HOLLYWOOD, Calif. — Serving his entire career in emergency medicine, Dr. Marc Eckstein has noticed a dramatic shift in both the nature and number of 911 calls in the city of Los Angeles.
“Most of our calls are not burning buildings, and most of our EMS calls are not heart attacks and strokes and shootings. It’s everything else,” said Eckstein, who is the director of emergency medicine for the Los Angeles Fire Department.
That ‘everything else,’ he says includes calls for the flu, mental health crises, substance abuse and chronic health issues involving the homeless, which he says often include a combination of both untreated mental health problems and drug or alcohol addiction.
“Part of our challenge is to identify those patients and say, ‘What is the best way to care for them?’” Eckstein said. “And many times taking them to the ER by ambulance is not the right answer.”
Instead an LAFD apparatus that looks just like an ambulance is able to meet non-critical patients exactly where they are, pairing an LAFD paramedic with an emergency-room-trained nurse practitioner on what’s called an APRU, an advanced provider response unit.
The LAFD program was spearheaded by Eckstein in 2016.
“It’s almost like a mobile urgent care is like what it is. The idea is to treat and release and navigate to primary care,” said Eckstein.
The LAFD invited Spectrum News 1 on a series of ride-alongs with the four units currently deployed at stations across the city.
The APRU’s serve areas with some of the highest 911 call volumes. They also happen to be areas where the homeless crisis appears to be intensifying.
Many of the calls Spectrum News 1 shadowed involved tending to the homeless in Hollywood.
“The number of homeless individuals has gone up markedly. It’s like swimming upstream,” Eckstein said. “A lot of them have serious chronic medical problems and to have almost all their care provided through EMS and the ER is very expensive.”
It can be especially expensive when those individuals become what some city officials refers to as “super users” or “frequent fliers.”
Eckstein recalls one in particular:
“In the course of two years we had 353 transports for a homeless woman with chronic alcoholism and mental health problems. She finally was amenable to receiving help and she was placed in detox in transitional housing,” Eckstein said.
The challenge is how to handle patients like that woman, who Eckstein says often refuse help but need social services and mental health treatment, instead of just a ride to the ER.
It was exactly this scenario that became the catalyst for Eckstein’s APRU program:
“I was working a shift in the ER a few years ago and a paramedic rescue comes in. They brought in a serial inebriate who is one of our super users," said Eckstein.
That man was brought to LA-USC Medical Center, where Eckstein also serves as Director of Pre-Hospital Care.
While the man waited for a bed, the paramedics radios began going off:
“There was an infant cardiac arrest that was dispatched. And I saw the look on their face. The frustration that really what they trained to do -- save lives and particularly a baby with cardiac arrest. And they knew that they couldn’t respond,” Eckstein said. “And the paramedics that would be responding would be a little delayed because they were coming from another district, because they’re transporting the same individual for the umpteenth time.”
Eckstein said he felt impelled to do something so he began to develop the pilot APRU unit, which earned support from the mayor’s innovation fund to get it out the gate.
The money to pay for unit would come from a public-private partnership that included contributions from some L.A.-area hospitals which stood to benefit from the pressure lifted from their emergency rooms.
“It was to really implement a paradigm shift. These patients shouldn’t be going to the ER every day. That patient needs to get to a sobering center, he needs to get into transitional housing, get into detox, get off the streets. I would hate to think that the chance of that baby surviving might have been hindered or compromised because we’re transporting the same person every day,” Eckstein said.
It’s not a magic bullet, but Eckstein says the APRUs are providing a massive relief to the fire engines and ambulances they assist.
In 2019, the city’s four APRUs responded to about 2,200 emergency incidents on scene.
“We’re trying to be innovative and efficient. Trying to provide the best service to all patients in need,” Eckstein said.