Ambulances across Southern California feeling strain of coronavirus surge
Paramedics wait hours to drop off patients.
Ambulances pass one hospital on their way to another.
Some folks, fearing for their health, call 911 for help — only to hear their conditions are not serious enough for emergency transportation.
The consequences of the surging coronavirus, catalyzed by holiday gatherings and pandemic fatigue, become more dire by the day. The pandemic has already sent thousands of Southern California families into mourning — and the death toll keeps climbing. Hospitals, facing an onslaught of cases, are being crippled.
And now, even ambulance services are being strained.
Paramedics throughout Southern California have faced increasingly long wait times to offload patients at hospitals. That, in turn, has created logistical complications when ambulances are needed elsewhere. Responses to 911 calls, at times, have been delayed. In some cases, ambulances won’t come.
Counties and cities have responded to the crisis in different ways, such as by diverting ambulances to hospitals that aren’t as busy as others or by pumping in more resources. In Los Angeles County, health officials have reinforced a frightful, albeit already-in-place, strategy for paramedics: If you can’t revive a patient’s pulse on scene, don’t head to a hospital.
“It’s frustrating for EMTs and paramedics,” said Jeff Lucia, spokesman for Care Ambulance Service, which operates in Los Angeles and Orange counties, “who are in a career to help people and be there when people need help the most.”
Yet, if conditions worsen, which officials predict will happen at least through January, health officials could further ration emergency response services.
Doing so, health officials warn, could lead to even more tragedy.
And not just from the coronavirus.
Long wait times
That’s how long one Torrance ambulance waited to offload a patient at Inglewood’s Centinela Hospital Medical Center on Monday, Jan. 4.
Paramedics have their own slang to describe waiting for their patients to be admitted to hospitals: Wall time.
Ten hours is a long time to lean on a wall with nothing to do. But the paramedics with McCormick Ambulance, Torrance’s private operator, are becoming well-practiced.
“They are notorious,” said Torrance Assistant Fire Chief Alec Miller, “for 10-hour wall times right now.”
Yet, Centinela is not alone.
Overcrowding has created long wait times at hospitals throughout the region. In L.A. County, Lucia said, ambulances were often idling eight-to-12 hours to admit patients.
Paramedics in Orange County, San Bernardino and Riverside counties have also, at times, had to linger for hours before admitting patients.
And boredom is not the only side effect.
“We had a couple of instances where McCormick was unable to provide an ambulance for our calls,” Miller said. “If they have a unit out of service, that affects the whole system.”
Steve Tracy, a spokesman for the San Bernardino County Fire Department, was more direct:
If an ambulance is tied up, he said in an interview late last year, “it can’t respond to other emergencies.”
And the surge has gotten so bad, particularly in Los Angeles County, that keeping up with calls has become difficult.
“No matter how many ambulances we put on,” Lucia said, “they are getting tied up at hospitals and not clearing for the next calls.”
Those delays, however, are not implacable. There are workarounds.
But it requires some creativity.
One such tactic is diversion.
That strategy is a way of balancing resources by having an ambulance go to one hospital instead of another, even if it requires driving miles farther than normal.
On any given day over the past week, 70% to 90% of L.A. County hospitals were on diversion because they couldn’t accept patients who required advanced life support. A handful of hospitals also declared “internal disasters,” turning away ambulances of all kinds to reduce the pressures on staff.
And one day early this week, 22 of Orange County’s 25 emergency receiving centers, according to the OC Health Care Agency, rerouted paramedic crews because of slow turnaround inside ERs.
But if every hospital needs to divert newcomers, some health officials say, the strategy becomes feckless.
That’s why Orange County’s health agency this week banned hospitals from diverting ambulances — for the second time in two months. The county’s director of Emergency Medical Services, Dr. Carl Schultz, also temporarily halted the practice in December.
“If nothing was done, ambulances would soon run out of hospitals that could take their patients,” Schultz said in a mid-December statement explaining his reasoning. “While this (ban) will place some additional stress on hospitals, it will spread this over the entire county.”
Not all hospitals, though, have experienced continuous hours-long delays.
Torrance’s two hospitals, for example, both had normal wait times early Tuesday, averaging about 30 minutes, said Miller, that city’s assistant fire chief.
But Providence Little Company of Mary Medical Center and Torrance Memorial Medical Center have both revived a strategy initially used at the start of the pandemic: They have triage units set up outside emergency rooms to treat patients, if necessary.
In all, L.A. County officials this week were erecting triage tents outside seven hospitals to alleviate long lines.
California, meanwhile, has started using its Fire and Rescue Mutual Aid system — often activated to respond to wildfires — to help the state’s response to COVID-19.
Firefighter paramedics and EMTs, for example, were being deployed to emergency rooms for 14-day operational periods — giving much-needed backup to exhausted hospital workers. UC Irvine Medical Center and Barstow Community Hospital were among the facilities to receive the extra bodies.
Some local agencies have also taken it upon themselves to increase resources.
Riverside County has asked American Medical Response, with which it contracts for emergency medical transportation, to provide more ambulances, said Shane Reichardt, a spokesman with the county’s Emergency Management Department.
Long Beach, in L.A. County, added four ambulances to its fleet around Christmas, Fire Department spokesman Capt. Jack Crabtree said.
And two of those ambulances exclusively work with patients exhibiting coronavirus-related symptoms.
Long Beach has also benefited from a more nimble, computerized form of diversion.
St. Mary Medical Center, operated by Dignity Health, has a computerized network connected to other hospitals in the Long Beach area that tracks available resources among its counterparts, Crabtree said.
An official there will tell paramedics which hospital to send each patient.
The result, Crabtree said, is that while ambulance crews are busy, they have had no trouble getting patients into hospitals.
“Even though it appears the people are busy,” Crabtree said, “when the public still calls 911 and needs help, we want them to know we’re there responding.”
Not responding to certain calls
That, in general, remains true across the region.
Even in L.A. County – the pandemic’s current national epicenter.
Despite emergency call volumes there being up across the board – mainly because of coronavirus-related requests – response times to the scene have not been affected, said Dr. Clayton Kazan, medical director for L.A. County Fire Department.
But response times typically refer to how long it takes an ambulance to get from one location to wherever the 911 call came from – and not the logistical task of figuring out which paramedic crew to send.
So health and public safety officials have gone beyond diversion and triage tents to get around long hospital wait times – by rationing emergency services.
One common way, officials say, is by directing 911 callers with less serious issues elsewhere in the health system, such as urgent care, a clinic or their medical providers.
Some people, for example, call 911 because they want to be tested for the coronavirus or are out of medication, said Eric Sherwin, a spokesman for the San Bernardino County Fire Department.
San Bernardino County is currently referring 25 to 50 people a day to somewhere else rather than calling an ambulance to take them to the ER, Sherwin said.
The request for coronavirus testing, Sherwin said, is an example of where “this policy is really helping us out.”
San Bernardino County, though, will still send paramedics to less-critical calls – but without their wheels.
If someone calls 911 because they, for example, have symptoms consistent with COVID-19 or the flu but do not appear to need hospitalization, the county will send a paramedic without an ambulance.
That strategy, adopted in November, has also succeeded in relieving the pressure off paramedics who had previously spent upwards of half a day leaning on a hospital wall, officials said.
The result, Sherwin said, is paramedics have been able to get people experiencing a true emergency to the hospital as quickly as possible.
.L.A. County, meanwhile, has gone further.
Health officials there, in one of several recently issued directives, have told paramedics not to transfer residents of skilled-nursing facilities or those under hospice care to hospitals if they decline life-saving treatments, such as ventilators.
Another directive told paramedics not to provide supplemental oxygen to patients unless their saturation levels dip below 90%, rather than the traditional 93%. Normal oxygen saturation levels are around 95%.
A third instructed ambulances to not transport patients to the hospital if they have virtually no chance of survival.
That directive, though, is not as drastic as it appears on the surface. Resuscitation policies, in fact, remain the same.
“There is no change to an effort to regain circulation, which is a minimum of 20 minutes, (or) requirements to provide medication in the field and transport individuals,” Dr. Christina Ghaly, the county’s Health Services director, said Tuesday. “The only difference is for someone who already died to not have the emergency department involved in managing the deceased’s body.”
None of the new directives, officials say, deviates enormously from typical standards of care.
But they could be precursors to even more draconian rationing efforts if the coronavirus doesn’t abate.
A dire prospect
And, officials say, long ambulance wait times and rationing care could, combined, be disastrous for folks with non-coronavirus medical emergencies – such as those who have heart attacks or get in serious car crashes.
Take heart attack and stroke survivors. They will still get transported to a hospital and treated, officials said. But it might take a bit longer to receive care.
And with those conditions, getting care quickly is crucial for recovery.
There are others, health officials have said, who may have treatable conditions but can’t get adequate care. So those conditions will become more severe – and potentially fatal
“The high census of COVID-19 patients in our hospitals is distressing,” Barbara Ferrer, L.A. County’s Public Health director, said Monday. “Not only for those with COVID-19 but for all others in the county who need acute care. Those who have a stroke or heart attack or experience a traumatic injury are finding it more difficult to access care than they did a month ago.”
Yet, even though medical workers and hospital leaders are already making tough choices about health care, the severe rationing hasn’t yet begun.
No hospital, in fact, has declared official crisis care standards – which would put them in a triage situation akin to a natural disaster.
But some fear the region could soon get there.
“Doctors, nurses and respiratory therapists and others are bracing,” said Carmela Coyle, president and CEO of the California Hospital Association, “for what will be in the next few weeks, a very difficult environment when it comes to caring for our neighbors, our family members and our friends.”
The only hope, health officials say, is to stanch the surge. Otherwise, countless more will die from the coronavirus.
Including those who never contract it.