SAN FRANCISCO -- In an earthquake-resistant bunker in the Western Addition, dozens of dispatchers are fielding 911 calls.
Call-takers tethered to phone headsets are typing vital information into computers and tossing it to others who assign police, fire and medical rescue units.
"It's like Battlestations, or another multifaceted video game," said dispatcher Dorian Lok, sitting at the "Fleet Seat" console with an array of four computer screens that monitor the city's ambulance fleet. "When it just flows, you have an adrenaline rush. It's like a team sport. Everyone knows what they're supposed to do."
Swift responses save lives, but the city's ambulances and fire engines are often late to the scene.
A Chronicle investigation of San Francisco's 911 dispatch system found that 27 percent of first responders arrive late on the scene of high-priority medical emergencies - increasing the medical risks to the stricken. Many of the delays are the result of slow processing of 911 calls.
The newspaper's review of about 200,000 emergency medical calls during the past four years found that at least 439 people died while waiting for a late ambulance or after delayed medical help arrived.
City officials are exploring potential solutions to reduce ambulance delays but have found there is no instant cure.
According to 911 medical experts, the elements of a model system include well-trained dispatchers, a sufficient number of ambulances and medics, efficient record-keeping, prompt responses to all neighborhoods, systemwide accountability, and a high rate of success in saving victims of sudden cardiac arrest.
San Francisconeeds to increase its recruitment of 911 dispatchers, national and local experts said, and enhance their training with updated manuals and protocols.
Local experts said the city should consider purchasing new ambulances, at a cost of about $100,000 each, to help reduce delays by deploying more units, and improve maintenance of its older ambulances.
Experts also recommend the hiring of additional paramedics for early morning and peak hours when delays are worse, and more personnel for the Fire Department's unit for patient-care audits, internal inquiries and analysis of response times. They also urge the city to increase its liaison work with the homeless to deter improper 911 calls.
"We are constantly looking at calculating different approaches to 911," Mayor Gavin Newsom said. "A new, robust system is in order."
Emergency officials have recently taken steps to streamline the dispatch center's call-processing procedures for medical calls to help improve the city's overall response times. They are also attempting to redeploy ambulances to better serve all neighborhoods.
But technical and human factors continue to hamper the city's emergency medical responses, including the culture clash between paramedics and firefighters and unresolved issues such as how best to deploy ambulances and crews.
An avalanche of 911 calls
San Francisco dispatchers are overwhelmed by the number of police, fire and emergency medical calls that need to be processed.
The city is among the few where the same dispatchers handle a mix of police, fire and medical calls - as well as nonemergency calls.
Dispatchers and 911 medical experts have given such systems mixed reviews.
"There is more prompt service and units are dispatched more quickly, but at what cost to the dispatcher?" said Diane Paulsen, a dispatcher. "I think the stress level has gone up."
Most of the 900,000 emergency and nonemergency calls received each year by the 911 call center at 1011 Turk St. are related to public safety. Many of the calls are transferred from seven-digit public help lines for the police and fire departments.
Emergency officials hope that the city's new center for 311 public service calls, which opened last year in another location, will help deter people from dialing 911 for nonemergency calls. The 311 system currently handles about 75,000 calls per week.
The 911 call center suffers from serious staffing problems. Yet recruitment does not seem to be one of the center's priorities. Its budget includes recruiting ads for city buses and trains. But its recruiters seldom visit job fairs and schools in search of candidates.
There are currently dozens of vacant positions at the call center, reflecting a nationwide shortage of qualified dispatchers.
It's an intense job that requires split-second judgments and precision, computer literacy, people skills and the ability to multitask. In medical emergencies, a 911 call-taker must not only extract relevant information from often-panicked callers, but also deliver triage instructions to help patients while paramedics are en route, such as advising a caller on how to handle an infant who is having an epileptic seizure.
"People think we're just telephone operators, but there's a lot more to it," Paulsen said.
Job stress has prompted some dispatchers to transfer to smaller Bay Area cities that offer signing bonuses of thousands of dollars for fully trained dispatchers. Others have become police officers and firefighters. Some have become exhausted and go on the disabled list. Still others are unavailable because they are receiving on-the-job training or out on maternity leave.
Dispatcher Janet Selinger-Noa said the worst part of fielding calls is "getting someone who's just hysterical or noncooperative."
"Sometimes the public can be horrific," she said. "They don't understand why we're asking questions. They may think we're interrogating them for a lengthy amount of time, assuming that we're not helping them."
The city's 911 dispatchers are encouraged by managers - and even ordered at the last minute - to work overtime. To keep the center staffed, the city spent about $2.6 million last year on overtime - enough money to pay the annual salaries and benefits for about 25 additional dispatchers.
San Francisco dispatchers have an annual salary range from $63,180 to $76,778, plus overtime.
"The room only operates on the willingness of workers to put in tons and tons of overtime," dispatcher Louise Lopez said.
Dispatchers also say they have difficulty scheduling personal days off. Some bleary-eyed workers have been reprimanded for falling asleep on the job, and others have made dispatching errors.
"We're in a unique predicament," said dispatcher Vanessa Francis, who commutes from Sacramento. "The public can't afford mistakes."
In November, 911 call-takers were given new orders: They were told to send help immediately when a call sounds like an urgent medical incident, before asking for additional information. This decision has lowered dispatch times by about 30 seconds, according to the newspaper's analysis.
Laura Phillips resigned recently as executive director of the Department of Emergency Management, which oversees the 911 center. Mayor Newsom's press secretary, Nathan Ballard, said her transfer to another job as a program director in the same agency was mutually agreed upon.
New deployment strategies
Since 2006, fire officials have experimented with posting ambulances at busy corners, but response times of ambulances and fire engines have not changed significantly, according to The Chronicle's analysis of urgent medical calls. The percentage of delays has gotten worse in five of the city's 10 emergency districts, improved in four districts, and remained about the same in another district.
Reasons for delays include the lack of an available ambulance nearby, traffic congestion, an erroneous street address, or a crew's unfamiliarity with an area if it is dispatched from another part of the city.
The volume of 911 medical calls is heaviest from 9 a.m. to 4 p.m., but responses are slowest between 4 and 6 a.m., when ambulance staffing is the lowest.
Residents of the Western Addition, Cole Valley and the Haight wait the least amount of time for 911 ambulance service. Residents of neighborhoods in the Ingleside and Excelsior districts such as Miraloma Park and Visitacion Valley suffer the longest delays.
Since March 2006, the number of ambulances assigned 24 hours a day to fire stations has been cut from 19 to eight, while the other 11 units have been posted to busy street corners so they can respond more quickly to 911 calls. Soon, the number of 24-hour, station-based ambulances will be reduced to four.
"We're redefining what we're doing," said Pete Howes, the Fire Department's medical operations director. "We're studying the response times and workloads of the ambulances on a daily basis.
"We have had challenges for years in the southern part of the city and west of Twin Peaks," he added, saying that most of the city's hospitals are in the northern end. "We also have to work within our budget."
The Fire Department's $258 million operating budget this year covers all firefighting and emergency medical costs. About 88 percent of the budget pays the salaries and benefits of firefighters, paramedics and civilians. The rest goes to such items as supplies and the maintenance of fire stations.
Howes said the reduction of 24-hour ambulances has eased the schedules of paramedics, reducing fatigue and the chances of traffic accidents and clinical errors.
But the redeployed units have each been assigned only two, 10-hour crews, resulting in fewer ambulances on duty from 2 to 6 a.m., when delays often occur. This scheduling is needed, Howes said, to put more paramedics on duty during busier hours. Still, the city's shortage of ambulances during peak hours often results in dispatchers sending a fire engine to a high-priority medical call without an ambulance as backup.
About three-fourths of the city's firefighters are certified as emergency medical technicians, or EMTs, who can provide basic lifesaving services.
To save money, the agency has begun posting one paramedic and one EMT on its ambulances instead of two paramedics. Such staffing can reduce quality of care, some medical experts said, because two paramedics are better able to ward off fatigue, fully assess a patient and quickly employ procedures in acute cases such as administering drugs or performing an intubation to open an airway.
Multiple units often show up at medical emergencies. Dispatching more than two units may be "over-triage," Howes said, but it ensures the presence of at least two paramedics on scene and the muscle for difficult situations.
It also means that those rescue crews are temporarily unavailable to respond to other 911 calls.
Howes assigns about 25 paramedics a day to fire engines and plans to raise that number to at least 31 this year. "The resources are already out there for fighting fires," he said. "By posting a paramedic on a fire engine, we enhance the capability of the team."
A question of priorities
Dr. John Brown, the Public Health Department's emergency medical director, said the fire agency will need to deploy additional ambulances or find better ways to manage its current fleet to meet the city's standards.
Fire Chief Joanne Hayes-White told The Chronicle that firefighting and ambulance services are "equal priorities," but her assertions are disputed by some rank-and-file paramedics and firefighters.
"If 70 percent of our calls are medical, why do we have 42 fire engines and only 20 or so ambulances?" asked Paramedic Capt. Mike Whooley. "If the call volume continues to rise, why aren't we actually adding ambulances?
"We're running some ambulances that are 10 or 12 years old," said Whooley, explaining that the city's hilly terrain quickly wears down ambulances' brakes and engines. "We've had to sideline crews because we haven't had units to put people in."
The fire chief said the department has plenty of ambulances in good working order and has increased its on-the-job training and supervision of paramedics to enhance their clinical skills. "We're doing cutting-edge procedures for pre-hospital care," Hayes-White said. "We're investing in new equipment."
Paramedics will be equipped this year with new 12-lead electrocardiograms to identify patients who are having a heart attack, and also electronic patient charts to study the efficacy of paramedic procedures and patient outcomes.
The Fire Department provides medical care or transport to about 70,000 patients a year, but it has a lean staff to review ambulance delays and patient records, including cases in which patients died after receiving a late response.
Budget pressures have led the agency to reduce its monitoring of pre-hospital care.
Last year, its "quality improvement" unit was reduced from two full-time staff members to one person because of a vacancy left by a departing staffer - resulting in fewer audits of patient services.
There are plans to install a computerized vehicle location system that will employ time-stamped, Global Positioning System data to better track the locations of ambulances and fire engines and to provide more accountability for response times. An ambulance's precise physical movements will be recorded. The city's current system allows only general tracking of units from one area to the next.
Emergency officials also plan to begin using "predictive intelligence" software in the call center this year to forecast where ambulances will be needed - based on historical patterns of call volume at different times of day - and to quickly reposition units as needed.
San Francisco has grappled before with the adequacy of its 911 dispatch system.
A management audit after the 1993 shootings that killed nine people at the 101 California St. office tower concluded that the 911 dispatch center, previously located at the Hall of Justice, "has suffered from benign neglect for most of its existence." It found that the center had a shortage of call evaluators and dispatchers, and that about half of its incoming calls were for nonemergencies.
Four years later, direct control of the city's ambulance service was transferred from the Department of Public Health to the Fire Department for budgetary and political reasons.
The decision, which came as fire agencies nationwide were taking over ambulance duties, sparked resistance from firefighters. Paramedics assigned to some firehouses were forbidden to park ambulances inside the station. Others were chased out with mops and obscenities.
The tensions between paramedics and firefighters undercut the quality of pre-hospital care. The culture clash between the two groups has eased in recent years, but some animosity lingers.
"We respect the firefighters. They're great," said Whooley, a paramedic since the 1980s. "And they can be great medics when they want to be. But they don't respect us. ... You shouldn't have to defend your job every day and what you do for a living."
"It was a rough transition at the start," firefighter Hal French said. "Old attitudes die hard. ... But it's gotten much better here."
Some firefighters voice an earnest commitment to medical calls.
"It's our job - without delay. As soon as the tones go off, everyone's out the door," said Stephanie McKnight, a firefighter for Engine 21 in the Western Addition.
Jonathan Best, a Connecticut-based expert on 911 medical services, said San Francisco appears to have a "synergy of technical and human factors that are contributing to a poor result."
Emergency officials "need to address each of these factors individually" in hopes of making small gains and overall improvement, Best said. "It's not simple for a city like San Francisco."