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L.A.'s Crippled Emergency Care: Not According to the Script

January 29, 1989|Brian D. Johnston | Brian D. Johnston is a Los Angeles physician who specializes in emergency care

How will Los Angeles know when its emergency-services system finally collapses? There is no agreed-upon end-point, or even a definition of collapse. There is no monitoring system in place to detect needless deaths resulting from system failure. Complications and resulting disabilities are much more difficult to identify and monitor--and local government has never adequately funded the mechanisms necessary to tell us how frequently they occur.

Many of us involved in emergency medical services in Los Angeles had thought the system might collapse the same way the trauma system went--hospitals in poorer parts of town would be forced by economic pressure to downgrade their emergency departments to "standby" facilities. When enough departments had withdrawn, a "black hole" without service encompassing the downtown business district would become obvious. People would die because paramedics couldn't get to them in time, or because there would only be a distant hospital to take them to--and it would be overburdened.

What we are seeing instead is a different sequence. Stopgap measures adopted by the state--a renegotiated Medi-Cal per-diem rate--have stabilized some of the more vulnerable downtown hospitals. Their emergency departments remain open while hospitals more peripherally located (Queen of Angels, Centinela) have withdrawn from the system. Meanwhile the publicly operated hospitals, principally County-USC and Martin Luther King Jr., have adopted much more stringent "closure" policies that shift a much larger load of indigent care on the remaining private hospitals.

County-USC now closes when its holding area for admitted patients exceeds certain patient-to-nurse ratios. The heart of the emergency department then stands fully staffed with doctors and nurses, but accepts no new patients. Many hospitals now are not fully staffing their critical-care areas because they can't hire enough nurses or because they refuse to lose more money hiring non-staff nurses from the nursing registries. The emergency departments in these hospitals rapidly fill up with patients who can't be admitted to critical care and therefore must remain in emergency wards.

The scenario of emergency-services collapse is now played out by the paramedics who, as reported recently by The Times, are driving about the city looking for a hospital to care for their patients. A spot check last Wednesday, a relatively quiet time, revealed that no trauma centers in the San Fernando Valley were accepting trauma patients. Fifteen basic emergency departments in Los Angeles were "closed to critical" or "closed to saturation," meaning they could not care for patients requiring critical care or the emergency department had more patients than it could safely handle.

The hospitals "closed to critical" and "closed to saturation" were asking paramedics to divert to other facilities, without knowing where they might be; 12 paramedic ambulances carrying patients were looking for a hospital to accept them. On a weekend night all the trauma centers and 40 emergency departments may be "closed." The "black hole" we feared and predicted has formed, but it has thus far gone unrecognized because it did not evolve as most had expected. Our emergency medical services are, nonetheless, circling the drain. There is no doubt that people are dying needlessly right now in Los Angeles.

What can be done? The problem is fundamentally political. We have the doctors, nurses and hospitals to do the job. We don't have funding for what is clearly a public obligation.

The solution must now take a two-pronged approach. In the short term, financial help must be provided to private and public hospitals so they can continue taking care of the poor. Charity care still costs money. A study done by the Los Angeles County Medical Assn. and the Hospital Council of Southern California in 1987 set the monthly cost at about $6.9 million. Since then the numbers of uninsured have increased dramatically. One analysis in San Francisco put the annual per-physician donation of services to the uninsured at $25,000 to $50,000; a similar study has not been done in Los Angeles but the amount is probably comparable.

More than half of the hospitals in California are running at a loss--the combined total is currently well in excess of $2 billion annually. Some hospitals and physicians have quietly decided they will no longer individually and voluntarily subsidize what should be a public obligation. Short-term funding and assurances of a public commitment to a long-term solution will be required to get them back into the system.

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