'Things Are Worse Than People Think': LA County Official On New Directives For EMS

Jan 5, 2021
Originally published on January 5, 2021 7:32 pm

In Los Angeles, ambulances are waiting for hours — up to eight, in some cases — to admit new patients at overwhelmed hospitals. The number of coronavirus patients in intensive care units has more than quadrupled since the beginning of November.

On Monday, Los Angeles County's Emergency Medical Services Agency directed EMTs not to bring people who have little chance of survival into hospitals and to conserve oxygen out in the field.

And with the holidays just behind us, public health officials warn that the situation could get worse for emergency services.

"A lot of what's happening right now, even though people are talking about it, people are reporting about it, people aren't really seeing it. And the reality is, things are worse than people think," says Dr. Nichole Bosson, assistant medical director at the LA County Emergency Medical Services Agency. "And I say that because I see how people are still congregating in groups and making decisions to have family gatherings or New Year's parties. And these decisions are what continues to impact our health care system."

In an interview with All Things Considered, Bosson explains what Monday's orders mean and what is being done to address the problems. Here are excerpts.

I want to start with some of these new directives that we've been hearing about, like not bringing in patients who have little likelihood of survival. Can you put that in context for us? How extraordinary is that measure?

Well, actually, it is best practice to resuscitate patients in cardiac arrest in the field where they are found. That is our normal protocol in LA County. So the shift towards not transporting patients who do not have restoration of pulse is a relatively small change. These patients have very limited chance of survival. And so these are the patients that we're asking the paramedics to call in to our base hospitals, discuss with the base physician and determine if further resuscitation is futile and therefore terminate resuscitation on scene. We are continuing to resuscitate patients in cardiac arrest, and we continue to transport all patients in whom our paramedics are able to resuscitate in the field.

How concerned should Angelenos be about the availability of oxygen right now? We are hearing from people like [LA County Public Health Director] Barbara Ferrer that January will likely be the worst month on record for LA. So I imagine oxygen supplies will only get stretched even more in the weeks to come.

We have made this move because of a limited supply of portable oxygen tanks. ... Because the paramedics and EMTs are spending more time in the field with patients. They are transporting longer distances because of hospital closures. They are spending more time waiting to offload patients at hospitals. And these patients need oxygen. And so they're using a lot of oxygen in these small portable tanks. And if we cannot get additional tanks and cannot fill the tanks, we risk to run out of oxygen for patients who need it. So this directive is meant to conserve oxygen in order to make sure that we continue to have enough oxygen to treat patients who really, really need the oxygen.

The waits for ambulances to offload patients at hospitals are getting longer. What is being done to address that situation?

We are implementing a surge response to develop ambulance receiving spaces at these hospitals. These are intended to be climate-controlled spaces where EMS can offload patients. And instead of having each individual unit, usually two paramedics or two EMTs, monitoring a single patient, they will be able to offload the patients and have a paramedic or EMT as appropriate staffing the area and monitoring several patients at a time. ... And we have a medical officer on duty 24/7 to help consult in terms of identifying the most critical patients and getting them into the hospital as quickly as possible and determining which patients may be stable, say, to go to the waiting room and be triaged in through the walk-in process. And by this way, we're trying to get more ambulances back into the field to respond to the critical emergencies and reduce the burden on the hospitals as well, because we know they don't have the staff to monitor these patients.

Copyright 2021 NPR. To see more, visit https://www.npr.org.

AILSA CHANG, HOST:

Ambulances are waiting for hours to admit new patients here at overwhelmed hospitals. EMTs are being told not to bring in people who have little chance of survival and to conserve oxygen out in the field. Also, the number of COVID patients in ICUs has quadrupled since November. And with the holidays just behind us, public health officials warn that the situation could get worse for emergency services. And that is why we are joined now by Dr. Nichole Bosson, assistant medical director at the Los Angeles County Emergency Medical Services Agency.

Welcome.

NICHOLE BOSSON: Thank you.

CHANG: So I want to start with some of these new directives that we've been hearing about, like not bringing in patients who have little likelihood of survival. Can you just put that in context for us? How extraordinary is that measure?

BOSSON: Well, actually, it is best practice to resuscitate patients in cardiac arrest in the field where they are found. That is our normal protocol in LA County, so the shift towards not transporting patients who do not have restoration of pulse is a relatively small change. These patients have very limited chance of survival. And so these are the patients that we are asking the paramedics to call in to our base hospitals, discuss with the base physician and determine if further resuscitation is futile and therefore terminate resuscitation on scene. We are continuing to resuscitate patients in cardiac arrest, and we continue to transport all patients in whom our paramedics are able to resuscitate in the field.

CHANG: I do also want to address the oxygen situation. How concerned should Angelenos be about the availability of oxygen right now? - because we are hearing from people like Barbara Ferrer, who's the LA County public health director. She's saying that January will likely be the worst month on record for LA, so I imagine oxygen supplies will only get stretched even more in the weeks to come.

BOSSON: Yes, we have made this move because of a limited supply of portable oxygen tanks. So we are having difficulty getting additional portable oxygen tanks for our EMS system and filling the oxygen tanks. And because the paramedics are and EMTs are spending more time in the field with patients, they are transporting longer distances because of hospital closures. They are spending more time waiting to offload patients at hospitals. And these patients need oxygen. And so they're using a lot of oxygen in these small, portable...

CHANG: Yeah.

BOSSON: ...Tanks. And if we cannot get additional tanks and cannot fill the tanks, we risk to run out of oxygen for patients who need it. So this directive is meant to conserve oxygen in order to make sure that we continue to have enough oxygen to treat patients who really, really need the oxygen.

CHANG: You mentioned that the waits for ambulances to offload patients at hospitals is getting longer. And I want to talk about that because, obviously, paramedics are not doctors. But if they are with critically ill or otherwise injured patients in these ambulances for, sometimes, hours at a time waiting at a hospital, that puts a tremendous amount of pressure on them and could put some patients' health at risk. What is being done to address that situation, these longer wait times for ambulances at hospitals?

BOSSON: Yes, we are implementing a surge response to develop ambulance receiving spaces at these hospitals. These are intended to be climate-controlled spaces where EMS can offload patients. And instead of having each individual unit - usually two paramedics or two EMTs - monitoring a single patient, they will be able to offload the patients and have a paramedic or EMT, as appropriate, staffing the area and monitoring several patients at a time.

This is, of course, being done in conjunction with a hospital triage officer. And we have a medical officer on duty 24/7 to help consult in terms of identifying the most critical patients and getting them into the hospital as quickly as possible and determining which patients may be stable, say, to go to the waiting room and be triaged in through the walk-in process. And by this way, we're trying to get more ambulances back into the field to respond to the critical emergencies and reduce the burden on the hospitals as well because we know they don't have the staff to monitor these patients. But with these patients - you know, need monitoring, and they need oxygen.

CHANG: Right. So as reports are coming out of Los Angeles, both the city and the county, what do you want people to understand about the situation here in Los Angeles?

BOSSON: The reality is things are worse than people think. And I say that because I see how people are, you know, still congregating in groups and...

CHANG: Yeah.

BOSSON: ...Making decisions to have family gatherings or New Year's parties. And these decisions are what continues to impact our health care system. So I know it's been said so many times, but what we're trying to convey to everyone from the public health sector is continue the measures that people did such a good job of in April that will prevent the spread of COVID.

CHANG: Is there a part of you that's just getting tired of repeating this guidance? Stay at home. Don't congregate. Are you getting tired of repeating that?

BOSSON: No, I just wish we had a better way of conveying it, a way that really, you know, convinces people that it's absolutely necessary - if we had a way to message this, to show people what we're seeing and, you know, convey the tragedy that is coming because we have not been able to fully contain this virus.

CHANG: Dr. Nichole Bosson, assistant medical director at the Los Angeles County Emergency Medical Services Agency, thank you very much for giving us your time today.

BOSSON: Absolutely. Thank you. Transcript provided by NPR, Copyright NPR.