You have sudden pain and call 911 for an ambulance. But instead of a five-minute trip to Howard County General, the driver takes you to a hospital 20 minutes away in another county.
For an average of 27 times a month from April through August, Howard County General was on Code Yellow -- too full for emergencies in which patients weren't in immediate danger of dying.
During the alerts, each of which lasted an average of 2.1 hours, ambulances were sent to Laurel Regional Hospital or St. Agnes Hospital in West Baltimore.
The Code Yellow policy, which most hospitals in the state follow, frustrates patients and doctors. It applies only to ambulances transporting patients, not to walk-in visits.
But during the hospitals' busiest times -- when filled stretchers line their halls and patients wait hours to see doctors -- officials say that sometimes the longer ambulance trip can result in faster care.
"Patients are not being hurt by the hospitals being on by-pass," ++ said John Donohue, Emergency Medical Services (MIEMMS) administrator for Baltimore City and Baltimore, Harford, Howard, Carroll and Anne Arundel counties. "It might be a little more inconvenient, but they get better attention."
Dr. David Paul, director of the emergency department at the county's only inpatient facility, said the system "is designed to produce the greatest good for the greatest number of people."
But Carl Behrens, whose elderly father relies on Howard County General for emergency care, questioned the rationale for hospitals sending patients elsewhere.
"When you reroute you're not doing your job anymore," Mr. Behrens said. "Hospital emergency departments are there to serve emergency health care needs of the community."
Mr. Behrens recently drove from his Burtonsville home to Columbia and then Laurel when told that his father had been taken by ambulance from Columbia to the Laurel hospital, which seldom turns away ambulances because its emergency room is full.
But 89-year-old Carlton Behrens had refused to be diverted to the Laurel hospital and then was returned home. He was OK, but his son was alarmed.
"I thought, did something happen?" said the younger Mr. Behrens. "With a longer transport when you're elderly, a lot of things could go on. I had never heard of this yellow alert business before."
But yellow alerts are common.
In August, when the hospitals statewide averaged 10 alerts, Howard County General went on yellow alert 32 times at an average of 2 hours and 15 minutes per alert.
For that month, that meant there were 69 hours -- nearly three whole days -- when ambulances transporting patients to Howard General could have been turned away.
The August totals were above average for the Howard hospital but within the limits set by the Maryland Institute of MIEMMS, which monitors the yellow alert system at 23 hospitals in the Baltimore metropolitan area.
Hospital administrators decide when their emergency rooms are too crowded to accept more patients by ambulance.
If two adjacent hospitals are on yellow alert, ambulance patients are rerouted to the next nearest hospital. In any case, the policy does not permit an ambulance driver to pass more than one hospital.
Under a new rule in April, hospitals can go on yellow alert no more than six hours a day and no more than two hours at a time. When they hit these limits, they have to get an exception from state monitors to continue with the yellow alert status.
Before the new limits, it wasn't unusual for hospital emergency rooms -- including Howard's -- to be closed to ambulance traffic the equivalent of one week a month because of yellow alerts.
In January, for example, yellow alerts at Howard County General hospital averaged 7.5 hours each time. Alerts at busier hospitals in Baltimore, Sinai Hospital and Northwest Medical Center, averaged 12 hours each time, MIEMMS records show.
State officials are studying the effects of the new alert system. An Emergency Medical Services task force will make recommendations to improve the yellow alert policy by early next year, said Mr. Donohue.
And for better or worse, Howard hospital officials said the yellow alert system is a necessity.
"We want to keep everybody here, but we can't put people at risk" while they wait in a crowded emergency room, said Susan Goodwin, Howard County General's senior vice president. "It's upsetting because we feel we can provide the best care."
Howard County General President Victor Broccolino said his staff is working to make the emergency room more efficient.
The hospital's "fast track" program provides four extra beds to get patients in less serious condition out of the emergency room quicker. More employees also are being placed on call to help when the emergency room begins to get crowded.
Although the hospital is expanding its outpatient facilities -- services that will help the hospital remain competitive with other health care providers -- hospital officials said there are no immediate plans to build a larger emergency room area to accommodate the 32,000 patients who visit each year.
The state cannot order hospitals with systematic crowding of emergency rooms to expand, Mr. Donohue said.
But expansion made Laurel Regional Hospital -- which takes many of Howard County General's yellow alerts -- more efficient.
Laurel hospital officials said that last spring that they tripled their emergency room -- to 22 rooms or treatment areas. For the 10 months ending in August, the hospital emergency room was filled only eight times, Laurel officials said.
"It's not really a staffing issue as it is a space issue," said Dr. Tom Burguieres, chairman of Laurel's emergency room department.
For ordinary citizens, the issue is fear of not getting the medical help they need, when they need it.
Elaine Margolis, co-owner of a senior-assisted group home in Columbia's Long Reach village, said at least two of her clients have been turned away from Howard General's emergency room. "It's really disturbing," she said.
The most recent incident, on Oct. 2, involved Mr. Behrens, who was found unconscious at the Long Reach home. When the ambulance was two minutes from Howard County General, the driver pulled over to inform Ms. Margolis, who was following in her car, that they were being diverted to Laurel Regional.
"It was a very strange occurrence," Ms. Margolis said. "There you are in the middle of an emergency, and they just stop."
Mr. Behrens, who had regained consciousness, refused to go to that hospital because his son was already on his way to Howard General. The hospital still refused to accept him.
The man's private doctor told rescue workers it was OK for him to go back home. Meanwhile, his son was trying to find where the ambulance had taken him.
"It made for a very trying afternoon," said the younger Mr. Behrens. "It wasn't fun for anybody."
Rescue workers said they also feel uneasy about yellow alerts because they see the anxiety on patients' faces when they are turned away from their local hospital.
"It does have an impact," said Chief Don Howell, head of Emergency Medial Services for the Howard County Department
of Fire and Rescue. "We're not transporting the patient to the nearest medical facility."