Swamped : Paramedics Face Their Own Crisis

The man had been lying on the sidewalk for nearly 20 minutes, the wink of emergency lights illuminating the blood flowing out across his shirt. Paramedics waited down the street until police could round up the youths who had shot him.

It was 2:30 a.m., more than 20 hours after the paramedics first pulled out of their South-Central Los Angeles station. There had been another shooting that day. A cutting. The usual traffic accidents, drug overdoses, heart troubles.

And the man on the sidewalk, a bullet in his side, was very, very quiet.

So it was that a routine medical assistance call erupted into a whispered argument, an exchange that purportedly was about diagnosis and treatment but was really about whether the man would live or die.

Dead or Alive?

“My partner said, ‘Let’s pronounce him (dead),’ ” said one of the paramedics, a 10-year veteran of the Los Angeles Fire Department. “He did have a heart rhythm. It wasn’t the best, but there was a heart rhythm there.”

According to regulations, they had no choice but to begin cardiopulmonary resuscitation, outfit the man in anti-shock trousers, inject him with medication, attempt to electrically charge his heart, take him to the hospital and--an hour, two hours later--finally return to the station for perhaps the only sleep they would have that night.

“If we pronounce him dead, all we have to do is give the police the paper work and go back to bed,” said the paramedic, who feared retribution if he identified himself.

“I basically told him (the partner), I, in all good conscience, couldn’t do that. So he stomped off and left me. He did it because he was tired . . . and I understood. I have never really known tired until I got that job.”

Chronic staff shortages and an overwhelming increase in medical aid calls on the 911 emergency line have brought the Los Angeles Fire Department’s widely respected emergency medical services program to the most difficult point in its 12-year history.

The city’s 354 paramedics struggled under a call load that topped 200,000 last year, a volume that has most squads working 70 hours a week or more and that many paramedics say has jeopardized their ability to care for the patients whose lives depend on them.

In the busiest areas of the city--South-Central and downtown--paramedics are routinely forced to accept overtime shifts that can keep them on the job for as long as 48 hours, often with little or no sleep. Paramedics at less busy stations, who can work longer at a stretch because they have rest periods, are clocking up to 96 consecutive hours on the job.

On any given day, an estimated 25% of all paramedics at work on the city’s 49 ambulances are there on an overtime basis, department records show.

“In 1975, I’d say this city probably had the finest emergency medical system in the country, in the world. But I don’t think you can say that now,” said Dr. Douglas Arterberry, recent chairman of the Fire Department’s medical advisory committee and a leader in bringing paramedic service to Los Angeles in the 1970s.

“The city fire system is on the thin edge of a major meltdown,” said an emergency room physician who has worked closely with the department for more than a decade. “They’re all stretched out.”

While there is no clear evidence that fatigue on the paramedic force has led to patient deaths, many paramedics say it is only a matter of time.

“Given that we make life-and-death decisions each and every day, it seems medically unsound to us to have paramedics being forced to work for 36-, 48- and 72-hour periods,” said Fred Hurtado, a paramedic supervisor and president of United Paramedics of Los Angeles.

‘People at Risk’

“I have been told by people . . . ‘Well, gee, we don’t get very many complaints about emergency medical service,’ ” Hurtado said. “The problem is, the (public) doesn’t know the risks that it’s being subjected to. . . . The number of people at risk is huge.”

Fire Department officials say they have purchased new ambulances and hired new trainees that they hope will ease the staffing shortage by next fall or sooner. They say the public can still expect quality emergency care from a system that has been one of the models for the rest of the country.

“I have a paramedic system which is the largest Fire Department-operated system in the country, and we believe it is the finest, with the best-trained people delivering that system,” Fire Chief Donald O. Manning said in a recent interview.

“I can tell you without any reservation that over the last three or four years, from a budgetary standpoint, the paramedics have received better consideration than any other department in the city.”

Concern over the quality of Los Angeles’ emergency care has emerged in recent months as paramedics, working without a contract since June of 1985, have clashed with the Fire Department over issues like wage parity with firefighters, better training for dispatchers, more help on emergency responses from fire engine companies and an end to forced overtime.

Debate Picks Up

The debate has focused attention on the evolution of pre-hospital care since the late 1960s, when paramedics first became available to provide trained medical help in the field to victims of accidents, heart attacks and other illnesses who without their help might die before ever reaching a hospital.

While Los Angeles was the first major city in the country to adopt a comprehensive system of pre-hospital care, other cities have since adopted far more sophisticated dispatching and response techniques.

And as poorer areas of the city begin to rely increasingly on the paramedic system as the only medical care they can afford, rescue squads have faced a workload increase that has more than half the paramedic crews in the city exceeding the limit recommended by most experts.

“We drew the line and said 15 runs (a day) was excessive and anything over 20 was outrageous,” said Ann Reiss Lane, chairwoman of the city Fire Commission’s emergency medical services committee for the last nine years.

“We have maybe a third of the stations where the workload is indeed excessive and something must be done, and we have continuously directed the department to resolve this problem,” Lane said. “But I don’t think you can blame management for the impasse, because every suggestion that’s been offered to the paramedics they’ve refused, or refused to even discuss.”

Budget Realities

Department officials say they are struggling to balance paramedics’ demands for more resources against a city budget already stretched so thin that some Los Angeles residents are being asked to pay extra taxes for services like police protection.

Moreover, they say, the workload problem could be quickly resolved if paramedics were willing to give up their prized 24-hour platoon shifts, which afford the luxury of working only 10 days a month.

The department has even proposed staffing extra part-time ambulances in the busiest areas of the city during the 4 p.m.-to-midnight period, when calls are heaviest, launching its first three part-time ambulances on a trial basis this month. But the union has vigorously opposed those options, Manning said.

In the meantime, paramedics in the busiest areas of the city say they are working under conditions that often leave them too fatigued to adequately care for their patients.

“There’s a lot of times . . . I’m so tired, you go on a call and you can just barely stay awake,” said Pat Devine, who works out of a fire station near MacArthur Park.

“When you take a paramedic and you start running him day in, day out, every day he goes to work he’s up all night, when you hit a certain amount of calls, something happens to your body, and something happens to your mind, and what you start thinking about is getting sleep or going home, and it starts reflecting from yourself toward your patients.

Shrinking Labor Pool

“I’ve been to the point literally where my partner had to keep saying, ‘Pat, wake up,’ while I’m driving down the road,” he said.

High attrition in recent months has caused the department’s staffing “pool”--40 extra positions used to fill normal vacancies--to slip to just three, forcing paramedics already working 56-hour weeks to be called on for still more overtime.

Many paramedics, particularly those at low-activity stations, are eager for the extra money and regularly volunteer for overtime duty.

Working the same 24-hour “platoon” schedule as firefighters, which allows them four days off after working a block of three 24-hours-on, 24-hours-off shifts, paramedics in less busy stations are normally able to sleep through most of the night.

But it is a dramatically different story for paramedics in the busier stations of South-Central and downtown Los Angeles, who often average more than 20 calls a shift with little or no time for sleep or meals.

There, it is often difficult to fill vacancies with overtime volunteers from quieter stations and paramedics must often be called in for mandatory overtime shifts, forcing paramedics already tired after a full day and night at work to work an additional 24 hours.

Some paramedics are working as long as 96 hours at a stretch under department regulations that allow them to work extended shifts on a voluntary basis.

“Sometimes it’ll turn into 72 hours straight, and at the station I’m at, maybe in the first 24 hours you get two hours of sleep, maximum,” said Andrea Anderson, a paramedic at Fire Station 46 near Vernon Avenue and Hoover Street in South-Central Los Angeles, one of the busiest in the city.

“Sometimes you just keep going the whole time,” she said. “I worked a 96-hour shift a month or two ago. . . . It wasn’t until the last night that I finally got two or three hours sleep.”

“There are some days down there that I’d work four or five days in a row,” recalled David W. Miller, who recently retired from one of the city’s busiest downtown stations.

“I did make mistakes. You just can’t be alert, working 23 hours a day, three days in a row,” Miller said.

Need for Sleep

Said one paramedic, who asked not to be identified: “You get in the front seat of the ambulance, it’s 4 in the morning and maybe your 22nd hour on duty, and you get called out on a heart attack and you say to yourself, ‘Oh, God, if there’s a God, let this son of a bitch be dead so I can get back to bed.’ ”

Maggie Quail Swan, a mobile intensive care nurse who gives medical instructions to paramedics over the radio from the base station at Cedars-Sinai Medical Center, said the fatigue level among Los Angeles inner-city paramedics has become obvious.

“We used to call them L.A. city’s ‘finest.’ Now we call them ‘the wet-heads’ because they’re forever standing over a sink with their heads under the faucet, trying to wake up. Unfortunately, we have to concern ourselves with the quality of care that they’re able to deliver when they’re that exhausted,” said Swan, who said she was not speaking on behalf of the hospital.

“When I hear that same voice (over the radio) two days in a row, I tend to listen more carefully to their assessment, and I tend to anticipate that I may have to ask more questions,” she said. “I have said a couple of times during a run, ‘Rescue whatever, this is a wake-up call,’ because you hear the guys and they’re sluggish, and they’re trying to piece the information together. . . .”

Los Angeles Load

Of 17 Southland cities with paramedic service surveyed in January by the United Paramedics of Los Angeles, only Oceanside, with just a few ambulances, had a higher call load than the average 3,913 calls each Los Angeles unit ran last year.

Of 12 major cities across the country surveyed by the union, including Boston, Chicago, New York, Washington, San Francisco and San Diego, Los Angeles paramedics handled more calls than any city except Baltimore.

The director of pre-hospital care at UCLA, Dr. Steve Rottman, said most other cities with a high volume of medical-aid calls stagger work shifts so paramedics work only eight to 12 hours at a time.

Los Angeles County Fire Department paramedics also work 24-hour shifts in several high-incidence areas, but a third paramedic is available to relieve squad members when they are exhausted.

Medically Unwise

“I think it’s inadvisable for anyone, especially in providing health care to the acutely ill and injured, to be put in the position of having to do so for protracted periods of time,” Rottman said.

“There are issues of having to be constantly sharp and making crucial decisions at points where fatigue, I think quite naturally, will intervene and interfere.”

The precise effects of fatigue are difficult to measure.

The 11 paramedics who have received disability pensions in the last four years, for example, are no more than the number granted to firefighters or police officers.

But a 1985 study conducted by the paramedics’ union showed that while paramedics at busy stations suffer about the same number of job-related injuries as their colleagues at quieter stations, they took an average of 78% longer to recover.

Department management officials said they are not familiar with the study.

Limits on Overtime

In its contract negotiations, the union is seeking to ban forced overtime for paramedics who have not had at least four hours’ sleep the previous day and to impose a 36-hour limit on forced overtime shifts.

The union is currently handling 14 grievances filed by paramedics who received two-day suspensions for refusing forced overtime--often in cases in which they say they were simply too tired to go on working.

“Fatigue is a problem, and I think it has to be dealt with, and that is precisely why I would like to look at changing the hours of work,” Fire Chief Manning said.

“If there is a legitimate concern in what they (paramedics) are talking about, you wonder why their union won’t meet with me to change their hours of work.”

Union officials concede that they would face heavy opposition from their members--particularly those in outlying stations who are able to sleep during the night--if they gave up platoon schedules to benefit paramedics working in the inner-city stations.

Instead, they say, the department should be finding ways to bring the workload level down to a point that paramedics are afforded enough time to rest--a goal that Manning says may simply not be attainable without spending millions on new ambulances and staff.

Hiring Effort

In the meantime, department officials say they are seeking to increase the department’s staffing pool from 40 to 60, and they have hired 41 new paramedics, who went into training last month. Fifteen of them will be available for work in early May, with the remainder completing training in October.

That, department officials say, should virtually eliminate the forced-overtime problem, though they admit that it will not relieve heavy workloads for paramedics in busy areas of the city.

The city is still at an impasse on salary issues with paramedics, who now earn about $2,800 a month and believe that, because they handle about 80% of the fire department’s calls, they should be earning at least as much as a firefighting engineer, who earns $3,680 a month. Department officials have offered a salary increase, but say the two jobs are not comparable.

“We don’t have a system without needs. But we have done a lot to address those needs,” Manning said. “We need to take and very carefully analyze what is the best way to deliver the system that is best to the citizen and best to the work force at a reasonable cost.

“Obviously, if you want to throw $50 million at it, you’ve got a lot of options, but we’re not going to throw $50 million at it. We’re in extremely tight budget times. The city has really given enormous consideration to the paramedic system, but that doesn’t mean it’s an endless checkbook for that system.”