By Deborah L. Shelton
Of the Post-Dispatch

Feb. 4, 2001

Edited by Virginia Baldwin Gilbert

For four months, Genevieve Geisel has been unable to shake a nagging question.

Did a local hospital break any laws when one of its nurses turned her ambulance away last fall?

It wasn't until she recognized her story Monday in a Post-Dispatch article on hospitals diverting ambulances that Geisel learned that a health care agency had determined that the hospital had in fact violated federal law.

On Oct. 2, an ambulance carrying Geisel, who had been injured in a car accident, was turned away from St. Anthony's Medical Center in south St. Louis County. Twenty-two minutes later, on the way to another hospital, she had a heart attack.

Geisel, 59, survived. But she now must undergo cardiac rehabilitation three times a week.

On Friday, David P. Seifert, St. Anthony's president and chief executive, offered an apology to Geisel and -- for the first time -- a thorough explanation of what happened.

"It should not have happened, and it will not happen again," he said in an interview. "There was no excuse for it."

Details filled in by the hospital and Geisel of this incident offer a rare glimpse into the complex world of emergency-department overcrowding and how multiple factors can compound to create a potentially dangerous situation.

While Geisel's emergency-room experience may seem extreme, diversions take place every day in emergency rooms throughout St. Louis and virtually every metropolitan area in the country.

On any given day, it's not unusual for three or four emergency rooms in the St. Louis area to be closed to ambulance traffic. On one particularly bad afternoon last month, nearly all of the emergency departments in the area were closed during the same two-hour period.

Health care officials say several trends have led to emergency department overcrowding and the frequent diversion of ambulances:

* An increase in the number of people seeking nonemergency care in emergency rooms.

* Shortages of nurses to staff beds throughout their facilities.

* A higher proportion of older, sicker patients seeking emergency care.

* The closure of several hospitals in recent years.

* Too few critical-care beds available in hospitals for those admitted through the emergency room.

Although emergency-room diversions occur throughout the region, the problem has been particularly severe on the Missouri side of the metropolitan area. Illinois hospitals have not experienced a similar rise, at least in part because of stricter rules placed on them by the Illinois Department of Public Health.

An unexpected ride

It was 4:40 p.m. on Monday, Oct. 2, and Genevieve Geisel was driving from her home in the St. Louis Hills neighborhood in St. Louis to her job at Ackley Uniforms in Crestwood. While headed west on Watson Road, just east of Trianon Parkway in Shrewsbury, she was struck by a car making a left turn.

She was uncertain at the time how badly she was hurt. But she felt intense pressure on her back. A witness called the Webster Groves Fire Department. Paramedics soon arrived, hooking Geisel up to oxygen and an intravenous line. Her daughter, Donna, was called and soon joined her in the ambulance, sitting in the front passenger seat.

Genevieve Geisel's doctor practiced at St. Anthony's Medical Center. So the ambulance headed there.

By 5:22 p.m., just before the ambulance arrived, the emergency department at St. Anthony's was crammed with patients. Forty-two people were being treated, 20 had been examined and were waiting to be moved to a hospital bed, and 17 others were lined up yet to be seen.

Because of the overflow, the hospital had declared itself on diversionary status and ambulances were being told to go to other hospitals in the area.

About 20 seconds from arrival at St. Anthony's, the ambulance carrying Geisel pulled onto Kennerly Road from Tesson Ferry Road. It was then that they radioed the hospital for the first time, hospital officials said.

On Friday, St. Anthony's officials allowed a Post-Dispatch reporter to listen to an audiotape of communications between the paramedics and the hospital dispatcher. The tape also captured a comment by the nurse involved in the incident. It hints at what would happen next.

"Tell them to go somewhere else," the nurse can be heard saying on the tape - even as the hospital dispatcher was telling the ambulance crew to bring the patient inside.

As paramedics were preparing to remove Genevieve Geisel from the back of the ambulance, the nurse came out of the emergency room. He told them the overburdened emergency room was full and the patient had to go elsewhere, Donna Geisel said.

"It didn't cross my mind that we should force the issue," said Donna Geisel, 27, of St. Louis. "We were in shock.

"We looked at each other, like: 'What do we do now? Where do we go?' she said. "The paramedics and I got back in the ambulance."

Paramedics called St. Joseph Hospital in Kirkwood, which agreed to accept Geisel. About 22 minutes later, she suffered a heart attack on arrival. She was admitted in critical condition.

Breaking the law

Seifert said St. Anthony's officials began to reconstruct the chain of events to figure out what went wrong after they were alerted by a doctor at St. Joseph. The doctor called the following day to complain.

Genevieve Geisel doesn't know whether the diversion contributed to her attack. But she is angry at the way she was treated. She didn't know at the time that St. Anthony's had broken its own health care policy and the law.

In December, the Health Care Financing Administration concluded that St. Anthony's violated a federal law that requires hospitals to evaluate and stabilize every emergency patient that comes on their property. The federal agency is charged with enforcing the law, known as the Emergency Medical Treatment and Active Labor Act.

During the investigation, which was conducted by the Missouri Department of Health, Geisel was never contacted nor interviewed. She also was not identified by name in the investigative report.

St. Anthony's could have faced stiff penalties, including a fine and termination of its Medicare contract. Instead, federal officials chose to accept a plan of correction the hospital had already implemented: mandatory educational sessions for emergency staff on the law they violated.

A complex problem

Hospital officials accept full responsibility for the incident, Seifert said Friday. But he said there were errors in judgment by others that afternoon that further compounded the problem.

Paramedics "should have called in earlier," Seifert said. If they had done so, a decision could have been made earlier to transport Geisel to another facility, he said.

Paramedics also didn't express any sense of urgency about her condition, he said. "If there's a critically ill patient, there is usually a lot of conversation back and forth, and they will call in at least a couple times," Seifert said. But according to the audiotape, only one call was received. At that time the ambulance was only seconds away.

Webster Groves Fire Chief Mike Capriglione said he couldn't comment on the timing of the paramedic's call because the case could eventually end up in litigation. But he said "the paramedics involved took all the appropriate actions and made the appropriate notifications."

Paramedics say that emergency rooms go on diversion too often, making their job difficult. Some say that during the worst times they have been forced to pull to the side of the road or circle the streets looking for a hospital willing to accept patients.

Hospital officials say they must sometimes divert patients because their care and safety could be jeopardized in an overwhelmed facility.

Genevieve Geisel was unaware of the debate over diversion. But for one afternoon, she found herself thrust into one of the most pressing and complex issues facing emergency medical care today. For her, the issue was simple.

"I was in pain," Geisel said. "I just wanted to get somewhere where I could get help."