LOS ANGELES -- It's a health-care nightmare right now in Los Angeles County.
For the last few weeks during the COVID-19 surge, the region's ICUs have had 0% capacity available. When there's no space at hospitals, ambulances have to handle the overflow.
This has resulted in some changes to how the region handles emergencies:
"We're trying to encourage people to not call 911 unless they really need to," Dr. Marc Eckstein explained.
He's the medical director and commander of the LA city Fire Department EMS Bureau. He said over the last few weeks at hard-hit hospitals, there have been lines of ambulances waiting for several hours to transfer patients.
During the week of Christmas, he said one hospital had 19 ambulances all waiting to offload at the same time.
"So you can imagine how many hours that kept our ambulances out of service. That keeps a large area uncovered."
When EMTs and paramedics can't transfer care, they can't respond to the next 911 call - which means there may be delays getting to an incident.
They also can't go to hospitals outside the county. The entire region is similarly impacted right now - so there's nowhere else to go.
"Those ambulances have to offload somewhere. They don't have a choice about offloading," said Dr. Christina Ghaly, director of the Los Angeles County Department of Health Services.
The county memo ordering ambulances not to transport patients who can't be resuscitated in the field is available here.
Starting next week, LAFD paramedics and EMTs will be staging in cots outside of hospitals, so ambulances can get back into service. That still leaves the patient sitting in a parking lot - but this way other patients can get care.
"Even if you're the lowest risk to get seriously ill from COVID, if you need emergency medical services through 911, or leave your emergency department right now, your care may be compromised or significantly delayed," said Dr. Eckstein.
Read the full interview with Dr. Eckstein below. Condensed for length and clarity.
What is the current situation right now in LA County?
Patients are being treated based upon acuity, meaning the triage systems are working as best they can. We're trying to encourage people to not call 911 unless they really need to. So if they just have flu symptoms, which is likely due to COVID, but they're not experiencing severe chest pain, they're not experiencing shortness of breath, they're able to keep down liquids, then the best treatment is to call your doctor or stay home. Not call 911 and not go to emergency department.
One of our biggest challenges right now is getting our ambulances out of the emergency department. When our paramedics and EMTs transport a patient to an emergency department, there's a transfer of care that has to take place. Patients who are unstable or unable to be safely transferred to the waiting room or to a chair, need a bed in the emergency department to be transferred to. And those beds are lacking right now. During peak periods, over the last few weeks, it's gotten to a point where we are waiting for several hours just to offload patients and transfer care. If they're waiting to transfer care, they can't respond to the next 911 call, which means we may have delays getting an ambulance to an incident. We're fortunate in that we have fire companies staffed by firefighter, EMT and paramedics to respond. But in terms of the response time for ambulances, there may be delays if our ambulances are still watching patients at the emergency department and can't get released to be sent back into the system.
I think this next four-to-six week period is going to be critical with our system being taxed. We're now seeing patients who are younger, who are less likely to have the usual risk factors to get severe COVID symptoms, coming in with profound hypoxia where their blood oxygen saturation levels are life-threatening. They have drastic changes to their chest X-rays, they're in severe respiratory failure. Some of the hospitals are actually running out of oxygen. So the system is really being taxed right now. People go into emergency departments without life-threatening problems, are waiting often 12 to 18 hours in the waiting room just to get seen.
What kind of wait times are patients currently experiencing?
So we've had some extreme examples. We had one area hospital during Christmas week that had 19 ambulances all waiting to offload at the same time. So you can imagine how many hours that kept those ambulances out of service, which kept some large areas uncovered. Another extreme example - a wait time of up to eight hours to transfer care. These were for COVID patients who required oxygen, so they couldn't go to the waiting room. And the hospital was literally exceeding their capacity and had no available open beds, nurses or other health-care providers to facilitate taking care of those patients. Having ambulances parked at the emergency departments for hours on end is not sustainable and has the potential to compromise public safety.
Why not take patients to other hospitals in other counties?
The reality is the entire region is severely impacted right now. So there's really nowhere to go. All the surrounding counties are equally impacted. Orange County and Ventura County, they're all experiencing the same surge right now. This is not hyperbole. This is not overstating the situation. We know we're going to be encountering probably the brunt of the surge within the next few weeks. It's not just people who have known or suspected COVID. If you are sick or injured or having a heart attack or get into a traffic accident or have a stroke, your ability to get timely care through the EMS system or the emergency healthcare system may be significantly compromised.
Even if the 911 system is there for you and we're doing everything we can to make sure it is, and we're able to get you evaluated and transported as quickly as possible, there's a pretty high likelihood that because there's no open ICU beds, you may be kept down in the emergency department for hours or days on end, which obviously is suboptimal to being in a critical care setting. So this is not just for COVID patients or so people who think, 'I'm healthy, I'm young, I don't have any risk factors for COVID. This doesn't affect me.' This can affect you when you least expect it. So we all really need to do our part right now to get through this surge.
Are you no longer helping dying patients because of lack of space? Is it to the point where you're deciding the fate of people's lives?
No, thank goodness. We're not at that point. So I want people to rest assured if you are unfortunate enough to have a life-threatening medical emergency or traumatic injury, like a gunshot wound, we will have risk first responders, EMT, and paramedics respond in a timely manner and get you to the right facility. The challenge is the right facility may be at a longer distance than otherwise because the closest facility may be completely closed to ambulance traffic, because they have no more room and the specialists may not be available. Most likely, the ICU beds may not be available, but we are not at the point where we're not responding, or treating life-threatening calls, but we're having to drive further to find our open hospital.
We are practicing compassionate withdrawal and comfort care, as opposed to the mantra where we do everything we possibly can and exhaust a lot of scarce resources at the expense of patients who have a lot higher chance of survival. We are enacting policies with our partners at the county level, whereby if someone experiences a cardiac arrest in the field, which is not the same as a heart attack, but if someone's heart stops, our dispatchers provide instructions for CPR. We'll have an engine company respond, we'll have paramedics respond with an ambulance, and we do everything we can on scene to resuscitate you. But if our paramedics cannot get your heart beating again on scene, we no longer will be transporting those patients because we know by the literature, those patients have virtually zero chance of survival. If we don't do our job in the field to get their heart going again, we don't want to transport those patients to the emergency department, so they can provide care for patients who are viable.
We're also looking at the same policy for victims of severe trauma, car accidents, shootings, stabbings, and so forth. We're not going to be transporting those patients either. If we can't get their hearts going again, if we can't get them resuscitated on scene.
So again, if you're having a heart attack, you'll get a robust response. We'll take you to the nearest appropriate hospital, which may be further than you're accustomed to if the nearest appropriate hospital's full. But if someone is in an unfortunate enough situation where the heart stops and they're in cardiac arrest, you will not be transported with very rare exception unless we can get them initially resuscitated in the field.
Likewise, for people who are in extended care facilities, like a hospice or nursing homes, and they have advanced directives or comfort care only, we were not going to transport those patients either because it's going to tax hospitals that don't have the capacity. And also it's not the right thing to do for those individuals, that want to be kept comfortable, to take them to an emergency department where they can't get to a bed, they're in the hustle and bustle of a chaotic emergency department, and also they can't see their family members because of the COVID restrictions.
What changes are you making over the following weeks?
Next week we're deploying some EMTs and paramedics at the most severely impacted hospitals with cots. So they will be able to monitor patients off ambulances in the disaster tents that most hospitals have constructed in their ambulance bays outside the emergency department. That will get ambulances back in the field. We'll have to only deal with this, during the brunt of this crisis for another four to six weeks. Hopefully things will get better, but make no mistake right now, the system has really been challenged, like it has never been challenged before. And it's incumbent on all of your viewers to do their part.
Even if you're the lowest risk to get seriously ill from COVID, if you need emergency medical services through 911, your care may be compromised or significantly delayed. So this is not the right time to have gatherings and be traveling.