By Jim Doyle
San Francisco Chronicle
Copyright 2008 San Francisco Chronicle
 AP Photo Members of the SFFD respond to a crash on the Golden Gate Bridge in March. |
SAN FRANCISCO — When Jeanette Grialou’s 78-year-old husband started having serious breathing problems, she dialed 911.
San Francisco dispatchers received her call and assigned it Echo status, the highest priority for a medical emergency. When help didn’t arrive for several minutes, Grialou called 911 again. Her voice grew more desperate and angry.
“Where are they? They’re supposed to be here,” she frantically told the dispatcher. “Where in the hell are they?”
Almost 13 minutes passed before an ambulance arrived at the couple’s home in the Parkside district, records show — nearly twice as long as the city’s goal of getting emergency medical assistance to the scene within 6 1/2 minutes on potentially life-threatening calls. That was too late to save her husband, Gustave, a retired salesman. Paramedics could not revive him. He died of heart failure.
Gustave Grialou was one of at least 439 people who have died in San Francisco since February 2004 while waiting for a late ambulance or after delayed medical help arrived, according to a Chronicle analysis of dispatch logs for about 200,000 high-priority medical calls.
In 27 percent of those calls, first responders failed to meet the city’s standard for getting help to the scene of high-priority medical calls. In some areas of the city, such as the Ingleside and Excelsior districts, the odds of an ambulance being late are almost 40 percent.
While it is impossible to know how many of the 439 people who died would have survived had
medical help arrived earlier, studies show a direct relationship between ambulance delays and the survival rates of patients in need of immediate resuscitation.
“A 30-second delay can mean everything to a patient who’s waiting for life-support systems,” said Mike Williams, president of the Abaris Group, a Walnut Creek consulting firm that helped create emergency medical standards for the state of California.
Many reasons
In an investigation that included dozens of interviews with city officials, front-line workers and experts as well as a review of hundreds of documents including dispatch logs and 911 audiotapes, The Chronicle found that delayed emergency medical responses are the result of numerous causes, from chronic understaffing, language barriers and botched dispatches at the city’s 911 call center to traffic congestion and unavailable nearby ambulances.
In San Francisco, the most serious emergency medical calls fall into two categories — Echo and Code 3. Echo-priority calls require immediate resuscitation, such as cases of stopped breathing, choking, drowning, severe allergic reaction and cardiac arrest. Code 3-priority medical calls, such as severe hemorrhage and difficulty breathing, are also presumed to be life-threatening.
In the past decade, San Francisco has gradually lowered its response times on high-priority medical calls — improving its overall performance by about 2 minutes. In 2001, more than 10 percent of its responses to such calls exceeded 10 minutes.
But dispatchers and rescue crews in San Francisco have been unable to meet the upgraded, 6 1/2-minute standard that city health officials adopted on Feb. 1, 2004, even though that goal is less stringent than a 5-minute goal in urban areas recommended in 1998 by the EMS (emergency medical services) Medical Directors Association of California.
The city’s objectives also are less rigorous than standards set by the National Fire Protection Association, which call for arrival on the scene within 6 minutes after a 911 medical call is answered.
In monthly reports, Dr. John Brown, who oversees San Francisco’s medical system for the Public Health Department, has praised the city’s rescue crews for cutting seconds off ambulance times.
But he acknowledges that last year, none of the city’s neighborhood districts met the overall 6 1/2-minute standard - which allots 2 minutes for dispatch and 4 1/2 minutes for medics to arrive. No more than 10 percent of responses are supposed to take longer.
For Echo or Code 3 medical calls, first responders arrive on scene in 8 minutes or less 90 percent of the time — falling short of the city’s goal by up to 1 1/2 minutes.
“We have a lot of room for improvement,” Brown said. “There’s always the danger or problem of complacency.”
S.F. lags behind
While it’s difficult to make meaningful comparisons to other Bay Area cities, given the differences in traffic and geography, Oakland and Santa Clara County reported 911 medical response times last year that were slightly better than those in San Francisco.
Oakland reported that 90 percent of its first responders on medical emergencies arrived on the scene within 7 minutes. Santa Clara County’s first responders on Code 3 medical calls have met a standard of arriving on scene within 8 minutes 95 percent of the time.
A prime indicator of a system’s commitment to a rapid response to medical emergencies is its record of saving victims of sudden cardiac arrest, which can cause death or brain damage without immediate treatment. San Francisco’s cardiac survival rate lags far behind the nation’s leading emergency medical service providers such as Seattle and Boston.
“If you can get someone there on scene regularly in 6 1/2 minutes, you’ll have more people leaving the hospital,” said Dr. Eric Ossmann, the emergency medical services director for Atlanta. “There is a direct relationship between the response times and the potential for return of spontaneous circulation and survival.”
Washington’s King County, which includes Seattle and its densely populated surrounding areas, had a survival rate in cardiac cases of 41 percent last year, saving 80 cardiac arrest patients. Boston’s survival rate was about 38 percent.
San Francisco’s record of saving patients who collapse of sudden cardiac arrest was about 17 percent as of 2004, the last year comprehensive statistics were kept. While that trails Seattle and Boston, it is better than rates in Chicago and New York, which are closer to 10 percent.
Budget pressures led San Francisco fire officials to stop tracking data on cardiac cases in 2004. This year, the city plans to again collect cardiac-arrest data after being invited to participate in a cardiac registry sponsored by the federal Centers for Disease Control and Prevention.
The weakest link
The 911 call center, plagued with problems from low morale to a proliferation of calls from people who don’t speak English, is the weakest part of San Francisco’s emergency medical response system, according to The Chronicle’s analysis of city dispatch logs from Nov. 1, 2003, through Dec. 31, 2007.
Fifty-seven percent of the time, the call center has failed to meet the city’s goal of dispatching urgent medical calls within 2 minutes, records show.
In the past four years, the center dispatched 90 percent of emergency medical calls in 3 minutes, 44 seconds or less after a 911 call was answered — almost double the city’s 2-minute goal.
Dr. Karl Sporer, an emergency physician at San Francisco General Hospital, tried to reduce dispatch times when he served as medical director of the 911 center.
“It was frustrating,” he said. “They need to make their decisions a little bit faster. They’re taking considerably longer than they should (on medical calls). ... You just send someone fast if you can’t figure it out.”
Miscommunication is common, and a dispatcher’s hesitation or faulty judgments about the severity of a patient’s condition can result in delays.
In November, after The Chronicle inquired about the city’s ambulance delays, the call center at 1011 Turk St. began instructing its call-takers to immediately dispatch help to callers who are reporting priority symptoms, which has resulted in substantial time savings on 911 dispatches.
Mayor Gavin Newsom “is encouraged by these preliminary results,” said Nathan Ballard, his press secretary.
The center, which is run by the Department of Emergency Management, receives about 900,000 emergency and nonemergency calls a year, most related to public safety. In addition to handling emergencies, dispatchers handle nonemergency calls that are routed to the 911 center from seven-digit lines for the police and fire departments.
The sheer volume of nonemergency calls means that the call center is sometimes slow to answer emergency calls, resulting each day in about 50 emergency calls that are abandoned by callers before being answered - an improvement since 2006, when an average of 105 emergency calls a day were abandoned.
San Francisco has struggled to consistently answer 90 percent of 911 calls within 10 seconds, a state standard. Because of the city’s shortage of call-takers, about 1 of 100 emergency callers waits more than 1 minute for the 911 call to be answered.
Many of the calls are placed by people who don’t speak English. The center relies on a state contractor to provide translators in 163 languages using three-way conference calls, but the process can delay dispatches.
Approximately one-third of the calls are from cell phones, which can make it difficult to establish the caller’s precise location.
Like other dispatch centers across the nation, the call center has difficulty recruiting and retaining dispatchers and struggles to keep enough call-takers on the floor 24 hours a day. The center is authorized to retain 186 rank-and-file dispatchers, but has only about 150 dispatchers and call-takers on the payroll, including trainees.
Qualified candidates are tough to recruit, especially given the night and weekend shifts the new hires are expected to work. About 55 percent of trainees are hired permanently as dispatchers.
Technical factors also slow the center’s emergency responses.
The call center does not have a Global Positioning System that tracks the precise locations of ambulances - to help send the closest available unit to the next emergency. Dispatchers cannot easily pinpoint the exact location of ambulances or forecast reliably where ambulances will be needed.
The center’s dispatch logs do not indicate how far an ambulance traveled to an emergency. Thousands of high-priority medical logs fail to indicate how long the 911 response took. The city does not track the survival rate of patients who receive late responses and are transported with lights and sirens to the hospital.
Dual mission
Ten years after the Fire Department took over the city’s ambulance fleet, the agency is still adjusting to its dual mission of putting out fires and sending help quickly to 911 medical incidents.
The number of fires in the city has decreased in recent decades. Medical calls currently make up more than two-thirds of the emergencies to which the department’s engines and ambulances respond.
According to paramedics and other 911 medical experts, the Fire Department has been slow to reorganize itself to provide state-of-the-art ambulance services.
“The Fire Department’s commitment to EMS isn’t as great as they’d like you to believe,” said paramedic David Anderson, a former quality improvement expert for San Francisco’s ambulance service. He was hired last year by the Austin-Travis County EMS Department in Austin, Texas, which is not run by a fire agency.
Anderson said the management of the San Francisco Fire Department “has no idea how to run an EMS operation. And with state budget cuts, the money just isn’t there to work on it.”
The Chronicle’s analysis found that 15 percent of the time, the city’s ambulances and fire engines fail to meet the city’s goal of arriving at the scene of an urgent medical call within 4 1/2 minutes after being dispatched — which contributes to the city’s overall response delays of 27 percent. That 4 1/2-minute standard does not include dispatching or the time allotted for medics to climb stairs or ride an elevator to reach a patient’s side.
The city is divided into 11 emergency districts that each consists of several neighborhoods. Although steps have been taken in the past two years to redeploy ambulances, fire officials are not providing equal response times to all neighborhoods.
Enough ambulances?
Paramedic Capt. Mike Whooley said the city needs to hire more ambulance crews. “Putting ambulances on the street seems to be our biggest problem,” he said. “At times, we have ambulances coming from way out on the avenues to downtown. Traveling a farther distance delays ambulance responses and reduces that unit’s availability for other calls.”
Fire Chief Joanne Hayes-White said the city has plenty of ambulances, noting that there are twice as many ambulances on the streets today as there were in the 1990s, when the Public Health Department ran the ambulance fleet. During peak hours, as many as 26 city-owned ambulances are on duty. In the late 1990s, there were rarely more than 13 on the streets.
Medics are deployed in ambulances and fire engines throughout the city, but they still arrive late on an average of more than 12,000 high-priority medical cases a year.
Some ambulances and fire engines have much worse delay records than others, but fire officials rarely hold paramedics and firefighters accountable for delays. They seldom conduct audits, postmortems or internal inquiries when delays are extremely long or coincide with patient deaths.
“No system is perfect,” said Pete Howes, the Fire Department’s emergency medical director. “We try to strive for good and fast. ... Thankfully, we’re not seeing a lot of clinical mistakes.”
Hayes-White defended her agency’s efforts.
“We do an above-average job, a very good job, in delivering emergency service,” she said. “But I would be the first one to say that we have work ahead of us.”
The chief also said the city’s response standard of getting help to the scene of urgent medical calls within 4 1/2 minutes after dispatch “seems like an unrealistic goal” in a densely populated metropolis “with narrow, one-way streets.”
But Brown, the Public Health Department’s emergency medical director, said the goal is realistic and that he wants to set the bar even higher: “Our ultimate goal is a 5-minute (overall) standard” from the time a call is answered to when help arrives at the curb, he said. “I don’t want to settle for mediocrity.”
Although Brown has oversight of the city’s emergency medical response system, he said he has no authority to order reforms that might improve response times.
Ultimate responsibility for the 911 medical system rests with Mayor Newsom, and there has been little improvement in emergency responses since he took office in 2004. The mayor acknowledged that San Francisco’s system has significant problems but said steps are being taken to address them.
“We have been moving to make the changes we recognize need to be made in real time,” Newsom said. “Despite these improvements in service, I am not satisfied. I acknowledge that there is work left to be done.”
The Grialou case
One key to improving performance, experts said, is collecting sufficient data on emergency cases to fully audit ambulance delays, examine particular treatments and learn from clinical mistakes. But in the case of Gustave Grialou and several others whose deaths coincided with late medical responses, officials could not explain why it took so long for help to arrive.
Grialou, a native San Franciscan, worked in the laundry and mortuary businesses before selling marine hardware until his retirement, and served as president of the French American Hospital’s board of directors. He was in failing health when his wife called 911 at 1:43 p.m. on Feb. 8, 2006.
The call center dispatched two rescue crews 2 minutes, 8 seconds after answering Jeanette Grialou’s call.
The ambulance dispatched on the call, known as Medic 12, had completed its previous assignment 20 minutes before it was assigned to the Grialou case — having transported a patient to Kaiser Hospital in the Western Addition.
Emergency officials said they did not know where Medic 12 was located when it was dispatched to the Grialou residence, but it took 10 minutes, 40 seconds after being dispatched to arrive at the scene - 12 minutes, 48 seconds after the initial call.
A fire engine with a paramedic also was dispatched, but showed up 2 minutes after the ambulance — even though Engine 18, which is based just 8 blocks from the Grialou residence, had been clear of any other emergency call for almost 2 1/2 hours when it was dispatched.
Howes said he could not explain the delays. “For me to try to extrapolate where ambulances could have been when I don’t know where they were coming from, I can’t give you good information,” he said. “If I was to drill down to the reason why this crew took 13 minutes to respond to this call, I’d have to bring them down and interview them. Given all the calls they’ve handled in the last year and a half, they probably wouldn’t remember.”
Hayes-White said the response to Grialou’s home was not ideal.
“We’d like to see every person in the city get the same response time - equal care and equal distribution of resources throughout the city,” the fire chief said. “That’s still a work in progress.”