L.A. Paramedic System Under Strain.

IT's just before midnight in the MTA yard at Sixth and Alameda Streets, a giant parking lot full of empty buses. Slumped inside one of the vehicles is a solitary passenger who never got off.

He is a Latino man, about 25, whose skin is gray and whose eyes are rolled up in the back of his head. There are no visible signs that he is breathing.

As a cluster of MTA workers stands around smoking cigarettes, Chris Granucci and Geoff Balchowsky, two paramedics from Fire Station No. 9 of the Los Angeles Fire Department, grab the man by the arms and legs and carry him off the bus, placing him on a gurney waiting outside.

Four firefighters, all trained in basic lifesaving techniques, surround the gurney and assist the paramedics. The man's white T-shirt and jeans are cut open and the paramedics start performing CPR. Syringes full of heart-starting drugs are filled and injected. An IV is prepared. Defibrillators are charged and the man is shocked.

They are working on a dead man. Resuscitation efforts continue as he is raced to the hospital inside an ambulance, but they have no effect.

Later, in the ambulance bay at L.A. County-USC Medical Center, Granucci, still sweating, sets about cleaning up and restocking the supplies.

"This was just in a dead guy's gullet," Granucci says, grimacing as he carries the blood-covered intubation gear into the hospital to be sanitized. He figures that the man died of some kind of drug overdose, because there was no obvious trauma to the body.

"I think we just saw another statistic," Granucci says.

There are lots of statistics generated by the paramedics at the Skid Row station of the L.A Fire Department. It is one of the busiest fire stations in the city, where the paramedics typically go out on at least 15 calls a day.

For paramedics like Granucci and Balchowsky, the job comes with a host of pressures - the kinds that leave no room for error. But behind the scenes there is another kind of pressure, one that threatens more than an individual life. It threatens L.A.'s entire emergency medical response system.

The population of Los Angeles County is expected to grow by 40 percent over the next 20 years. With all those people come more car crashes, more violent attacks, and a larger indigent population without health insurance. Already, Los Angeles County is home to about 3 million uninsured patients - more than are found in any single state in the union, let alone county.

More people moving here means more traffic. More traffic means more accidents, and that means more demand for paramedics.

While the number of emergency calls to the fire department has been on a slow but steady climb over the past few years, many expect the figures to soar.

"We're just about at our limit now," said Jim Lott, executive vice president of the Healthcare Association of Southern California. "We already have to do (ambulance) diversion because of (hospital) capacity issues. Hospital go on standby and don't take ambulance runs because they're saturated on a regular basis, particularly on Friday and Saturday when you have more people drinking and acting up."

Some say that population growth in certain areas of the county, like segments of the San Fernando and the San Gabriel valleys, are already pushing the system to its limits.

"We have 150 fire stations and 55 paramedics squads," said Capt. Steve Valenzuela of the Los Angeles County Fire Department. "Not every fire station can have a paramedic squad, but every third or fourth one can have a squad that covers three or four stations."

In the war zone

Even during the week, the scene is chaotic at station No. 9 - so much so that when Nicolas Cage wanted to do a ridealong to prepare for his role as the frantic paramedic in "Brining Out the Dead," he did it there.

The station is located at the corner of Seventh and San Julien streets, a grim intersection populated by homeless people clustered under tarps and prostitutes wearing wigs and leather miniskirts.

"If this were a TV show, it would be 'The Twilight Zone,'" said paramedic Alfred Hernandez, 27. "Some of the things you see after a.m. - you wouldn't believe it."

The paramedics here work 24-hour shifts for days at a time. The station becomes their home away from home, complete with a sleeping area, locker rooms, barbecue grill, gym, kitchen, handball court and television room with rows of matching blue recliners.

Not that anyone gets much of a chance to kick back and relax. The pace is relentless, with calls ringing out over the loudspeaker. Paramedics average three or four hours of sleep a night.

Sitting in the station's kitchen, Hernandez watches television as most of the firefighters go upstairs to work out. A lot of the paramedics don't often get the chance to visit the gym - too many calls come in to get into any sort of routine.

"You don't get a body like this by working out," he joked, munching on a doughnut. Hernandez is a large man, but by no means fat.

At 7:52 a.m., there's a call for a drug overdose at Seventh Street and Gladys Avenue. Hernandez and Granucci rush for the ambulance.

"I was in the shower," Granucci laughs. "I had my hand on the knob and was getting ready to turn the water on. So close!"

The patient, a redheaded man in his 20s, is standing at the intersection with a Big Gulp from 7-Eleven in one hand and a big bottle of Prozac in the other. He waves the ambulance down.

After talking to the man and monitoring his heart rate on an EKG, they transport him to County-USC. He's in stable physical condition, but needs someone to keep an eye on him for the next couple of hours.

"He took too much of his antidepressant," Granucci says. "He was trying to hurt himself."

The scene at County-USC is one of controlled chaos. Ambulances from all over the city drive up the steep incline into the emergency bay, bringing in patients to the trauma center. The back-supports used to stabilize victims of car crashes and gunshot wounds are scattered on the ground throughout the bay - most of them smeared with blood.

"County's just more Skid Row," Hernandez said. "But if you're in a massive trauma, there's no other place you would want to go. It's where the doctors are that can save you."

Shortage of ERs, paramedics

Every time a patient is transported, the ambulance driver checks an onboard computer to determine which nearby hospital trauma center has beds open.

It's not always easy to find one. In the Los Angeles area there are 13 certified trauma centers. In the last 15 years, 35 emergency rooms at hospitals all over the county have been shut down.

At the same time, the number of calls for emergency treatment is going up.

In 1990, there were 237,144 such calls in the city of Los Angeles, 74 percent of which came into the fire department's 911 dispatch center. By 1998, that had increased to 241,117 EMS calls, 78 percent of the total. At the county level, there were 137,774 EMS calls in 1998, 65 percent of the total 911 calls.

This bucks the trend in other major cities, where the percentage of EMS calls has been falling over the past decade. In Chicago, there were 212,367 calls for EMS to the fire department in 1990, 63 percent of the total that came in. Last year there were 246,451 EMS calls, 58 percent of the total.

"We're talking about sheer numbers (in Los Angeles) - the more people you have, the more opportunity there is to have blunt trauma, people running into each other in their cars, hothead outbreaks and people acting up," Lott said. "People versus machines and people versus people are the issues here."

More often than not, the Skid Row paramedics take their charges to County-USC, where those without insurance can receive care. The paramedic in the back of the ambulance calls ahead with the patient's vital statistics, and estimates the arrival time.

Each rescue call takes about 45 minutes, including the time set aside for transporting the person to the hospital and filling out the required paperwork.

Few paramedics choose to work in Skid Row because of the intense workload and extremely unpleasant conditions; after a few months, many of them request a transfer elsewhere, meaning that crews from other stations have to be shuttled in for month-long shifts. Granucci, for example, is usually stationed in North Hollywood, but was picked to go to Skid Row for a month.

But staffing isn't just a problem downtown; fire stations all over the city and county are chronically understaffed with paramedics.

All paramedics are also fire fighters, and because the washout rate is high, getting fire fighters successfully through the training program and into the stations isn't easy.

Tens of thousands turn out for the entry exam each year, and the ranks are whittled down to several hundred through testing, physical exams and interviews.

The problem also comes from funding the paramedic positions, according to Rick Guerrero, president of Local 1014 of the International Association of Fire Fighters, the union for county fire fighters.

"Traditionally the Department of Health Services has administered the paramedic program and they determine the allocation of available positions," he said. "That determines our ability to send people through the training... it's like musical chairs. If you have five chairs and six people, someone doesn't get to sit down."

Paramedics average $65,000 a year, but with overtime that can go way up - and there's no shortage of overtime in Skid Row.

'Gruesome Twosome'

Many of those who do make it through training as paramedics consider their job to be the best in the world. Granucci and Hernandez have formed a good rapport in their time together. Granucci is a jokester, pretending to trip over gurneys in the emergency room and singing along to Limp Bizkit songs on the ambulance radio. Hernandez prides himself on being one of the nicest guys in the fire department - until after midnight, when he admits to getting a little cranky "when the weirdness sets in." Other paramedics refer to the duo as "The Gruesome Twosome."

At 12:24 p.m. on a recent Friday, Hernandez and Granucci get a call: A woman has collapsed in line at Cole's Buffet downtown, possibly suffering a seizure.

Most cars pull to the right and stop as the ambulance speeds through the downtown streets, but pedestrians are another matter. Several stop in the crosswalks and gape, while others dart across the street to get out of the way.

"Yeah, move it," Granucci mutters to an overweight man jiggling toward the curb in front of the oncoming ambulance. "You need the exercise."

At the restaurant, a woman in her mid-50s is laying on the floor, covered by the sawdust that is scattered everywhere. Most people in the restaurant are ignoring the scene; one man is standing to the side picking numbers for a Lotto ticket.

"It's just a seizure, right?" a waitress asks. "She was standing there and all of a sudden she fell over. I jumped on the phone and called 911. Is it just a seizure?"

Judging by the dilation of the woman's pupils, the paramedics determine she's had a massive aneurysm. Her speech is slurred and she's confused. They put her on a gurney, carry her up the steps and load her on the ambulance.

While the ambulance is bouncing and swaying down Mission Road toward County-USC at 55 mph, the woman is given an IV. She's hooked up to an EKG, and her airway is cleared. Her socks and shoes are ripped off and her reflexes are checked. She's intubated so that her respiration is regulated through a pressurized bag, although she continues to spit up purplish blood.

"She was breathing but she didn't have a gag reflex," Hernandez explains later. "We had to intubate, so that if she vomited she wouldn't asphyxiate."

The entire trip takes six minutes.

"God, that poor lady," Hernandez said, about 20 minutes later. "At first she was talking and then I asked her name and she started spelling something crazy."

(Four days later, Hernandez found out that the woman died while at County-USC.)

Minutes after dropping that victim off, the paramedics are back at a downtown hole-in-the-wall restaurant, where a belligerent man demands to be taken to his hotel room because he's feeling weak. He doesn't want to go to the hospital and fusses while the paramedics try to hook up an EKG.

"You gotta' be honest with me or I'm going to take you to the hospital against your will," Hernandez says. "The only way I'm letting you walk away from me is if you show me you're well."

"Hell yeah, I'm fine!" replies Frank, who is 77. "I want you to take me to my hotel."

"I can't do that, sir," Hernandez says. "I can only take you to-a hospital. Do you feel all right?"

"You don't understand my problems," Frank says, clutching his walker. "Call me a cab."

Hernandez calls him a cab and the man, still angry, demands to know his name. Hernandez writes his and Granucci's names down on a piece of paper and puts it in Frank's pocket. The man gets in the cab and drives off.

"See, you bend over backward to help, and I'll probably get a complaint against me," Hernandez says.

First line of contact

Paramedics respond to all calls, no matter how seemingly minor: an elderly man falling out of his chair, a woman with food poisoning. "People don't have doctors anymore, so they call us," Hernandez says.

One in three people who go to an emergency room have no insurance, according to Lott. Some wait until their situations are so dire that paramedic care is a necessity - even though their illness may have started as something as minor as a cold, it can quickly turn to pneumonia.

Even with Los Angeles County's growing emphasis on outpatient clinics and preventative care, many paramedics believe it's inevitable that they will increasingly be the first line of contact with the medical system for many of the indigent.

On the way back to the station, Granucci and Hernandez swing through the heart of Skid Row. The paramedics say they typically receive fewer calls in the last days of the month. It's on the 1st and the 15th - the days when paychecks and welfare money come rolling in - that things turn ugly. More money means more drugs, and more drugs means stabbings and shootings.

As the ambulance rolls south on San Julien, Hernandez spies "Shorty," a dwarf who has been on Skid Row for at least 15 years. Legend has it that she is a former roller-derby champion who now has two drug convictions and is informally known as the "mayor" of Skid Row. She's often seen shaking a plastic jar of change and is famous for her appetite for crack cocaine.

"Slow down, slow down, there she is," Hernandez tells Granucci. "Ask her if she wants a blanket."

Granucci stops the ambulance and rolls down the window.

"Hi Shorty! Hi sweetheart!" he says. "Do you want a blanket?"

Shorty mutters something unintelligible. Granucci gets a woven, white blanket from the back and hands it to her. She clutches it against her chest as Granucci drives the ambulance off.

"Wow. She wasn't on crack that time," Hernandez said. "But you still can't understand her,"

Denizens of the neighborhood occasionally stop by the fire station, but they know the rules. When the garage door is open, they can't go beyond the groove in the cement where the front door latches to the ground. Some stand forlornly at the entrance - always behind the groove - and wait for a fire fighter or paramedic to bring them a glass of water in a Styrofoam cup or a blanket.

The station house

The hours between 5 p.m. and 8 p.m. are usually the calm before the rush of calls that come after dark. During this time, paramedics eat dinner with the firefighters in the station, and some settle down to watch movies. Tonight's fare is barbecued meat, potatoes, sauteed mushrooms and zucchini, with "U.S. Marshals" starring Tommy Lee Jones playing in the background.

After three or more 24-hour shifts, there's nothing a paramedic would rather do than go home and go to bed. But at home, there's a wife he hasn't seen in almost a week and kids who miss their dad. All paramedies talk about the high divorce rate.

"You've got to know how to balance it," Granucci admits. He places quick calls home during the day to his wife and kids.

A lot of shift-swapping goes on so paramedics can spend time with their families. On this particular day, Hernandez works the morning hours for another paramedic so he can go to his child's Halloween costume parade at school.

The exterior of the station belies the comforts inside. At No. 9, one of the numbers giving the address on the front of the 40-year-old fire station is gone, replaced with a makeshift "4" constructed out of duct tape.

Overall, however, the place is in good shape. It's huge compared to other stations and can fit an engine, a 50,000-pound hook-and-ladder truck, the ambulance, a pickup truck and the battalion chiefs truck.

While government funding has been steadily increasing over the years, it isn't enough to keep up with the pace of required improvements. In April, a $744 million bond measure failed that would have built more police and fire stations.

"If we had the bond money, we could replace (the stations) that are over 50 years old," said Capt. Bill Wells of the Los Angeles Fire Department. "Some of our stations in South Los Angeles have to sit their ambulances outside all day and all night... bond issues are our only way of replacing fire stations, and it's where our capital improvement funds will have to come from."

City fire officials say the bond proposal also would have helped them meet their goal to respond to 90 percent of all emergency calls within five minutes.

Right now, the average response time in Los Angeles and the San Fernando Valley is 5.5 minutes for the first unit to show up from the time 911 is dialed, with the paramedic ambulance showing up one minute later. In the county, the average response time for first units on the scene is between three and four minutes, and a privately contracted ambulance usually shows up within six minutes.

According to standards released by the American Medical Association, emergency medical response in urban environments should be under eight minutes.

Back on the street

Later, at around 9:30 p.m. Granucci and Balchowsky (who by this time has replaced Hemandez) are back out. The streets are mostly empty, except for a stunning woman in a white tube top and high heels loitering in a doorway. Her curly hair is teased and towers above her head. She stares at the ambulance and even from the street it's clear she is wearing an incredible amount of makeup.

Except...

"It's not a woman," Granucci says. "It's a HeShe. Look at the size of the hands and feet. You can always tell."

Granucci says paramedics regularly get calls for help from transvestite prostitutes who have been severely beaten by their customers.

"You always see guys cruising down this street by themselves -- and. they don't realize they're looking at men," he says. "Then things get going... and they realize it's a man and they flip out."

Paramedics look at this world as a war zone. They enter it during the worst kinds of crises and try to salvage who they can. As often as not, their overdose patients become enraged at them for killing their buzz, and their trauma victims admit that they would rather die than continue their lives on Skid Row.

While these paramedics focus on their jobs on the front lines, the question of how their support system-- the trauma centers, the number of ambulances and the quality of the stations -- will handle the pressure of more emergencies remains.

"We're over-bedded in Los Angeles hospitals with the need we have, but we're under capacity in regard to the need for emergency services," Loft said. "We are in crunch time right now."

Traffic a Major Hazard

A woman suffers a stroke in a downtown restaurant and is en route to County-USC Medical Center in the back of an ambulance. The sirens are blaring, the lights are flashing, and the driver, as required by law, is pausing at each intersection to make sure no one careens into the vehicle.

At Fourth and Alameda, every single car stops. Except one.

A silver Porsche Boxster races through the intersection, heading north on Alameda. It misses the front of the ambulance by about five feet. The car is close enough to see the expression on the driver's face: he's totally surprised.

Getting an ambulance through traffic is the most obvious hazard that paramedics have to deal with in Los Angeles. And learning the ropes is largely dependent on lots of on-the-job training.

"Here are the keys, here's how you work the lights, and don't crash," is the way Chris Granucci, a paramedic for the Los Angeles Fire Department, describes his training.

The one piece of shared wisdom among paramedics is to keep an eye out for swank cars -- the nicer the car, the less likely the driver is to stop.

"The way they sell the new cars now is by advertising that they keep out the outside noise," said Capt. William Wells of the Los Angeles Fire Department. "We're that outside noise."

There are high-tech traffic solutions in the planning stages, Wells said. Currently on Ventura Boulevard, buses have devices that can turn the lights at each intersection to green to keep the buses running on time. A similar device is being tested for ambulances.

But what if the problem is more severe, like the 405 being tied up for miles in each direction because of a crash?

Caltrans has constructed lanes with enough room for emergency vehicles to get by, either on the center divide or on the shoulder. In the case of a massive freeway tie-up, the dispatcher will also send two ambulances to the scene, one from either direction.

"Sometimes the reporting party doesn't know what side of the freeway they're on, or exactly where they are," Wells said. "By sending two, we get to it quicker, and one of the ambulances can see it and pass along the location."

There's also another, albeit more expensive way to avoid traffic, according to Capt. Steve Valenzuela of the Los Angeles County Fire Department: approach the crash scene by air.

"Helicopter transport is a major evolution in our services," Valenzuela said.

The county has four helicopters that are equipped to transport trauma patients to hospitals, specifically from car crash sites, ocean or mountain rescues. In the county service, crew members are all trained paramedics who can sustain the they land at the nearest hospital with a trauma center and a helipad.