Delays Compound S.F.`s Ambulance Crisis

Sept. 21--A patient at a skilled nursing center facing a life-threatening emergency waited more than 33 minutes for an ambulance to take them to a San Francisco hospital.

Residents at an Excelsior district home called 911 at 2:25 a.m., but an ambulance didn't arrive until 3 a.m.

And in the Sunnyside neighborhood, a family had to wait almost 28 minutes for an ambulance.

Those are just three examples of the San Francisco Fire Department taking more than the city's standard of 10 minutes to get an ambulance to a life-threatening emergency medical call, a problem city officials acknowledge has gotten worse over the past year.

A Chronicle analysis of a year's worth of data shows, however, that delays are not spread around the city equally: Neighborhoods on the city's southern rim were the most likely to suffer.

The analysis comes as city leaders are pledging to tackle San Francisco's ambulance crisis -- created by a shortage of both working vehicles and medical personnel -- and one supervisor is calling for changing law to ensure minimum staffing and equipment levels.

Longer than 10 minutes

Over the yearlong period, starting in June 2013, there were at least 402 cases in which it took an ambulance more than 10 minutes to arrive at the scene of a life-threatening emergency -- known as a Code 3 call -- and more than half of those calls were to addresses in outlying neighborhoods, stretching from the Sunset, St. Francis Wood and Ingleside to the Excelsior, Visitacion Valley and the Bayview. Fire officials say those delays aren't surprising, given the geographic distance between the outlying neighborhoods and city hospitals.

But the response times are particularly troubling given the neighborhoods are among the city's more violent and home to many elderly residents, supervisors who represent these areas said.

"It's disturbing, appalling and unacceptable -- but not surprising," said Supervisor Malia Cohen, whose district includes the Bayview, one of the city's most violent neighborhoods. "I expect the Fire Department to provide the same level of service to every part of San Francisco."

While the outlying neighborhoods suffer the worst delays, it's not because that's where the majority of the city's 911 calls originate -- neighborhoods in the city center, including the Tenderloin, Civic Center, Hayes Valley, South of Market, parts of the Mission and the Western Addition -- called for ambulances twice as often during the yearlong period.

Over that time, the Fire Department responded to a total 84,520 911 calls. The three battalions on the city's southern side saw an average of 600 calls a month, while the rest of the city averaged closer to 900 a month. Yet those southern areas made up just over half of the 402 late ambulance arrivals -- 202 in total.

In general, the central neighborhoods -- which are closer to the hospitals where ambulances transport patients and get redispatched -- saw a smaller percentage of delays compared with their overall call volume.

City standards not met

Yet city officials and emergency medical workers say many of those calls, particularly to the Tenderloin, are not for life-threatening emergencies, but for chronic inebriants. For example, the department responds to Episcopal Community Services' Next Door Shelter on Polk Street two to three times a day, Fire Chief Joanne Hayes-White said, and the organization's executive director, Ken Reggio, said ambulances generally get there quickly.

The city has been struggling for years to meet its own requirements for getting ambulances to emergencies, and officials acknowledge that the problem has worsened over the past year as aging ambulances continued to deteriorate and staffing shortages worsened because of attrition.

San Francisco's own standards call for an ambulance to arrive at life-threatening emergencies within 10 minutes 90 percent of the time, and for someone with medical training in life support -- usually a firefighter or medic on a fire truck -- to arrive in less than five minutes. From June 2013 to April 2014, the department barely met that standard for nine months and exceeded it during two months.

The standard set by the National Fire Protection Association is to have a first responder on the scene within four minutes from the time they get rolling, 90 percent of the time, and advanced life support, usually a paramedic on an ambulance, to arrive in eight minutes, 90 percent of the time.

San Francisco fire officials say they are meeting the initial response goal of five minutes, but agree it has become more common for patients to wait longer than 10 minutes for an ambulance -- there was a 25 percent increase in these incidents from 2012 to 2013, for example.

While city leaders insist that public safety is not at risk and that the most life-threatening cases are the department's highest priority, medics and firefighters say the waits can be painful for patients and stressful for emergency workers.

James Green, a paramedic and firefighter, said during one recent call for shortness of breath, firefighters had to intubate -- or run a plastic breathing tube down the victim's windpipe -- for half an hour.

"While I'm doing that for you, you are conscious -- you are fully awake ... (and) waiting for 30 minutes for a paramedic," Green told the San Francisco Fire Commission last month.

Raw dispatch data suggest the picture might be worse than indicated by the year's worth of data analyzed by The Chronicle, which covered only the most extreme cases: calls in which the patient remained in life-threatening status while being transported.

More than 20 minutes

Last month, there were 241 calls dispatched as Code 3 where it took more than 20 minutes for an ambulance to arrive -- an average of eight times per day. Nine times that month, it took more than an hour for an ambulance to arrive.

Though originally dispatched as life-threatening, some of those calls were probably downgraded to a non-life-threatening emergency once the first-wave emergency crews arrived on scene, which would bring the number down. But Hayes-White acknowledged that the summer was challenging, saying personnel shortages caused delays.

"The numbers worsened over summer, and we knew that would happen," she said.

A fix can't come soon enough for city residents who have waited seemingly endlessly for an ambulance to arrive.

Scott Harris, a father who lives in the Haight, describes the 20-plus minutes he waited for an ambulance as the most terrifying of his life. On Valentine's Day, Harris' 2-year-old son spiked a fever -- then he suddenly sat up, locked his eyes and "completely checked out."

Harris and his pregnant wife called 911 three times before an ambulance arrived more than 20 minutes later. His son, who came to just as the medics walked in, was taken to a hospital, where doctors said the boy had a seizure brought on by his fever.

"At one point the attending physician came in with his chart and said, 'I want to check the times here -- it doesn't make sense. Did you wait to call 911?'," Harris said. "When I told her it took over 20 minutes for them to arrive, her jaw dropped."

Harris said he's not sure what he would do if the scenario repeated itself.

"I could have gotten to the hospital in a fraction of the time it took an ambulance to get here," he said. "How can this happen?"

New medics hired

City leaders insist the problem will not linger.

Hayes-White and Mayor Ed Lee said they are working on the problems of short staffing and lack of investment in ambulances, which occurred as the city's 911 calls increased.

On Aug. 30, 35 new medics hit the streets, 16 of them new positions, the rest replacements for workers who retired or were promoted. By spring, the department expects to have 19 new ambulances. The department has had funding for new ambulances since 2012, but said the procurement process took longer than expected.

And the city has asked two private ambulance companies, which already respond to about one-quarter of San Francisco's emergency calls, to start picking up more patients.

Those changes, said Hayes-White, should "immediately relieve pressure on the system."

City leaders are also working on ways to reduce the number of repeat callers, she said, possibly resurrecting a policy of stationing a paramedic captain in the Tenderloin to assess patients before an ambulance is dispatched.

Hayes-White said the department is tracking how the new hires and help from private ambulances affect response times. Data, she said, will bolster fire officials when they go to the mayor for more funding.

More funds needed

While Lee granted the Fire Department $3 million for additional ambulances and staff this year, it was less than a third of the department's $10 million request. Fire commissioners say the department needs more money than the mayor has offered and have publicly discussed asking his office for additional funds, or even appealing to voters with a public awareness campaign or a ballot measure.

"It may be awhile before the city coffers are as flush as they are now. If we can't get it done now, when will we get it done?" asked Commissioner Francee Covington.

Supervisor London Breed has been raising the issue publicly since March, and wants the chief and mayor to move quickly. Last week, she questioned Hayes-White's leadership and called for minimum staffing and ambulance levels.

"I am, of course, glad something may improve, but why did it have to take this long and go this far?" she asked. "Why was public safety jeopardized before something happened?"

Marisa Lagos and Greta Kaul are San Francisco Chronicle staff writers. E-mail: mlagos@sfchronicle.com, gkaul@sfchronicle.com Twitter @mlagos, @gretakaul

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