A man loses a finger near Pier 33 and waits 40 minutes for an ambulance to take him to the hospital.
Firefighters spend 20 minutes giving an unconscious man CPR on Market Street before medics drive him away.
A 91-year-old woman waits for an hour and 20 minutes to be transported to the hospital after calling 911 from her Mission District home.
These incidents point to what emergency workers say is a lack of investment in the people and equipment necessary to help respond quickly to those in need - and points to the bigger problem of whether San Francisco is equipped to deal with both everyday and large-scale emergencies.
Ambulances, emergency rooms and dispatch centers are perennially understaffed, workers say, which regularly leads to backlogs at the 911 center, forces noncritical patients to wait for transportation to hospitals, and leaves patients lingering for hours before they can receive care or a bed at San Francisco General Hospital, the city's only trauma center.
Fire Chief Joanne Hayes-White and other city leaders said they are making changes to help deal with the problems, such as an increase in 911 calls, which have jumped by nearly 22 percent between 2007 and 2013, according to a recent city report, likely because of an increasing population.
"The system is strained," Hayes-White said. "On an average day in the city ... we make it work. Should we have more resources? Yes. We are in a building mode. ... There's an additional strain I have noticed in the last six, nine, 18 months."
Hayes-White, Emergency Management Director Anne Kronenberg and Roland Pickens, who oversees patient care for the Health Department, all noted that the city's 2014-15 budget includes money to hire emergency workers and buy new ambulances. They insist San Francisco and the Bay Area have plans in place for bigger disasters and stress that critically ill or injured patients are never turned away or asked to wait for care.
But people who staff the city's ambulances, dispatch centers and hospitals painted a picture of overtaxed workers in already high-stress environments and say low morale has become the norm. They say dispatchers are struggling to pick up 911 calls, ambulances are taking more time to arrive at medical emergencies and patients are often waiting for care at the hospital.
At the Fire Department, broken-down ambulances and short staffing have resulted in a drastic increase in "medic-to-follow" calls - that's when a fire engine responds to a medical call within five minutes, but an ambulance doesn't arrive to transport a patient until later.
Local 798 President Tom O'Connor, whose union represents firefighters and medics, said the division's staffing shortfall is putting patients at risk. He said medics have worked up to 48 hours of mandatory overtime in a single week.
"Our great concern right now is that we don't have enough people to staff all the ambulances necessary to respond to 911 calls," he said. "People are waiting for an ambulance for 20, 30, 40 minutes."
City records show that medic-to-follow calls occurred nearly 2,500 times in 2013, up from about 2,000 in 2012.
O'Connor said the city is falling short of state mandates that require it to respond to 80 percent of all calls for ambulances (two private companies respond to the rest). And a May 12 memo to Hayes-White from Deputy Chief Tom Siragusa raised concerns about what he called an "unusual" number of medic-to-follow calls in the preceding month and cited one day in particular with "unacceptable" wait times.
"I am concerned that a serious negative outcome will be the result of a lack of medical units available," he wrote. "The current medic situation is unacceptable and needs to be addressed as soon as possible."
Equipment issues also plague the department, officials say. On any given day, nine of the department's 45 ambulances are in the shop for repairs, said Assistant Deputy Chief Ken Lombardi, though only 16 are generally on the street at any given time.
Medics said the bigger problem is when ambulances break down during emergencies.
Last summer, as crews responded to a shooting at a South of Market jewelry store that left two people dead, one ambulance was unable to get its back doors open, forcing the crew to borrow another vehicle to transport the injured suspect to the hospital, according to a medic who did not want to be named.
City leaders say they are beginning to tackle these issues.
The fire chief asked the mayor to include an extra $10 million in next year's budget for 42 new medics and equipment, and received $3 million - enough for 16 new hires, the refunding of a supervisor's position, three additional ambulances and other supplies.
In all, the department expects to have 19 new ambulances by next year, as it buys vehicles that were funded in years past but took a long time to procure.
But union officials believe the department needs 53 new employees and to fill dozens more vacancies.
Workers at San Francisco General Hospital say they are also frustrated by a lack of resources.
Nurses at the city's main emergency hospital say it is regularly understaffed, in part because the city has failed to hire dozens of nurses even though money exists in the budget. Perennial bed shortages often result in patients who are ready to be transferred out of the emergency room staying there for hours, taking up space that other patients need. And ambulances carrying noncritical patients are, on average, being diverted to other hospitals nearly 40 percent of the time because of the staffing and bed shortages.
Nurse Liz Hewlett said she was on duty in the hospital's trauma unit last July when an Asiana plane crashed at San Francisco International Airport, killing three people and injuring 180. She said off-duty hospital staff rushed in and nurses already at the hospital hustled to move patients around to make room for the casualties.
"I think, personally, that the hospital stepped up to the plate that day - it was the best day of my nursing life, because I got everything I needed to do to do my job," she said. "But the next day, it was back to the same thing: fighting for nurses, fighting for supplies."
Pickens, who oversees patient care at the Department of Public Health's institutions, said city officials have both short- and long-term plans to address some of the issues.
The agency will be adding 18 full-time emergency room nursing positions at General Hospital in the coming fiscal year, he said. And while the hospital's 37 percent ambulance diversion rate is high, Pickens noted that General Hospital never turns away critical patients.
Rebuilding the hospital
The city is also in the midst of an $890 million rebuild and expansion of the hospital, which is to be completed by the end of 2015. The new emergency room will be double the size of the current one, he said.
"I think we have pretty robust infrastructure when it comes to responding and surging up for disasters," he said. "We are not an island all by ourselves, all hospitals in the city try to come together, and we share resources, share the burden - that's why we have a coordinating Office of Emergency Management - if one hospital is overburdened, we will shift to another."
Yet Department of Emergency Management dispatchers say the problems start when citizens call 911.
Dispatchers are struggling with both staffing and technology - particularly a new, $3.7 million 911 dispatch system that rolled out last month. In its early days, police and fire officials complained that officers were having trouble getting information from dispatchers on their computers, forcing them to take written notes while listening to their radios.
And dispatchers say the new system is far more time-consuming and cumbersome than the old one.
"It takes several more steps to do the same things we used to do," said Sean Dryden, who has been a dispatcher for four years. "It's compounded an already bad situation with staffing. ... It's definitely a public safety issue, first because hold times are going to be longer, it takes longer to process each call, and it's harder to find information, not only for us but for police officers."
Callers on hold
Even before it launched, they said, 911 callers regularly had to wait on hold because of understaffing. According to a recent city controller's report, San Francisco only answers an average of about 80 percent of 911 calls within 10 seconds. Union officials said that's far below the standard set by the National Emergency Number Association, which recommends a 10 second response 90 percent of the time.
Kronenberg, whose department manages the 911 system, and Robert Smuts, the agency's deputy director for emergency communications, said the new system has some bugs that are being worked out but overall the transition went smoothly. It's taking time for dispatchers to become comfortable on the new system, they said.
"We had a dinosaur (of a system) in here, and the dispatchers were very used to it," Kronenberg said. "We knew there would be glitches - anytime you have a project that ... huge, no matter how much testing and planning and training you do, there are always things that happen."
Smut said the number of calls the agency handles, including police, fire and medical, has also risen sharply in recent years - 22 percent between 2010 and 2013.
Kronenberg said she has pushed for more dispatchers and that 10 new hires are finishing their training. Another 10 will start this fall.
Investing in staff
But workers question whether those hires will keep up with the agency's attrition rate or result in enough call takers on busy days. The union that represents dispatchers believes there should be one call taker for every 50,000 people in the city at any given time - or about 20 people during the work day or big events. Currently, said Dryden, there are only eight to 10 dispatchers working during those times.
The problems have caught the attention of some City Hall leaders, who say San Francisco government as a whole needs to stay focused on broadly investing in staffing and resources, not just responding to problems as they flare up at individual agencies.
"What I am concerned about is making sure we are consistently moving in a direction of replacing our emergency vehicle fleet and replacing and adding to our emergency response teams ... not just letting institutional knowledge walk out the door when folks retire," said Supervisor London Breed, a former fire commissioner. "We can't ignore the fact that we always need police officers, firefighters, paramedics - these are kinds of things that protect lives and safety."
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