Non-Emergency Medical Service: What Happens When South L.A. Calls 911
Paramedics examine him and determine that he’s having an anxiety attack—no reason for an ambulance ride. They talk to him, calm him down and educate him about what was happening. After a few minutes the attack ends. The man feels better, understands what was happening to him and thanks the paramedics. He is no longer in any danger, but still wants an ambulance ride.
Minutes later, he’s waiting at St. Francis Medical Center even though he does not need to be there. Once there, he ties up both E.R. resources and the ambulance and paramedics who took him—waiting for up to three hours until a bed opens up.
“This happens all the time,” said Chi Kredell, a firefighter-paramedic who works at Station 65. “A lot of the calls we get here are for people who don’t need to go to the hospital, but we transport them anyway.”
It’s department policy to offer transportation to anyone who has a medical issue, excluding a “minor extraneous injury,” such as a broken finger or a small cut. This means that if someone has a fever, a headache or an upset stomach, paramedics will deliver the person to an emergency room even when they believe the issue is not truly a medical emergency.
In many cases people who live in low-to-middle-income neighborhoods like those served by Martin Luther King Jr. Community Hospital choose to take ambulance rides even when deemed unnecessary, all with the public picking up the tab.
This is the reality of healthcare in Los Angeles’ most impoverished neighborhoods: emergency rooms are filled with people who would be better served at health clinics or doctors' offices, but are either unaware of this fact or unable to pay for these services. Each call uses resources that take away from those who most need it—precious resources including everything from ambulances and paramedics, to emergency room beds and doctors.
Gary Izquierdo, another Firefighter-Paramedic, has been working out of Station 65 since 2001. He and Kredell work in what could be called the most challenging environment for paramedics, providing emergency medical service to Los Angeles’ poorest neighborhood.
Even for professionals, it can be overwhelming.
“This battalion alone runs one sixth of the department’s calls.” Izquierdo said. “The six stations in Battalion 13, of the city’s 114 total stations, cover about one sixth of the calls that the fire department receives as a whole.”
Izquierdo believes that people in poorer neighborhoods are often less aware of what constitutes a life-threatening emergency; they end up calling 911 because they don’t know the difference between heartburn and a heart attack.
“You go to a place like Malibu, they have fewer calls, because people don’t call if they have the flu, or a fever, a cough, are vomiting, or have diarrhea. Those are things that we get called for all day long. I’d say that 85 percent of the patients out there, don’t need a paramedic,” said Izquierdo. “That’s a rough guess, but for most of these people, we act as primary care.”
He then described a typical call:
“I show up because he’s been throwing up. I ask ‘How long have you been throwing up for?’
The guy responds, ‘About a day.’
‘Have you taken anything or tried calling a doctor?'
‘Have you ever had this before?’
‘Yeah, I got sick a couple of weeks ago.’
‘Would you like me to take you to the hospital?’
‘Okay, let’s go.'”
When each call goes like this, it overwhelms emergency services, and consequently challenges their abillity to support the volume of calls.
Any mention with “Watts” and “Paramedics” in the same sentence likely conjures up images of gunshots, stabbings and overdoses. Although those sorts of emergencies do occur, it’s critical to remember that the neighborhood is not the warzone outsiders often portray it as.
The reality is that Watts is a poor neighborhood, and its residents, by and large, lack access to health insurance, education and the medical resources that people in more affluent communities often take for granted. Steps are, however, being taken to increase access to healthcare throughout Southeast Los Angeles County. A new hospital, The Martin Luther King Jr. Community Hospital in Willowbrook will be opening in the 2015, providing care to residents of Compton, Watts, Lynwood, Willowbrook and Inglewood.
This hospital, while smaller than other local facilities like St. Francis Medical Center in Lynwood, will help relieve pressure on other nearby facilities, by adding 131 acute-care beds along with a 21-bed emergency department. (For context, St. Francis Medical Center has a 46-bed emergency department.) But for people who work in the area, the issue is far more complex than just physical resources.
“In this area, you could throw as many hospitals as you like, and it’s not going to make a difference," said Izquierdo. "Unless you had an ER that had 200 or 300 beds, it’s not going to matter.”
Izquierdo understands that this problem is one of basic health education, a problem he tries to address when on calls. He cited an example of a mother who called 911 because her toddler had a fever. Rather than immediately taking them to the hospital, he first asked whether she had given the child any Tylenol, Ibuprofen or even a cool towel under the arms. Then he explained to her what the steps she should take to help her child feel better.
“But at the end of the day I asked her if she wants to go to the hospital, and she said yes."
“It’s a lot of young families who weren’t taught by their parents what to do, and think that going to the hospital is going to fix someone who has a cold," Kredell said.
Kredell added that there are other factors too, like mere transportation issues. When he arrives, he’ll sometimes ask the callers if they have a car; often they’ll answer no.
“I know right way that they have stomach pains and want to go to the hospital and can’t get anywhere,” Kredell said. “At that point I’ve just got to shut my mouth, no more education, and just get this person to the hospital so we can help the next person. Sometimes I just have to write off teaching. And it sucks.”
Overall, Station 65’s paramedics believe that people are not necessarily abusing the system, but rather the people calling 911 genuinely believe that there is an emergency occurring and that an EMS response is the only way to mitigate it.
Elizabeth Burner, Associate Professor of Clinical Emergency Medicine at L.A. County/USC Medical Center, agrees.
“Everyone who comes to the emergency department is having some kind of crisis. I may judge their crisis to be not so severe, but there was a reason they came to the emergency department,” Burner said.
When ambulances are transporting patients with fevers instead of strokes, however, these varying states of crisis weaken the entire system. These issues are further compounded by the socioeconomic makeup and healthcare history of south Los Angeles. According to the 2013 Los Angeles Health Atlas, 39 percent of the residents in Southeast Los Angeles, including Watts, are reported as having “fair or poor health,” contrast just 7 percent in West Los Angeles.
“Most of these people are husband and wife working two or three jobs and barely making it," said Dr. Lee Weiss, Medical Director of Emergency Services at Emergent Medical Services. "They leave for work at 4 AM and when they come home at 7 PM or 8 PM, they’re not going to a clinic and pay; they’re going to go wherever they can go the fastest, and they use ambulances to get there."
Weiss's company staffs emergency rooms at 23 facilities across Southern California, including Inglewood Centinela Hospital, Hubert Humphrey Comprehensive Health Center and the Martin Luther King Jr. Multi-Service Ambulatory Center
For L.A.’s poorest, getting healthcare becomes less about how to receive proper care, and more about where care can be received the most quickly and cheaply.
Becuase it’s federal law for emergency departments to not require upfront payment, "people chose to go to them instead of urgent care clinics, because most of the urgent care clinics are private entities,” said Weiss. “There’s not a test there that isn’t going to cost anything. It’s a private entity; customer beware.”
Viewed in context of a deficit of time, transportation and money, it becomes clearly easier for a person to hitch a MediCal-sponsored ambulance ride to the mergency room than go to a health clinic where they have to pay and visit during certain business hours.
"The number of people using EMS as a taxi is, not only way to high, it’s alarming," said Weiss who sees the effects of this first hand as he works in Emergency Departments at various facilities around Los Angeles each day. "We’re using precious resources for a process that isn’t valid.”
“The problem is, for the county and the city, how do you say you should go to the ER and you shouldn’t go to the ER," Weiss said. "Especially in this litigious environment that we exist in."
Litigation is a legitimate fear for public agencies. Already they are running at the constraints of their budget, and litigation is a tremendously easy way to hemorrhage money, especially in the field of medicine. The worry, paired with a lack of healthcare education and endemic poverty combine into the situation we see occurring now; ambulances and emergency rooms filled with people who would be better treated in a health clinic, but with nobody able to differentiate how or where these people shoudl be treated on the fly.
“All patients shall be offered transport by Department ambulance, with the exclusion of minor extremity trauma where no circulatory, motor, or neurological compromise exists," reads the LAFD policy.
A similar story plays out for L.A. County, where patients are not offered transportation, but the answer is never no if asked.
“The real issue is how do we match the right patient, to the right provider, at the right time,” said Weiss. “And that’s one of the things we don’t do very well.”
Considering the tremendous challenges associated with matching all three parameters for normal care, it’s no wonder our emergency care providers choose to to transport everyone instead. They eliminate the risk of a big mistake, but it's still woefully wasteful, and fails to teach people the differences between a heart-attack and heartburn.
Contact Staff Reporter Matthew Tinoco here.