M.B. firefighter criticism reveals broader concern of overtaxed system
by Ryan McDonald
In August 2016, Chief Robert Espinosa of the Manhattan Beach Fire Department appeared before the Manhattan Beach City Council to discuss the potential impact of a looming decision over which Manhattan would have no control: Hermosa Beach’s consideration of eliminating its own department and contracting with the Los Angeles County Fire Department.
The departments of the two cities had long had what Espinosa described as a “special relationship.”
“Both cities have only one paramedic ambulance to perform patient transfers. In either city, a second patient on a competing incident or competing for an emergency requires us to use automatic aid to assist each other. And that happens quite frequently,” Espinosa said.
Hermosa’s City Council voted to transition to the county in April of last year, and the county officially took over on the first of the year. The unanimous decision addressed years of understaffing in Hermosa and brought one of the most advanced and respected departments in the country to the city.
The impact on Manhattan has been more complicated. Following a no-confidence vote in Chief Espinosa, several Manhattan firefighters have said that the transition to the county has changed the availability of units to aid them in emergencies. At a Manhattan council meeting earlier this month, Capt. Dave Shenbaum described a Feb. 25 incident in which Manhattan firefighters responded to a call of an unconscious person, but had to wait 15 minutes for an ambulance and backup paramedic resources. The reason for the delay, Shenbaum said, was because the county was not dispatching paramedic units from Hermosa, but was instead sending them from other cities farther away.
“L.A. County continues to provide automatic and mutual aid, but paramedic resources are now traveling from much further distances, responding from cities of Hawthorne, Gardena, Lennox, Lawndale, and Inglewood,” Shenbaum said.
Officials from the county fire department stress that they are continuing to honor their agreements with the Beach Cities, agreements that preceded the takeover in Hermosa. And while stories like the one Shenbaum shared prompted a social media outcry from some residents worried about the impact on future emergencies, Manhattan firefighters have said that they don’t find fault with the county; indeed, Shenbaum described it as a “world-class fire department.”
What emerges instead is a complicated picture of small departments taxed by rising demands for emergency medical services and hints that the decision that Hermosa faced last year, between paying for added staff or switching to the county, could await other departments in the coming decade.
History of help
The phrases “automatic aid” and “mutual aid” appear nowhere in the 60-page contract with Los Angeles County that the Hermosa City Council approved in April. The closest is a provision dictating that in the event an “engine company” is summoned on a call estimated to be longer than 30 minutes, then the county will dispatch resources from one of its other stations to backfill coverage in Hermosa.
But what is mostly happening instead, Manhattan firefighters say, is that when firefighter paramedics are requested, those units are often coming from slightly more distant stations, like those in Gardena or Hawthorne, while the unit in Hermosa is staying put to focus on that city.
Capt. Keith Mora, of the county department’s public information office, said that there was not a fixed policy that paramedic units in Hermosa would not leave the city.
“The approach that the county takes is a regional approach: we respond with the closest engine needed for what’s requested,” Mora said.
Every day, county fire personnel review large scheduled events, weather and other factors that could influence the shifting of units throughout the area. The “regional approach,” Mora said, means that it is possible that a given caller will get the second closest-unit. And he acknowledged that “we do have to account for our areas first. That’s our responsibility. But we make every effort to provide for our partners.” The county has aid agreements with 29 other agencies in the region and was not going to wade into an intra-department battle.
“This is their model. If they’ve only got one resource, and its tied up, then it just really depends on the status of other units. And we only have a small sample size in the time that we’ve been [in Hermosa] so far, so it’s difficult to ascertain exactly what’s happening,” he said.
According to Espinosa, the county has provided aid to Manhattan about 50 times since taking over; by comparison, the Hermosa department provided aid 62 times in the same stretch last year. But Espinosa said those numbers do not indicate whether those units came from Hermosa or farther away.
Any change to the arrangement is likely to be felt because of how dependent the departments have long been on one another. According to a study from Citygate on the interdependence of Manhattan and Hermosa’s departments, between 2010 to 2015 Manhattan firefighters requested aid from Hermosa more than 3,200 times. (Hermosa sought aid from Manhattan on 2,600 occasions in that time period.)
In an interview, Mayor Jeff Duclos said that he and mayor pro tem Stacey Armato were set to meet this week with county fire officials and that the situation with Manhattan would be one of the issues they discussed.
“We’re settling into a period of transition with county fire. For us, it’s been a positive change. We’ve seen an improved level of service for our residents. We’re aware of the comments, and we greatly value our relationship with Manhattan Beach. It’s never been stronger than it is today, and at this point, the situation is under review by L.A. County,” Duclos said.
In the meantime, Manhattan firefighters have pointed to multiple incidents since the first of the year in which they say their units have arrived on the scene, then had to wait at least 14 minutes for a county unit coming from somewhere outside Hermosa. They said that prior to the transition, it took an average of three minutes for a paramedic-staffed ambulance to reach an incident in Manhattan from the Hermosa station. (It’s not clear, however, how often a Hermosa ambulance, which in the past were often called to help throughout the region, was idle at the station at the time of pre-transition Manhattan calls.)
The Easy Reader provided Mora, of L.A. County, with dates, engine and squad numbers for four of the incidents identified by Manhattan firefighters, but as of Wednesday morning had not received a response.
Manhattan firefighters say that the delay is not just for backup units, but also for an ambulance itself. And while ambulance availability is impacted by city-level decisions, it is also subject to larger forces of straining the state’s medical system.
By policy, the county fire department does not handle transportation from incident to hospital in any of the cities it contracts with. Hermosa’s council elected in September to contract with McCormick Ambulance, a Torrance-based private medical transport company. Prior to transitioning to the county, Hermosa had one ambulance staffed with department paramedics, and a limited contract with McCormick, for use in less serious calls, or when HBFD and MBFD units were unavailable.
Manhattan, which has about twice as many people as Hermosa and three times the land area, has one paramedic ambulance, and no contract with McCormick, or any other private ambulance company. Manhattan also has a second ambulance, which is staffed with non-salaried emergency medical technicians, not paramedics. Manhattan firefighters and administration differ slightly as to how frequently the EMT ambulance is available: Espinosa said it runs between 20 to 25 percent of the time, while Shenbaum estimated it was available three to five days per month. Manhattan firefighters say that simultaneous calls often leave the department scrambling to find an ambulance.
Joe Chidley, CEO of Torrance-based McCormick Ambulance, said that the main factor driving arrival time of a private ambulance is the distance between the incident and where the ambulance is stationed at the time. All of McCormick’s ambulances are equipped with GPS, and the closest ambulance is sent to any call. The dispatcher will talk with public safety personnel, who can decide whether or not to accept the ambulance. Although Manhattan does not have a contract with McCormick, the company charges on an as-needed basis.
“When Manhattan Beach calls for an ambulance, we don’t have them on a contract basis, but we try to make it available. That’s the way we’ve always done it, and most of the time, we’re able to,” Chidley said.
Hermosa’s transition to the county and subsequently expanded agreement with the transport company has not changed the specific availability of ambulances for Manhattan, Chidley said. What has changed in recent years is the overall demand for emergency medical services and the availability of hospital space in which to treat people. He said that McCormick, which has been in business in the South Bay for 50 years, is continuously adding ambulances to the fleet, and that demand is “at a peak, the highest that we’ve ever had.” In Manhattan, firefighter calls for service vary slightly from year to year, but have been on an upward trend over the last two decades — from 2472 in 1999, to 3751 in 2017, an increase of more than 50 percent; staffing levels during that time period have not changed.
On your schedule
Complicating matters, when paramedics and EMTs arrive at the hospital, they are often held up and prevented from moving on to the next call, along with the ambulance there arrived in, because there is no space available to handle the patient they are dropping off.
Cathy Chidester, director the Los Angeles County Emergency Medical Services Agency, said that emergency department crowding has been especially acute recently because of the harsh flu season. The problem began to emerge in November and peaked in January following the county’s takeover in Hermosa.
Although crowding became especially problematic recently, the hold up it imposes on emergency responders has been an area of potential reform for years. It has even inspired its own nomenclature: officials are hoping that “ambulance patient offload time,” or APOT, will displace the colloquial “wall time” used by paramedics.
No matter what it’s called, there is no doubt that waiting consumes too much time of emergency responders’ time. Average APOT times vary widely across the state and within Los Angeles County, and measurements have only recently become standardized, but officials know they have a way to go.
“The target is 20 minutes. I’d be happy with 50,” she said. Firefighter-paramedics say that waits of three or four hours are not uncommon.
Hospital emergency departments try to communicate with public safety agencies when they are “on diversion,” meaning they especially full and not apt to handle more patients. But the goal is to bring a patient to a hospital fewer than 15 or 20 miles away, both because of the shorter transport time and to keep the patient closer to family that might visit.
“But when you have all the hospitals in the area on diversion, then really no one is on diversion,” Chidester said.
There are some basic reforms under consideration that would help free up ambulances and emergency responders, They include hospitals hiring additional nurses to watch patients, but they will require buy-in from other participants in the medical field.
And these may just be scratching the surface of a bigger problem. Healthcare experts are increasingly raising concerns about overuse of medical services. Several years ago, Atul Gawande, a public health researcher and surgeon and Brigham and Woman’s Hospital and Boston, published an influential article in the New Yorker magazine about the nation’s “epidemic of unnecessary care,” which concluded that pointless testing, expensive procedures, and visits to emergency rooms were being used to address conditions that could potentially be treated more effectively — and almost certainly more affordable — by a primary care physician.
Representatives from the Hospital Association of Southern California did not return calls for comment for this story. But Chidley, of McCormick, said, “People are calling 911 for whatever they want. The system is maxed out, and it’s not just unique to Los Angeles.”
Chidester said that volume at emergency departments is inherently difficult to predict and deal with. She said that the promised decline in emergency room usage following the expansion of insurance coverage from the Affordable Care Act has yet to materialize.
“One of the first things they’d point to is that it will decrease the load on ER. It hasn’t. If you’re sick and you don’t feel well, you call your physician and they’ll say, ‘Come on in next Tuesday afternoon.’ But if you feel sick and your kid feels sick, you want to address now. ERs work around your schedule,” she said.
The data on high levels of calls for aid between Hermosa and Manhattan came from a study done as part of a proposal, then under consideration but since abandoned, to combine the Manhattan and Hermosa departments to create greater efficiency. (Appropriately enough, the study was requested by John Jalili, who at the time was serving as interim city manager of Manhattan Beach and is now in the same role in Hermosa.) And it underscores the way in which the departments of the South Bay are already dependent on one another, regardless of institutional boundaries. Whether this cooperation is sustainable among burgeoning demands for emergency medical care, however, remains to be seen.
“What tends to be problematic is when we are relying on each other so much for paramedic calls. We should reevaluate that, for each city to provide adequate paramedics for their own city, and only rely on neighboring cities…for the rarities, for unusually high call volume circumstances,” Shenbaum said. He said El Segundo’s fire department was the only independent department in the area that was staffed in a way that didn’t make it dependent on automatic and mutual aid.
Next month Manhattan will consider various modifications to its ambulance program. Along with beefing up its EMT-staffed ambulance and contracting with McCormick, Espinosa said it would consider adding a second ambulance staffed by firefighter-paramedics. That option, however, would require hiring as many as six new firefighters to staff it.
The pending decision is a kind of miniature version of the reckoning that Hermosa faced in deciding between enhancing staffing of its own department or switching to the county: a delicate balancing of service, price, and local control. And while public safety continues to be the first priority of South Bay residents, the escalating salary and retirement costs of these employees will surely influence elected officials.
Earlier this month, Redondo Beach Mayor Bill Brand asked staff to look into the feasibility of joining the county fire protection district. And in a letter last month to the Easy Reader, former Manhattan mayor Mark Burton wrote that Manhattan should consider joining the county as well. He touted the resources of the county department, but what he emphasized was savings.
“If the City of Manhattan Beach joined the L.A. County Fire Protection District, our city could save millions of dollars a year in personnel costs, operations costs and pension costs,” Burton wrote.