.

“It remains the legal and moral responsibility of the hospital to provide care for the patient once he is on the hospital premises,” he wrote. “Patients in need of urgent interventions must receive them, regardless of whose gurney they are located on.”

A county investigation did not find that the deaths were caused by the waits, which Eckstein estimated at 30 minutes in both cases.

* On the night of Feb. 15, between eight and 12 ambulances were parked outside Antelope Valley Hospital in Lancaster. Inside, paramedics and patients waited for hours because the 28-bed emergency room was full. The delays left the valley of 318,000 people virtually uncovered by ambulances.

* Several times lately in the Antelope Valley, paramedics waiting at hospitals have sought permission via radio from supervisors 70 miles away to administer intravenous medications to patients. That was because they could not get the attention of a doctor or nurse just yards away.

* Last Monday, five ambulance crews were stuck simultaneously at King/Drew in Willowbrook.

Wright’s ambulance, transporting a 42-year-old woman with difficulty breathing, was sidelined for 2 hours and 19 minutes in the early evening, when ambulances tend to be busiest. Hooked to a portable oxygen tank, the woman also showed signs of liver problems and anemia. A week earlier, Wright said, he had waited three hours with a homeless man injured in a fall. The man finally gave up, got off the gurney and left.

Los Angeles city ambulance squads reported themselves out of service about 22,000 times last year because they had to wait for an open bed longer than the 15 minutes allotted by the Fire Department, Eckstein said. In those cases, squads waited an average of 30 to 35 minutes.

The delays affected one in every seven patients transported by city ambulance. It’s as if two ambulances were out of service each day, Eckstein said.

“The paramedics by default become ER nurses or part of the hospitals’ staff,” said Eckstein, who is also an ER doctor at County-USC Medical Center in Boyle Heights.

Some medics are so sure they will face delays that they bring crossword puzzles, books and folding chairs. They have dubbed the collections “NAV kits,” which stands for “not available.”

“Sometimes we need a little gallows humor,” said fire Capt. Marc Segal, one of the city’s emergency medical services supervisors.

Officials at the county’s most overcrowded hospitals say that patients in critical condition--bleeding uncontrollably or not breathing--are seen immediately by a doctor or nurse. And most patients receive at least a quick once-over by a triage nurse within the first half-hour.

“I don’t think any hospital in Los Angeles County will have a problem defending what it is doing,” said Jim Lott, executive vice president of the Healthcare Assn. of Southern California, a hospital trade group. “It is treating patients as fast as it can.”

Health experts attribute the problem largely to a critical nursing shortage, which leaves ERs and intensive-care units understaffed; too few inpatient beds, which delays transfers out of the ER; and low payments for emergency and trauma care, which has forced some ERs to close. One ER shut in Pasadena this year and another will close in Marina del Rey by August.

Later this year, Los Angeles County officials will consider shutting ERs at Olive View-UCLA Medical Center in Sylmar and Harbor-UCLA Medical Center near Torrance to close a massive health-care budget gap.

All county residents are at risk, officials say. “When you have these long waits, it delays the response to the next incoming call, which could be from the mayor of Los Angeles, for all we know, or a street person,” said Virginia Hastings, head of the county emergency medical services agency. “This EMS system serves all 10 million people, not just those without insurance.”

For years, Los Angeles County and other regions have allowed hospitals, when full, to temporarily close their ERs to ambulances. Ambulances then are diverted to other hospitals close by. But when every hospital in an area is full, even temporarily closed ERs must accept patients. That’s when ambulances stack up.

“I don’t think you need a medical degree to know that this is not the way it should be,” said Dr. Brian Johnston, an ER physician at White Memorial Medical Center in Los Angeles. “Throughout the area, waiting times have gone from frustrating to dangerous.... If this continues, people will die.”

Battalion Chief Michael Metro, EMS director for the county Fire Department, said he can pinpoint the exact date--March 19, 2001--when he became alarmed about such ambulance backups. On that day, one of his squads waited 3 hours and 55 minutes with a patient at Lancaster Community Hospital.

“That is just an absolutely extraordinary amount of time,” Metro said. “When that occurred, we said, ‘My God, we’ve got to get the players together.’ ”

Los Angeles County appears to have one of the worst ambulance-gridlock problems in the nation. Although ambulances elsewhere must often travel long distances to find open hospitals, only a few other cities--including Las Vegas and Albuquerque--also have long waits for paramedics once they arrive at the ER.

In Las Vegas, some hospitals have stationed extra paramedics to wait with ambulance patients in emergency rooms so that transporting squads can return to the streets. Paramedics at the Las Vegas Fire Department also offer to take patients to a second hospital if they are told to wait at the first one. That does not happen in Los Angeles County because officials here believe it would put hospitals at risk of violating federal law.

The law requires hospitals to examine and stabilize, if necessary, any patient who arrives on their grounds. Technically, paramedics could drop off patients and leave. But, in Los Angeles County, their superiors tell them not to, both for ethical reasons and because they would risk being sued by patients who suffer harm.

The county sets rules for the 31 fire departments, more than 15 private ambulance companies and more than 80 ERs that make up its emergency response system.

One of those rules limits the flexibility of ambulance squads by requiring them to deliver patients from certain areas to specific hospitals. At times, this keeps paramedics from considering less-crowded alternatives.

As waits worsen, government officials and hospitals are looking hard for solutions.

The city Fire Department is considering software upgrades so that paramedics can see on their laptops how many rescue ambulances are waiting at each hospital.

If two or more ambulances are waiting--or one ambulance has waited longer than an hour--paramedics would be advised to go somewhere else.

Another possibility is to allow one medic crew to watch over several ambulance patients, allowing others to return to service. Or, the city could continue to add ambulances: In the coming year, the Fire Department will increase the number on hand to 117, from 83 in 1999.

In the Antelope Valley, the county Fire Department has equipped two more of its engines to handle paramedic calls. The two hospitals with ERs have added staff and pledged to triage patients more quickly.

Antelope Valley Hospital officials say the wait times there have decreased since the winter. But the underlying problem remains: The region had fewer inpatient beds in 2000 than in 1990, even though the population grew by 27%.

Countywide, Hastings said, “I’m not sure that there’s one easy answer to all this.”

Segal, the Los Angeles EMS supervisor, is trying to solve one crisis at a time. This past week, fire dispatchers asked him to visit King/Drew and ease the backup there.

As Segal walked through the emergency room, he found that every bed was taken, and overflow patients with IVs and oxygen tubes were sitting in wheelchairs and desk chairs.

Segal managed to free one ambulance before leaving. It was called into action one minute later.

Four other squads were left in the parking lot.

“It’s a travesty to the citizens here,” Segal said of the waiting times. “They should have candy stripers or volunteers or techs scouring that hospital for gurneys.”

King/Drew officials say they are packed beyond their limit. Their emergency room has an official capacity of 33 beds, but they routinely handle 40 to 50 patients at any given time, borrowing beds from other parts of the hospital.

The hospital expects to relieve some of the overcrowding by buying additional computerized monitors that will allow some ER patients to be moved more quickly to regular beds upstairs.

But what King/Drew really needs is nurses, said Dr. Eugene Hardin, chairman of the emergency medicine department.

“It’s very hard to keep nurses in the county, because we overwork them,” he said. “And once we do that, they ... just leave. It’s hard to blame them.”

Another factor is that patients believe they will be seen more quickly if they summon an ambulance, whether or not their conditions are urgent.

For liability and other reasons, paramedics and emergency medical technicians do not turn away non-urgent patients.

Some hospitals are trying to curb unwarranted ambulance calls by asking patients with minor illnesses to get off ambulance gurneys and sit in the waiting room with walk-in patients.

Hospital officials say patients who come to the ER on their own can be as sick, or sicker, than patients brought in by paramedics.

“I can’t say to somebody with chest pain who’s lying in my stretcher, ‘I’m sorry, you have to get up because I have a paramedic here who’s bringing somebody in by ambulance,’ ” said Dr. Philip Fagan Jr., emergency room medical director at Good Samaritan.

Paramedics sometimes feel, though, that overwhelmed hospital staff members aren’t taking heed when they should.

Eckstein wrote Good Samaritan in February to express his concerns about the two patients who died after waiting for emergency beds. The first, a young man complaining of chest pain, died Dec. 15; the second, an elderly woman suffering signs of shock from internal blood loss, died Feb. 14.

Regarding the first patient, Eckstein wrote: “Our paramedics reportedly told the [department] staff that this patient’s vital signs were worsening, but were allegedly met with some indifference.”

“Naturally, both paramedics were extremely concerned that this young patient, who was talking with them in the field, died after waiting for 30 minutes on their stretcher in your [department] without receiving care until he went into cardiac arrest.”

The second patient also went into cardiac arrest after 30 minutes, and resuscitation attempts were unsuccessful, Eckstein wrote in the letter, which was obtained by The Times.

The county Department of Health Services found no link between the delays and the deaths, citing incomplete records and conflicting accounts from paramedics and hospital staff members.

Good Samaritan’s emergency room medical director, Fagan, said the hospital handled the cases appropriately. “Everything was done that could have been done within the capacities that we have,” he said.

“The fact that someone dies does not necessarily mean that it’s the fault of the people involved.”