Just before 10:45 a.m., Keith Marks called 911 and the Los Angeles County emergency response system sprang into action. A fire engine, a paramedic squad and a private ambulance — eight men in total — rushed to the Martin Luther King Jr. urgent-care center in Willowbrook.
When they arrived, Marks, 56, was sitting calmly in a wheelchair just outside the entrance. His complaint: he was having joint pain from gout and wanted his medication refilled.
"I can't walk," he said. "I need to go to the closest emergency room."
The paramedics checked his vital signs. Marks told them he called 911 after the county clinic wouldn't see him for free because he had other insurance. Then the paramedics did what Marks wanted — sent him by ambulance to St. Francis Medical Center.
During an eight-hour period at L.A. County Fire Station 41 last week, paramedics responded to a handful of calls but only one actual emergency — a man who reportedly had a seizure while driving on the 105 Freeway. Several other calls, they said, could have been handled differently if there were other options. The call from Marks was one.
"Really, what are we going to do for gout?" Capt. Ernie Clayton asked.
The incident illustrates a chronic problem — unnecessary 911 calls that result in costly trips to already crowded ERs, which divert resources from true emergencies. Increasingly, uninsured patients rely on 911 as their only way into the healthcare system.
Now, four decades after public safety agencies began launching fast-response paramedics, counties around the nation are overhauling the 911 system to save money, improve care and reduce ER overcrowding, an especially acute problem in the Los Angeles area. Federal health reform is driving the changes, as hospitals try to reduce readmissions and the healthcare system prepares for more patients.
In San Francisco and San Diego, paramedics have worked with law enforcement to reduce the burden of alcoholics on the 911 system. Paramedics in Maine, Minnesota and Colorado are beginning to treat patients in their homes, doing preventive and follow-up care and helping manage chronic illnesses.
"The emergency room is expensive and not always a pleasant experience for patients," said Maine's community paramedicine coordinator, Kevin McGinnis. "It is much better to treat them where they are."
Although the discussions in Los Angeles County are just beginning, officials said they hoped to make changes to the 911 system in the next few years. This is the perfect time, they said, because there is federal money available for new efforts to deliver better care in a more cost-effective way.
"People are calling 911 not because they are really, really sick or really, really injured. It's because they have no other option," said L.A. County Fire Department Chief Deputy Mike Metro. Fire departments cannot continue to add engines and paramedics to meet the need, he said. "We have to have the ability to make different decisions."
Paramedics in L.A. County responded to 543,715 calls in 2010 — a little more than one call every minute. About one in five patients taken to the ER might have been better served elsewhere, according to Cathy Chidester, director of the county's Emergency Medical Services Agency.
Under current emergency response rules, there is little flexibility. After receiving initial aid, 911 patients have only two choices — either go to the emergency room or stay behind. In L.A. County, more than three-quarters take the ambulance ride, which can cost up to $1,500, even when their complaints are as minor as a cough or a headache. By law, emergency rooms must take patients regardless of insurance status.
Officials are exploring whether ambulances could take certain 911 cases to clinics rather than hospitals. They are also exploring whether paramedics could treat some people at their homes and refer others to primary care doctors or advice lines. And they are considering mobile health vans in some cases.
"This is a skilled workforce," said Mitch Katz, director of the county Department of Health Services. "Their basic choice is to transport a person to the emergency room or not. That is not a very nuanced choice."
Katz said the goal is that all patients "go to the right place and the right time to see the right person."
California officials also are looking for ways to make the process more efficient and expand the role of paramedics, said Howard Backer, director of the California Emergency Medical Services Authority. Paramedic teams — staffed to provide service 24 hours a day — are qualified to do several medical procedures, such as insert breathing tubes and conduct electrocardiograms.
With additional training, Backer said they could help fill the primary care gap in California. "There are EMS personnel everywhere," he said. "It's natural to look at how we can do the most with the resources we have."
Changes won't be easy. California law restricts where ambulances can take 911 patients, and insurance, private and public, reimburses only when they are transported to hospitals. Clinics also would need to have the right hours, staffing and expertise to take the patients.
Then there is the concern about errors in judgment. What happens if a patient is taken to a clinic but really needed to go to an ER? What if a 911 patient is treated at home but really needed to see a doctor?
"It all comes down to liability," said Patrick Hanrahan, an L.A. County firefighter-paramedic. "We don't want to be left on the hook."
Hospital personnel already talk with paramedics in the field, so under a new system, nurses and doctors could help quickly determine the best place for a 911 patient to be treated, said Jim Lott, executive vice president of the Hospital Assn. of Southern California.
"This is long overdue," Lott said. "The communication is there, the technology is there, the expertise is there. There is no reason why this kind of triaging can't be done effectively."
Another problem is that paramedics and ambulances often get stuck with their patients waiting for ER beds to open; creating new protocols could make the process work more smoothly. "If you have ambulances waiting at the emergency room … the people who need the care are not getting it," said Brian Bledsoe, who teaches emergency medicine in Nevada and has written several EMS textbooks.
At Station 41 in Willowbrook, paramedics said they have responded — with lights and sirens — to babies who wouldn't stop crying, people who couldn't sleep and alcoholics who drank too much. "In their eyes it's an emergency," Clayton said. "We know better. But once the call is made, we have to care for them."
On the day Marks called from the urgent-care center, paramedics from a nearby station headed to a Watts motel for a call about a man with a gunshot wound. But the victim, Terrance Montgomery, said he was shot and had been treated nine days earlier. The motel owner said she called 911 because Montgomery owed her money and she wanted him off the property.
As he was loaded into the ambulance, Montgomery, who is uninsured, said he hadn't seen a doctor since leaving the hospital the previous week. "This is going to be my follow-up," he said.
Later in the afternoon, paramedics went to the home of 90-year-old Nathan Shands, who had been vomiting for a few days. His granddaughter said she couldn't get him into the car, so she called 911 to take him to the hospital. She hadn't expected so many people to show up.
"She just wanted transport to the hospital," Clayton said. "She didn't understand 911 response."