LAFD's SOBER Unit Finds Success in Early Going

As firefighters around the country begin to fully understand that the new normal is an abundance of medical calls, some fire departments are thinking outside the box and developing creative new ways of maximizing resources to better serve the public.

The Los Angeles Fire Department (LAFD) has done just that with a one-year pilot program called the Sobriety Emergency Response (SOBER) Unit, which aims to provide better and more efficient medical care for inebriated individuals while helping these patients utilize social resources to combat their addictions.

In an exclusive interview with Firehouse.com, Dr. Marc Eckstein—the EMS Bureau Commander and Medical Director for the LAFD—talked about the genesis and goals behind the SOBER Unit and some of the early success he's seen so far.

"I've been in EMS for about 30 years, and it's no secret to anybody at any level in EMS the number of serial inebriates that we respond to and transport," Eckstein said. "And it's obviously quite the revolving door given the recidivism. Our medics roll all day long on these patients."

As any firefighter or paramedic can attest, suspected inebriate patients are in altered mental states and often require Advanced Life Support transport. California law mandates that paramedics transport inebriates to the nearest emergency room—regardless of whether or not the facility has available psychiatric care.

One of the main issues facing the LAFD is that hours can sometimes go by while a paramedic or EMT remains at an emergency room with a "walled" patient.

"It's a morale killer for our medics because they're unable to respond to the next call. That's just another reason to say, 'Hey, let's try a different approach.'"

In Los Angeles, a great many of these inebriate ER transports are homeless people who receive varying degrees of workups Eckstein says are often "redundant, expensive and unnecessary." They're then sent back out onto the streets and the cycle of alcohol abuse repeats itself.

"We have over 50,000 homeless people living in the county, and a high percentage of these individuals are struggling with alcohol. It has a huge impact on our EMS system and on the hospitals. We have to do something."

So what if the cycle could be broken by not only the capabilities of the facility where these patients are transported but also by the versatile makeup of the first responders who assess and care for them?

After the Los Angeles County Department of Health Services opened the city's first sobering center on Skid Row about a year ago, Eckstein saw the perfect opportunity for the LAFD to launch the SOBER Unit and form a partnership with the center to ease the burden on fire department resources and hopefully provide better patient outcomes.

A non-profit group from Exodus Recovery staffs the sobering center, while the SOBER Unit—which for now predominantly covers the Skid Row area 40 hours a week—is made up of LAFD firefighter/paramedic Eric Ingstad, nurse practitioner Nancy Richardson and case worker Victor Chavez, the latter two provided by the center.

"In terms of patient safety," Eckstein said, "to have a nurse practitioner who obviously has a much more extensive amount of medical training and clinical experience to be able to medically clear the patients, and team her up with an experienced paramedic who knows field operations, scene safety and those elements. And the third component of a case manager who fills in the gaps by establishing a rapport with the patients."

That rapport provided by the case worker is essential to the SOBER Unit and the sobering center functioning in tandem because the patients have to be willing to be transported to the center if the paramedic and nurse practitioner are in agreement on the assessment.

"They've really created a formidable team."

Protocols are in place for the on-duty hours of the SOBER Unit, which can be called in directly from dispatch under certain patient criteria or by other first responders who arrive and do a preliminary assessment. If a patient agrees to be transported, the transfer of care is rapid and patients can speak to a mental health professional sometimes within 20 minutes as opposed to waiting for hours at a hospital.

"Patients are able to metabolize the alcohol in their system in a safe and monitored setting," Eckstein said of the center. "There is a nurse or a (medical practitioner) there 24/7. The patients are then offered social services to help them detox and eventually break the cycle."

Since the program launched in mid-November, Eckstein says around 100 patients have been taken to the center, which works out to about 4.5 transports per shift for the unit. That may not seem like much, but with every minute or even hour that can be shaved off these incidents, it can only benefit a big city fire department running around 150 ambulances to 1,000 calls and making between 600 and 700 transports per day.

"We're really excited about the opportunity here," Eckstein said, adding that the response from out in the field has been outstanding. "It's a win-win for everybody. It ultimately benefits the patients, saves taxpayer money and frees up our very busy field resources."

Eckstein also pointed out that his SOBER Unit paramedic works within the scope of his practice to avoid any potential liability and that standard HIPAA protections are in place. The LAFD also plans to be fully transparent with the data it receives on patient outcomes and will adhere to strict evaluation practices.

"We're monitoring this very carefully. It's a one-year pilot program to basically demonstrate safety and efficacy. And we're hopeful that Health Services will open additional sobering centers around the city."

While Eckstein's primary mandate is to provide outstanding medical services, there's no denying he understands how valuable certain resources are to the LAFD as a whole.

"We can't keep sending fire engines and trucks and paramedic ambulances to patients who are hearing voices or serial inebriates. We have to better match the demands with our service. And when we send the wrong resources, we may be compromising someone who needs the services of a fire engine or paramedics.

"And then adding insult to injury, we're taking a patient to a place where they won't get the care they really need."