Hospitals across Los Angeles County have become so slammed with patients in recent weeks that county officials have instructed ambulances not to transport patients to the hospital with virtually no chance of survival and to preserve supplemental oxygen supplies by only administering it to people who desperately need it.
While both directives did not deviate enormously from typical standards of care, they came as a precursor to possibly more instructions for health care providers to begin rationing care as officials braced for even more hospitalizations as a result of Christmas and New Years gatherings.
The directives from the L.A. County Emergency Medical Services Agency come as L.A. County hospitals continued to be slammed with new coronavirus patients — more than 800 per day now — on top of patients with other illnesses such as heart attack, stroke and seasonal flu.
Close to 8,000 patients with COVID-19 were now hospitalized with 1,627 in Intensive Care Units as of Monday, Jan. 5, according to the state.
Overloaded hospitals have meant that ambulances are waiting to off-load patients at times for as long as six to eight hours. On any given day over the past week, 70 to 90% of L.A. County hospitals were closed to ambulances for advanced life support treatment. And a handful of other hospitals declared “internal disasters,” turning away ambulances of all kind to reduce the pressures on staff.
At several hospitals, county officials were working this week on ways to alleviate the long waits by erecting triage tents outside facilities, according to Dr. Nichole Bosson Assistant Medical Director for the Los Angeles County EMS Agency.
Those hospitals included Queen of the Valley, Pomona Valley, PIH in Whittier, Good Samaritan, St. Francis, Centinela and MLK Community, Bosson said.
“We are trying to have a system to release the majority of the ambulances and maintain a core staff to monitor the patients in an area that’s protected and climate controlled,” Bosson said. “For those who are stable they can be triaged in the waiting room… We are trying to get these ambulances back into circulation so they can respond to emergencies.”
In yet another directive, paramedics were asked to not transfer certain patients to the hospital from skilled nursing facilities or those under hospice care if they desired comfort care rather than life-sustaining treatments such as a ventilator.
While each of these steps was being taken as a first step toward rationing, Bosson and others said ambulances were still able to respond to typical emergencies and hospitals were still able to treat the vast majority of patients. If a patient survives a heart attack or stroke, or is involved in a traffic accident, and need medical care, they will be transported to a hospital and treated, officials stressed. It just might take a bit longer to receive care.
Call volume was up across the board for L.A. County Fire Department mainly due to COVID-19, but in general response times to the scene have not been affected, said Dr. Clayton Kazan, medical director for L.A. County Fire Department.
“But we have had intermittent challenges with ambulance response because of their prolonged offload times at the hospitals,” Kazan said. “The hospitals across our County are heavily saturated with COVID patients, and, as a result, we are seeing our EMS resources held at the hospitals for extended periods of time.”
Bosson stressed that the current directives do not deviate greatly from typical standards of care.
The directive to not transport certain patients only pertained to those cases where responders were unable to achieve a pulse at the scene, following a traumatic accident or a sudden cardiac arrest or stroke. Normally, patients are rarely transmitted in this condition. Standard of care is to treat them at the scene until they regain circulation. And only a very small percentage of patients will survive at the hospital if they are transported without a pulse.
“Patients who are resuscitated in the field have the best chance of survival,” Bosson said. “A recent publication showed if you don’t get a return of pulse in field, you have almost no chance of survival.”
In some cases, patients were transported to a cutting-edge machine being studied as a pilot project called an ECMO machine — similar to a heart lung machine — but that program has been suspended due to the pandemic.
On the oxygen saturation directive issued Monday, Jan. 4, medical providers are to only provide supplemental oxygen when saturation levels fall below 90%. Up until now, doctors have generally provided oxygen when saturation levels fall below 93%. A saturation level of 95% is normal but some older people may have normal levels that are lower.
Source: Orange County Register