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Ambulance system ‘inadequate’

Medics say long trips to ERs are harming patients

(Published December 16, 2002)

By JOHN DeVAULT

Staff Writer

Arriving at an elder care facility on Southern Avenue SE, D.C. paramedic Kenneth Hatch found an old man in serious trouble. The man was unconscious, he had signs of internal bleeding and his blood pressure hung just above zero.

Time to move fast – and, luckily, Greater Southeast Community Hospital stood right next door. Hatch punched in a call to the hospital from his ambulance – and got a shock.

"They said no, we’re full, we’re closed down," he recalled. "I argued, ‘I’m right next door – I’m across the parking lot.’

"I didn’t need the ambulance," Hatch said last week. "I could have wheeled him across in his bed."

But Greater Southeast stood firm.

So Hatch hit his siren and headed for the closest available emergency room: George Washington University Hospital in Northwest Washington.

Even with rush hour traffic, Hatch said, he made the cross-town run in a fast 15 minutes. But it wasn’t quick enough: His patient was pronounced dead on arrival at GW Hospital.

"Fifteen minutes – that’s a long time when you’re dealing with a critically injured patient," Hatch said.

"It makes me angry," he added. "I’m not in this for the glory or the money. It’s because I care about people. The people on this side of town [east of the Anacostia River] are getting a really bad deal."

Since D.C. General Hospital’s trauma center was shut down last year, as part of the city’s plan to set up a privatized health care network with Greater Southeast as its hub, the east side of the District has been without a nearby hospital that’s adequately equipped to deal with the most serious medical emergencies.

Critics say Mayor Anthony A. Williams failed to ensure that financially shaky Greater Southeast would step in to raise its own emergency facilities to critical-care level, as promised when the District’s only public hospital was closed.

But, local hospital officials say, the emergency care crunch is not confined to the city’s east end. Faced with answering the emergency needs of residents from all eight wards of the city, hospital emergency rooms in Northeast and Northwest Washington are now strained to the breaking point – affecting every D.C. resident.

"This is a citywide crisis," the city’s Emergency Medical Services chief, Stephen Reid, said last week.

According to EMS workers, the wait in an ambulance for ill or injured, non-critical patients to see a doctor can be as long as one to two hours.

"This is affecting areas all the way over to Sibley," said Reid, referring to the hospital in upper Northwest.

Reid said he was not aware, however, that the situation has resulted in any deaths or serious health complications.

After last week’s city-sponsored health care summit held in the wake of the bankruptcy of Greater Southeast and its owner, Doctors Community Healthcare Corp., a spokesman for Mayor Williams acknowledged that the city’s emergency care system has serious problems.

"The emergency response system in general is inadequate," mayoral spokesman Tony Bullock said. "The question is, ‘Are they overwhelmed?’ I don’t really know the answer – but it’s the kind of question the mayor’s health care forum is designed to take up."

But some hospital officials said last week that they could answer Bullock’s question before the summit. Though they say they want to work with the city to ease the crisis, their emergency rooms are overwhelmed – and they say the Williams administration bears much of the responsibility.

"Every emergency room in town is getting hit," said Dr. William James Howard, medical director at Washington Hospital Center. "All you have to do is look at how often they go on diversion."

The D.C. Hospital Association last week released diversion rates for hospitals across the region – that is, how many hours per month hospitals have been forced to temporarily close their emergency rooms to ambulance arrivals due to overcrowding.

The data showed that in the two years since the city closed D.C. General, diversion rates have gone up at every hospital in Washington, with several hospitals’ numbers rising sharply.

For example, Howard University Hospital closed its doors to ambulances during 2000 – when D.C. General was still open – for only 10 or fewer hours per month. But during 2001 and 2002, that number jumped to between 100 and 200 hours per month – a 1,000 percent to 2,000 percent increase.

George Washington University Hospital also showed sharp increases, and Providence Hospital and Washington Hospital Center showed further increases in their already high diversion rates.

During the first half of this year, three hospitals – Washington Hospital Center, Howard and Greater Southeast – were each closed for 1,000 hours or more, translating to an average of four hours of closure every day.

"That’s a significant jump," said Joan Lewis, senior vice president of the hospital association. "Those numbers actually scare people."

The city’s protocol calls for only one hospital to go on diversion at a time, but EMS workers say that recently, that rule has frequently been broken.

Veteran paramedic Edward Morgan said that on Dec. 9, after stabilizing a recent open-heart surgery patient suffering from severe breathing difficulties, he was told that Greater Southeast and Howard were both on diversion – and Washington Hospital Center had run out of beds.

So he headed to the last available trauma center in the city, at GW Hospital – only to have his patient go into respiratory arrest just as the ambulance arrived at the hospital. Doctors revived the woman, he said, but he didn’t know the outcome of her case. "Her situation didn’t look good," he said.

"We noticed increases [in emergency room patients] two years ago, as soon as people started talking about closing D.C. General," said Washington Hospital Center’s Dr. Howard. "Now, we’re having significant problems with patients waiting for beds."

He also said volume at the hospital’s emergency room has almost doubled since D.C. General closed in June 2001.

EMS workers note that problems at one hospital spill over to the city’s other hospitals.

"The status in Southeast can load up Providence so fast, they may have to shut down," Morgan said. "And that’s happened numerous times. You may live just around the corner [from a hospital], but it will affect you."

Said Hatch, "The other night there were eight ambulances at Howard, and six were from Southeast."

At midday on Dec. 12, a reporter for The Common Denominator counted 11 of the city’s 29 ambulances among 13 ambulances crowded around the emergency room entrances of two hospitals – Providence and Washington Hospital Center.

Critically injured patients are triaged to the front of the line. But everybody else, whether an arrival by car, foot or ambulance – regardless of their city quadrant of residence – must join the queue, officials said.

"An ambulance doesn’t bump you to the front of the line," said Chief Reid. "It’s like the deli counter at Safeway. You get a number and you wait."

Reid asserted that "there are no racial boundaries to this crisis."

"It doesn’t matter if you’re black, white or Asian, Ward 3 or Ward 8. It’s just like with a fire," he said. "The fire doesn’t care who you are."

The current situation means that, at any given time, a third to a half of the city’s ambulance fleet may be waiting at local hospitals – especially since paramedics are required to stay with their patients until a doctor can provide treatment.

"A month or so ago, a unit sat at Greater Southeast for six hours, because there was no one to receive that patient," Chief Reid said.

Currently, ambulances are being pulled out of their service areas for hours at a time – sometimes leaving whole areas of the city without a nearby ambulance.

"At any given time, there may be no ambulances in Southeast at all," said paramedic Brenda Durrett. "They’re all on runs to Northwest."

And the same problem occurs in Northwest, she said – because ambulances serving Adams Morgan or Cleveland Park, for example, may be stuck waiting at Providence or Howard. Or, they may be called to Northeast or Southwest to cover for an ambulance unit that’s stuck in line at a hospital.

City and hospital officials note that some national trends contribute to the crunch: Emergency room visits are rising across the United States, and many cities are coping with a shortage of nurses.

But critics of the District’s current situation say most of its causes are local.

Chief Reid said a promise by the city to hire 72 new EMS personnel to cope with D.C. General’s closing was only partially delivered on, undercutting his department’s ability to add five more staffed ambulances to the 29 now on the streets. Reid said the department needs 43 ambulances to meet current needs.

"Our supply just isn’t meeting the demand," he said.

Hospital officials said the biggest factor in emergency room overcrowding is the Williams administration’s fumbled plan to bring in Greater Southeast as D.C. General’s replacement. Central to that plan was the assurance from the city that Greater Southeast would upgrade its emergency facilities to include a top-level critical care center, replacing D.C. General’s.

Sister Carol Keehan, chief executive officer at Providence Hospital, said that upgrade never happened.

"They never got it up and running," she said, "and what they got to has crumbled in the last couple of months."

Washington Hospital Center’s Dr. Howard noted the "significant commitment" necessary to create a trauma center. "You need to hire trauma surgeons. You need to hire neurosurgeons and orthopedic surgeons and ophthalmic and eye/ear/nose/throat specialists to be standing by. And that’s just the beginning," he said.

"No, they did not establish a trauma center at Greater Southeast," he asserted.

Mayoral spokesman Bullock acknowledged that despite the city giving Greater Southeast Community Hospital at least $37.2 million in D.C. tax dollars for the first year of the contract, Greater Southeast never spent the funds necessary to allow it to take over D.C. General’s emergency functions.

He blamed that failure on faulty language in the city’s contract with the company. The contract was imposed on the city by the now-dormant, congressionally created, financial control board – with the mayor’s full support – over the unanimous objection of the D.C. City Council.

"The language is sufficiently unclear on that … that they may not be contractually obligated to build out their ER to the level we’d like to see – and we need to address that immediately," Bullock said last week.

City officials said last week that Greater Southeast recently regained the capacity to accept critical care patients for at least temporary stabilization, before moving them to better-equipped hospitals. But some EMS workers said that, effectively, that isn’t true, since – as has been the case ever since D.C. General closed, they said – the hospital is often on diversion and not accepting ambulances.

"They’re still closed more than they’re open," Morgan said.

Statistics that support the view that Greater Southeast is recently serving fewer patients was released last week by the D.C. Fire and Emergency Medical Services Department. The data – comparing the third week in November 2000, 2001 and 2002 – seem to show that over the past three years, Greater Southeast has served an ever-declining proportion of D.C. hospital patients who live in its part of the city. In November 2000, Greater Southeast served 73 percent of those patients; in November 2001, 52 percent of them; and in November 2002, just 22 percent of them.

The data suggest that other hospitals – primarily Howard, George Washington, Washington Hospital Center and an urgent care center at D.C. General’s campus – are treating the patients that Greater Southeast has lost.

That most of those hospitals are a 15- to 20-minute drive away from Greater Southeast disturbs Morgan, who said he remembers a cross-town trip with an unconscious, 46-year-old seizure victim earlier this year.

"We picked him up less than five minutes from Greater Southeast – but we called ahead, and they said they weren’t taking patients," Morgan said.

So he and his partner headed for the nearest available appropriate care, at Howard University Hospital. Initially, Morgan said, the patient "was doing pretty good."

But, he said, as they traveled through the Third Street tunnel, "he coded" – the patient went into respiratory arrest, and later cardiac arrest. Morgan said he and his partner started cardiopulmonary resuscitation. Then they pulled out of traffic briefly to insert a breathing tube down the patient’s throat. After 20 minutes they reached the hospital – where the man was pronounced dead.

"The ER doctors asked us what happened, why it took us so long," Morgan said.

He said he believes that if either D.C. General or Greater Southeast had been available, the man’s life could have been saved.

"We could definitely have gotten to Greater Southeast in time to save him," he said.

Copyright 2002, The Common Denominator