<i>60 Minutes II:</i> No Vacancy

Could an emergency room turn away an ambulance carrying a 5-year-old boy who is having a life-threatening medical emergency. It's not impossible.

Today, emergency rooms are so overwhelmed, they're sometimes turning away the sick and injured. Although they cannot deny care to someone who walks in, ERs are increasingly going on what's called "diversion."

It amounts to an emergency room putting up a "no vacancy" sign that tells ambulances to look for help elsewhere. A delay in care might be not be life threatening for someone with a broken leg, but what about a middle-aged woman in cardiac arrest or a child who had stopped breathing? Vicky Mabrey reports.

In Columbus, Ohio, in March, 2000, Ann and Chris Carlson woke to find their son Nicholas unconscious.

Although Nicholas was disabled - he was born with a rare birth defect that left him unable to walk or talk - in his fiv,e years he'd only been in the hospital once and had a normal life expectancy. But on that morning, a recent bout with pneumonia took a turn for the worst.

By the time the ambulance arrived, Nicholas was in cardiac arrest. Paramedics worked furiously to save him as the ambulance raced to the nearest hospital, Riverside Methodist. A paramedic called ahead to tell the ER they were coming. The hospital told the paramedics they were on diversion.

The paramedic protested, saying the case was extremely serious. He was told to divert anyway.

"I could not hear the transmission," says Ann Carlson. "The gentlemen doing the transmitting was in the back of the squad and I was sitting up in the front with the driver. I wasn't able to see Nicholas and I could only see the back of the one of the five people that were working with Nick. The next thing I heard was "We've been diverted." And that's the first I knew about it."

After the nurse at Riverside told the paramedic they were full, the ambulance headed to Ohio State University Medical Center. It took just a few additional minutes to get there. As they were pulling into the OSU ER, the Riverside ER called offering to take Nicholas. But it was too late. He was prononced dead in the OSU ER 20 minutes later.

At 7 a.m., when Nicholas was ill and dying, the Riverside emergency room was totally filled, says Dr. John Drstvensek, medical director of the Riverside ER.

"Every bed was filled with a patient. And 16 of those beds had admitted patients. There were no beds available in the hospital. So people were delayed in getting up to the floor. So their care is continued in the emergency department," he says. The hospital was filled, he says.

In the overwhelmed ER that morning, Drsvensek admits, a mistake was made. The hospital could have seen the child, he says. Diversion should have been overridden.

"It could have been done. And we urge the EMS and the nurses that if you have a patient in extremis, a critical condition, someone who has a code blue - their heart stopped, and they're on resuscitation, that they are just to go to the closest emergency department without fail."

But because there is no federal law mandating that, there are no guarantees for patients like Nicholas Carlson.

Ann and Chris Carlson will never know if being turned away from the closest ER contributed to their son's death, but they do hope that telling their story will help bring attention to the problem.

"It isn't the system that we've grown up to believe that's there," says Ann Carlson. "They aren't able to respond the way we've always assumed they would. I think the system needs to be ironed out, so that unstable cases don't get turned away from help."

"This is as important a public health issue as I think we have in this country today," says Stuart Atman, an economist and professor at Brandeis Uiversity. He has advised five presidents on health-care policy.

He says he never thought he'd see a time when ambulances were being turned away from emergency rooms.

"We had too much capacity for most of my working life. And it's only been very recently, as we've shrunk down our system to make it more efficient, that the problem is the magnitude and duration that it's happening in this country today."

Over the last decade, a lot of the fat has been cut out of health care to make it more efficient. But many now believe the cuts have gone too deep, forcing hospitals to close and putting almost a 1,000 ERs out of business in the last 10 years.

But while the number of ERs has plummeted, the number of patients has grown. Along with an older and sicker population, many people who can't get an appointment with their primary care physician end up going to the ER. Add to that the 43 million uninsured Americans whose main access to health care is through the emergency room, and you've got more than 100 million visits a year. The result: Most ERs are so overwhelmed they routinely turn away ambulances.

"Diversion is an incredibly important public health issue," says Altman. "The average American, it cuts across income lines, race lines. You are in that ambulance. And you are the same, no matter what poer you have. And if that ambulance is told they can't go to hospital X and Y and they have to go to Z, they will divert. And what is troubling to me is the idea that it's happening too often. And it's happening in many parts of the country: in Los Angeles, in Chicago, in Boston, in New York, in Atlanta."

It's not just small community hospitals; even world-renowned medical centers go on diversion - and not just once in a while. Last year, the Johns Hopkins' ER turned away ambulances over a quarter of the time. During the first six months of this year, the Cedars-Sinai ER has been closed a full 35 percent of the time. The Cleveland Clinic ER was on diversion nearly half of last year.

Which leaves the paramedics who work the street struggling to find a place to take their patients.

"When you call 911, you call in an emergency, you expect everything to go perfectly well," says Bill Mergendahl, executive director of a private ambulance company in Cambridge, Mass. "You expect to be taken to the closest hospital or the hospital of your choice. And sometimes that's not going to happen."

He says that in his 15 years of responding to 911 calls, he has never seen it this bad. "On a daily basis, there is definitely at least one hospital closed," he says. "Sometimes we've seen as many as three hospitals on diversion all at the same time."

Last November, Mergendahl was working dispatch when 55-year-old Cynthia Lline called 911. Earlier that month, she"d had a heart attack and received a life-saving cardiac catheterization at Mount Auburn hospital - less than two miles from her house and the only place in Cambridge capable of doing that procedure.

But three days after being released from the hospital, Kline experienced chest pains and called 911. Her son Jesse says that his mother, who was trained as a nurse, pleaded with the paramedics to take her back to Mount Auburn.

But Bill Mergendahl had to tell his paramedics that the Mount Auburn ER was closed to ambulances - the hospital had run out of ICU beds and cardiac monitors. So in spite of Cynthia Kline's pleas, the paramedics had to take her to the next best place - Cambridge Hospital.

What would have happened if paramedics had called Mount Auburn and asked to bring her there?

"It's very likely that they would not have been able to let us bring Ms. Kline there, as they're on divert," says Mergendahl. "By definition, their resources are already maxed out. They may not even have a bed to put Ms. Kline in."

According to one paramedic, on the way to hospital Cynthia Kline was "agitated, scared and fearful that she was going to die." And she had reason to be afraid. Shortly after arriving at the Cambridge ER, doctors determined she needed to be "transferred to Mount Auburn for a cardiac catheterization." But there was no time. Cynthia Kline died in the Cambridge Hospital ER waiting for a transfer.

Mergendahl says that if Mount Auburn had been open, it was possible tha Kline might have lived: "Ms. Kline was very sick. Certainly it would have been optimal to have been able to bring her directly to Mount Auburn where she was regularly followed. Unfortunately, I don't know that we'll ever know the answer to that question."

Altman says he is not surprised by cases like this. He thinks that these cases are unacceptable: "I think we can develop an emergency room system and a hospital system that does not accept the idea that...people are expendable."

"The problem is, to solve it is going to sort of require a lot of changes in pretty powerful individuals within our health system. And it's not a snap of the fingers problem to solve. But it is solvable."

Altman says the responsibility for solving the problem must be shared by everyone - the hospitals have to give their ERs greater resources. The ERs themselves must run more efficiently. And finally, patients have to stop using the ER for non-emergencies.

But until all that happens, Altman expects to hear about more tragedies involving ambulance diversions - and considers what he might do to avoid learning about it firsthand.

"I might call 911 and then not let them take me in an ambulance," he says. "Because I think ambulances can stabilize patients. But I think before I get into that ambulance I'd find out where they're going to take me. And if they weren't going to take me to a place I wanted to go, I'd beg, borrow and steal somebody to drive me to the place of my choice."

But that wasn't an option for Cynthia Kline - so she placed her trust in the system. Officials at Mount Auburn and Cambridge Hospitals declined to be interviewed about her case. An investigation by the Massachusetts Department of Public Health found no fault in Cynthia Kline's care - though her son Jesse has hired a lawyer to investigate whether there was any malpractice.

Jesse Kline says things were not handled properly: "There's no way that someone calls 911 and doesn't get a chance to live. That shouldn't happen."

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