“We went to an elementary school on Figueroa. The kid—he was maybe ten—had fallen of the bleachers and had a good laceration across the forehead,” says Jonni Lang, a firefighter and paramedic, as he runs a finger across his temple. “The school requires he goes to the hospital, the mom is worried about the cost. We stitch him up right there.” Lang smiles. “The mom is ecstatic about time and cost, the kid was stoked because he felt good about himself, and the regular rescue comes to take him to the ER, and we were able to say, ‘We got it, guys.’ ”
Lang is on one of the five teams that ride with the Los Angeles Fire Department’s Advanced Provider Response Units, which were created to address a jump in the number of emergency calls the department had been getting. Historically, 911 calls that were directed to LAFD rescue units had been increasing by maybe 2 percent a year. Around 2011 the pace began to pick up. Some 85 to 90 percent of 911 calls in L.A. are medical-related, and most of them result in a trip to the emergency room. By 2016 the LAFD had seen a 20 percent rise in the number of such calls the department was handling. The emergency medical directors had to become more creative about how to meet the growing need.
So they decided to pair a seasoned firefighter/paramedic with a civilian nurse practitioner or physician’s assistant to treat people in the field. It’s a radical idea that originated in Mesa, Arizona, in 2007. Since then, similar units have rolled out in south Denver and Anaheim. The pilot program in L.A. began with one unit in January 2016; this past July, four more units were added, serving a giant patchwork of neighborhoods from Arleta to downtown and from South L.A. to the Valley.
An APRU vehicle looks like a regular red fire department ambulance, but it’s actually an urgent-care unit on wheels. A standard ambulance team can only assess, stabilize, and transport a person to the emergency room. APRU teams have the equipment and know-how to draw blood for lab tests, perform ultrasounds, provide diagnoses, and prescribe medication. Right on scene. Dispatched on 911 calls that are specified “low acuity”—in other words, for stuff like back pain, minor trauma, and ground-level falls—APRU teams can do what is normally reserved for the hospital. They can let the man who got wobbly in his garden know he’s just dehydrated and not having a heart attack.
To date L.A.’s APRUs have tended to more than 1,000 patients, freeing up rescue units to deal with life-threatening situations in which every minute counts, and they have given overloaded emergency rooms more space and time to treat trauma cases. The hope is that they will save the city, hospitals, and patients money as well as time. A trip to an ER can run $800 for the ambulance alone, plus the premium paid for being treated in the hospital. Currently patients pay nothing for an APRU visit since various area hospitals and the L.A. Fire Department Foundation are funding the project.
“It’s a game changer,” says LAFD medical director Marc Eckstein, the ER doctor who founded the L.A. program. “This allows us to send the most appropriate resources, especially with regard to lowacuity patients, the homeless population, and patients with mental health and substance abuse issues.” Another huge benefit of APRUs: They can provide a referral on the spot for a social worker or mental health counselor.
The unit that works Skid Row can transport intoxicated patients to the Dr. David L. Murphy Sobering Center, where they’re given beds, showers, food, and necessary medical treatment. By doing this, the Skid Row unit alone has freed up more than 4,000 hours of emergency-room-bed time.
“We can take people who are hearing voices or want to hurt themselves to a psych facility,” Lang says. “Other rescues can only take them to an ER. And at an ER they may have to sit and wait and take up a precious bed for 72 hours. At a psych facility they will get care right away and could be out in as little as 24 hours or be put in a mental hospital ward as long as needed.”
Terrance Ito is a nurse practitioner and fellow paramedic who’s worked with Lang in the program. “We had a 21-year-old alcoholic who called 911 maybe 15 to 40 times a month,” he says. But with medication and a counseling program we put together for him, he’s back on his feet, holding a steady job, and is off alcohol.” The project will run until July 2019, when assessments will be done and next steps will be determined. Ito is clearly sold on the effort, though. He likens the start-up to “building a bridge as we walk on it.”
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