Family rushes to hospital

Word about Tate was spreading quickly among family members.

Her mother, Daisy Tate, received a call from Tiffany’s supervisor, who told her Tiffany had a serious reaction to her medication and that she was going to Froedtert. The supervisor didn’t mention anything about a stroke.

Daisy Tate dialed Tiffany’s brother, David, who was at his factory job in Waukesha.

She told him to get to the hospital right away.

David and Tiffany were especially close.

The pair were two years apart, and nearly shared the same birthday. The family, including their two older sisters, lived near N. 24th and W. Burleigh streets. As kids, David and Tiffany went to Auer Avenue School and learned to swim at nearby Moody Pool.

Their love of swimming translated into frequent trips to Wisconsin Dells water parks with their own kids.

To friends and family, Tiffany was “Tipp,” a nickname she picked up as a girl when she would often stand on her “tippy toes.” It was on her license plate.

Now, Tipp was in trouble. And David Tate had to get to her.

Across town, Alvin Blalock also got word something was wrong. He and Tiffany, his longtime girlfriend, had known each other for more than 10 years and were together for five. The couple planned to get married someday.

Alvin and Tiffany lived in the downstairs unit of a bungalow on Milwaukee’s near north side, with their newborn son and her 15-year-old daughter from a previous relationship. Tiffany’s mother lived upstairs.

Blalock was stunned by the news. Tiffany had seemed fine when she left for work. He didn’t have much time to think.

Blalock took 8-month-old Alex to stay with his mother and rushed out.

John Diedrich / Milwaukee Journal Sentinel Tiffany Tate's brother, David Tate.

John Diedrich / Milwaukee Journal Sentinel Tiffany Tate's brother, David Tate.

David Tate was already speeding to Froedtert, 10 anxious miles punctuated by calls to and from other family members.

As David ran through the front door and inquired at the information desk, he was shocked to learn his sister wasn’t there.

“It didn’t make any sense to me,” David Tate said in an interview. “Damn, she was at Froedtert. She works there. She was right there.”

David called one of his sister’s co-workers, who told him where Tiffany had been sent. David jumped back in his car and raced to West Allis.

He told his wife and father to meet him there.

Meanwhile, Daisy Tate got another call — this one from West Allis. A nurse said Tiffany had a stroke and was at the hospital.

The news hit Daisy like a bolt. She, herself, had suffered a mild stroke years earlier.

“I said, ‘Oh my God.’ I just broke down,” she said. “I knew what a stroke was like. I knew.”

Trying to get the attention of her granddaughter, who was downstairs, Daisy Tate frantically banged her cane on the wooden floor.

Octayvia Fountain ran up the stairs, but when she heard the news, she couldn’t process it. That morning her mom had come to give her kisses, like she did every morning. They were going to go together for school registration later that day. Octayvia would be a sophomore starting at a new high school in a few weeks.

To her, mom was “Superwoman.”

This can’t be happening, she thought. This can’t be happening.

John Diedrich / Milwaukee Journal Sentinel Tiffany Tate's daughter, Octayvia Fountain (left), and mother, Daisy Tate.

Rare option becomes common

The practice of ambulance diversion has long been under fire.

A 2001 report from the U.S. House Committee on Government Reform found diversions were so widespread they represented a threat to emergency medical readiness, including in the event of a terrorist attack.

In 2004, a study on diversion in Houston attributed several deaths to the practice.

Read more Patients in ambulances still being turned away from hospitals even as some cities end the practice Paramedics grapple with ambulances being turned away from hospitals even as other cities, including Milwaukee, ban the practice of ambulance diversion. Some hospitals turn away ambulances when the patients are more likely to be poor, study finds A study finds private hospitals are more likely to turn away ambulances when a public hospital is on diversion, suggesting hospitals may be diverting for financial reasons.

Read more Patients in ambulances still being turned away from hospitals even as some cities end the practice Paramedics grapple with ambulances being turned away from hospitals even as other cities, including Milwaukee, ban the practice of ambulance diversion. Some hospitals turn away ambulances when the patients are more likely to be poor, study finds A study finds private hospitals are more likely to turn away ambulances when a public hospital is on diversion, suggesting hospitals may be diverting for financial reasons.

Two years later, a report from the non-profit Institute of Medicine — which provides advice on health and medical issues to Congress and the government — concluded diversion “should be eliminated except in the most extreme circumstances, such as a mass casualty in a community.”

A 2017 study found that African-American patients had an increased chance of dying from heart attacks and strokes as hospitals in largely minority neighborhoods were going on diversion more often than others.

“Diversion has been aggressively abused,” said Corey Slovis, chair of emergency medicine at Vanderbilt University and the medical director for the Nashville Fire Department. “There is a diversion scandal, with too many hospitals going on diversion when they could be open.”

Study after study has found diversion does not even work.

The reason is simple: Ambulances account for only a fraction of patients arriving in emergency rooms. So, the front door is not really even closed.

Instead, experts say, the focus should be on the “back door” — getting patients already in the emergency room either discharged or admitted to the hospital.

“Picture pouring water into a cup that’s full,” said Howard Mell, an emergency room doctor and spokesman for the American College of Emergency Physicians. “Once you start spilling, it doesn’t matter if you pour a little less or how much you pour, you still have a mess.

“You have to solve the back door, and diversion does not do that.”

So why not end it?

A 2008 study from the Society for Academic Emergency Medicine found hospitals may actually make more money during times of diversion. That’s because there are often higher profits on scheduled surgeries. And those surgeries can wind up canceled when beds are filled by patients coming from the emergency room.

In a statement, the Wisconsin Hospital Association said “true diversion” is necessary at times for unanticipated, critical situations and in such cases, it is important that hospitals and ambulance crews quickly communicate to divert patients safely.

Hospitals might also turn away ambulances if equipment breaks down or if there is an unexpected problem, such as flooding or electricity being out. In a case several years ago, Children’s Hospital of Wisconsin shut down for several hours because a man with a gun was in the building.

Still, the vast majority of diversions, experts say, are due to overcrowding.

Defenders describe diversion policies as “a necessary evil” intended to protect patients from long, dangerous waits at a crowded hospital. The key, they acknowledge, is to get the ambulance patient to another less-crowded hospital that has the same capabilities.

Rutgers University Lewis Nelson

Rutgers University Lewis Nelson

The problem: When one hospital closes its doors, it simply spills more water — and sends extra ambulances — onto the next hospital, which may then have to close its doors. Indeed, sometimes hospitals close simply in anticipation of getting more patients.

“You really don’t want to be brought to a hospital that doesn’t think they can do the job properly,” said Lewis Nelson, a doctor and chair of emergency medicine at Rutgers Medical School in New Jersey.

On the morning Tate fell ill at the Medical College, seven of the 12 hospitals in Milwaukee County were on diversion for at least part of the day — including Aurora West Allis Medical Center.

Taken together, the hospitals turned away ambulances for a total of 34 hours that day, according to a Journal Sentinel analysis of state data. The data doesn’t show how many ambulances were diverted as a result.

Froedtert was on diversion for 690 hours in 2014, the equivalent of nearly 29 days. Yet that only ranked it sixth among Milwaukee hospitals that year. Aurora St. Luke’s was highest, with 1,319 diversion hours — the equivalent of nearly 55 days.

When half of the county’s hospitals were on diversion at the same time, the EMS director could force them all to open. Between 2014 and 2015, that happened on at least 97 days, state data shows.

It did not happen on Aug. 19. 2014.

Large clot leads to crisis

The ambulance carrying Tate arrived at the West Allis hospital emergency department at 9:23 a.m.

It had been a little more than an hour since Tate first began showing signs of a stroke.

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Share your story Have you or someone you know been affected by ambulance diversion?

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Tate had a large clot that had broken off from somewhere in her body, perhaps one of her legs, her medical records show. The clot had moved through her body and become lodged in her carotid artery — a large and vital vessel carrying blood through the neck to the brain.

Tate had experienced problems with veins in her legs for years and she contended with other health problems. Like her mother, she had diabetes. The years on her feet cooking had taken its toll.

Nevertheless, cooking was what she loved.

She learned to cook on childhood trips to Mississippi to see aunts and uncles and cousins. She mastered fried chicken, Chinese rice and homemade egg rolls. She made southern catfish whenever her aunt came up from Alabama.

After graduating from Milwaukee Tech High School, she started as a cook at Whitefish Bay schools and Nicolet High School, then at Potawatomi casino restaurants and finally at Davians, which stationed her at the Medical College.

After a shift, she’d head home and cook more there — lately with a spatula in one hand, the newborn on the opposite hip.

Cooking was a way to keep the family together.

“She’d call and say, ‘Fatty, you gonna come over for some barbecue?’” David Tate said. “We’d drink some fruit drinks and listen to the blues.”

When he arrived at the West Allis hospital, Tate found his sister in an emergency room bed in a hospital gown. Her work uniform — a black polo shirt and khaki pants — was stuffed in a bag nearby.

David Tate, brother of Tiffany Tate, recalls the day of Tate's stroke.

She was disoriented and tapping her hand against her right ear.

A nurse explained to her brother the tapping was because of the stroke and the pressure on her brain.

“She said, ‘There’s something in my ear. There’s something in my ear,’” David Tate said. “That’s the last thing I heard her say.”

One doctor ordered a clot-busting drug be administered through an IV in her arm, records show. But another doctor ordered that treatment stopped because possible bleeding was detected in her brain.

The policy at West Allis was to transfer all patients having a serious stroke to a hospital capable of a higher level of care, either Froedtert, Aurora St. Luke’s Medical Center or St. Mary’s Hospital, said Matthew Braun, a spokesman for Aurora.

“We can’t change the fact that she was brought to West Allis,” Braun said. “The team did the best they could to get her to the highest level of care as quickly as possible. Time is of the essence in these cases.”

With Froedtert closed, the closest top-level care was at St. Luke’s — five miles away.

The problem: The fire department ambulance that had brought Tate to West Allis was gone. The crew’s job was to make the hand-off, then get back to Wauwatosa.

A private ambulance was summoned. It arrived 15 minutes later. By this point, Tate had lost consciousness.

As the ambulance was leaving, David Tate, his wife and father rushed to his car to follow. In those moments, the West Allis hospital went on diversion.

They were racing the clock to St. Luke’s.

This video by Johns Hopkins University School of Medicine shows how a blood clot is removed during a stroke.

Paramedics had to follow orders

In Milwaukee County, ambulance diversions had been commonplace since at least the early 1990s.

Initially, there was little direction provided to paramedics on what to do when a hospital closed, sometimes leaving them to search willy-nilly for an open hospital, said Ronald Pirrallo, who was then the head of Milwaukee County’s Emergency Medical Services department.

Paramedics sometimes found ways around the diversions.

One veteran paramedic said they might drive a patient to the hospital, stop in the parking lot, have the patient sign out “against medical advice” and point them to the front door of the emergency room.

In other cases, 911 wouldn’t be called at all. Instead, patients would have someone drive them to the hospital to ensure treatment.

Pirrallo spearheaded creation of a new policy.

“It was designed to improve patient care and avoid overcrowding at any one individual hospital,” said Pirrallo, now a professor of emergency medicine at the University of South Carolina.

That policy meant the crew that transported Tate had no discretion.

Joe Schwark was the lead paramedic and commander on the call with Tate. For him, it was likely one of a half-dozen that day. In a year, he had hundreds.

He could not remember the specific call, but knew exactly how it would have played out once he was told that diversion was in effect.

For paramedics, Froedtert is the go-to facility, given its top-level designations in all areas. But unless Tate was bleeding uncontrollably or had a blocked airway, he had to follow orders.

“There were bigger players making the rules,” he said. “You just followed directions even if you didn’t generally agree with a lot of this stuff.”

Schwark said his most likely route that day would have been to take 87th Street south out of the medical center grounds.

That would have sent them right past the entrance to Froedtert’s emergency room — “close enough to spit on the driveway,” Schwark said.

Emergency departments nationwide have been quietly deploying a controversial tactic of turning ambulances away.

Grasping at straws

With possible bleeding in the brain, the next step for Tate was a technique in which doctors use a tiny catheter to try to physically remove the clot.

Froedtert had been able to do this since 2005 and became one of the first hospitals in the country to receive the advanced certification in 2013. St. Luke’s had received its designation as an Advanced Comprehensive Stroke Center three months before Tate's stroke.

The ambulance carrying Tiffany Tate, now unconscious, arrived shortly after noon. More than three-and-a-half hours had passed since she first showed signs of having a stroke.

Studies have found the best outcomes when patients receive the treatment inside of three hours, though it has been shown to work up until 24 hours later.

Using the catheter, doctors tried to reach the clot in Tate’s neck through an artery in her leg. The procedure didn’t work.

Family photo Tiffany Tate, right, and her daughter, Octayvia Fountain.

Family photo Tiffany Tate, right, and her daughter, Octayvia Fountain.

By now, Tate’s family had gathered at St. Luke’s. Blalock, her boyfriend, was in the waiting room. So was her brother and his wife, her older sisters, her parents and her daughter.

They tried to grasp how she had deteriorated so quickly. Family members were pacing, asking anyone who came by what was happening.

“It was really an emotional time,” David Tate said. “We just wanted answers, to know that she was going to be alright.”

Doctors emerged with bad news: Tate’s prospects were dim.

Pressure was building in Tate’s brain from the bleeding. Doctors wanted to try a radical step: Remove part of her skull to relieve the pressure.

Her family thought about the future, about how baby Alex and Octayvia would not have a mother if she died now. How Tiffany Tate had always dreamed of owning a home and had finally made that happen. And how much she loved family, how she held everyone together.

There was so much to live for.

They told the doctors to do whatever they could.

Plan to end diversion had been drafted

On the day Tiffany Tate suffered her stroke, a preliminary plan for ending ambulance diversion in Milwaukee County had already been drafted.

It ran two pages and was the brainchild of Riccardo Colella.

Office of Emergency Management Riccardo Colella

Office of Emergency Management Riccardo Colella

When Colella took over the county’s emergency medical services a year earlier, in 2013, he began examining how the diversion policy could be putting patients at risk. He set out to change it.

Colella, trained as an emergency medicine doctor and professor at the Medical College of Wisconsin, didn’t have the authority to force the issue. Rather, he had to talk, one by one, with all the major health care players in the area, including Aurora, Froedtert, Ascension and Children’s Hospital.

What would it take to end diversion? Not curb it, but end it, he said.

The solution, studies had shown, was not even in the emergency department.

Rather, it came from addressing things that left the emergency room bottlenecked: slow paperwork, rooms not being cleaned quickly enough, the time it took to discharge patients.

For Aurora Health Care, which owns one-third of the hospitals in Milwaukee County, the changes that needed to be made were far-reaching, said Steve Francaviglia, who is in charge of the system’s Milwaukee hospitals.

It meant creating a new process where patients would receive their initial diagnosis over video monitors from doctors in another location. That would help get tests ordered quickly.

The X-ray Department was examined to make it move more quickly, as was patient transport. Housekeeping was studied and improvements made to better notify other departments when a room was ready for a new patient. Schedules were tweaked.

Other health care systems made similar changes.

The first thing phased out, in January 2015, was diversions for those who had the most severe cardiac issues, such as needing to be resuscitated. The end of diversions for other stroke and heart attack cases came in March — six months after the day Tiffany Tate suffered her stroke.

All diversions were ended in April 2016.

Milwaukee County hospitals were on diversion for nearly 4,800 hours during a six-month period in 2015. In the same time frame the following year, the figure plummeted to 13 hours, according to a county report.

Colella said there have been no reports of problems with patient care to his office since diversions were ended.

Advocate Aurora Health Steve Francaviglia

Advocate Aurora Health Steve Francaviglia

Nevertheless, ambulance diversion is still happening in other areas around the state including in Waukesha and Racine counties, according to state data. At least 65 hospitals in the state have diverted patients to some degree over the last two years.

That includes some Aurora hospitals outside Milwaukee County. Francaviglia said efforts are underway to end diversion throughout the health care system.

Colella said he was not aware of Tate’s case until the Journal Sentinel brought it to his attention. But, he said, it illustrated all the problems with the diversion system.

“Cases like this, where there are issues with access, was really one of the principles behind changing the policy,” he said, adding the aim was “to bring people with time-sensitive illness to the closest place that could take care of them."

Bedside vigil kept

For weeks, Tate’s family and friends kept a vigil at St. Luke’s.

The diagnosis was grim. She was being fed through a tube. One of the doctors told David Tate his sister would never get up from the bed.

Still the family wasn’t ready to let her go. They directed that she be resuscitated if she had a heart attack or stopped breathing. When more intensive hospital care was not practical, they had her transferred to a long-term care facility and eventually to a nursing home in Glendale.

Frustrated by what happened, David Tate called lawyer after lawyer to see if the family had a case against Froedtert, against the Medical College, against anyone.

In Wisconsin, non-economic awards in any wrongful death cases are capped at $350,000. In medical malpractice cases, the cap is $750,000 for damages such as pain and suffering. The limits were established by the state Legislature and upheld by court decisions.

That means many lawyers are not interested in taking such cases, which are often expensive to prepare. David Tate said he was also told by some of the lawyers that he would never win against Froedtert. It was too big.

More importantly, there was a question of who to sue. It wasn’t as if the hospital gave her negligent treatment. Rather the system itself delayed his sister’s treatment.

What’s more, a 1993 federal appeals court decision made the prospects of winning a case less likely.

In Chicago, a newborn who lived five blocks from the University of Chicago hospital went into cardiac arrest. The hospital was on diversion and refused to take the child, who later died. The court ruled in favor of the hospital.

It is considered a bedrock case in the area of ambulance diversion and liability, cited by attorneys and judges who face the issue nationwide. It was decided in the 7th Circuit Court of Appeals, which has jurisdiction over Wisconsin.

At the Glendale nursing home, the weeks stretched to months. Every day, visitors came, but Tiffany Tate did not improve. Instead, she got worse.

She died shortly before midnight on Dec. 9 — two weeks before her son’s first birthday.

Experts say diversion was wrong

Maria Raven

Maria Raven

Several health care experts who reviewed the case for the Journal Sentinel said Tiffany Tate should have been taken to Froedtert, regardless of any diversion policy.

“To me, if someone is on the grounds of your hospital, they are yours,” said Raven, the emergency room physician and professor in San Francisco. “It is really sad. There were so many failures.”

Michael Carome, a former top official in the U.S. Department of Health and Human Services and now medical director of Public Citizen, a public policy group, said the delay in getting Tate to a top-level stroke center diminished her chances of survival.

“I would think there is a very high probability that the (delay) reasonably contributed to her adverse outcome given what we know about the golden window to quickly treat an ischemic stroke,” Carome said.

The experts said it is impossible to know if Tate would have survived if she had gone straight to Froedtert.

But they were unified in this: She would have had a better chance.

Alvin Blalock, longtime boyfriend of Tiffany Tate, recalls the day of Tate's stroke.

Years of questions

Four years have passed since Tiffany Tate’s death.

The family has tried to make peace with the case, but frustration has simmered under the surface. When a reporter unearthed the case, David Tate initially did not want to participate. It was still too raw.

He has since decided sharing his sister’s story could help end ambulance diversions in other places around the country.

“Why are they turning away ambulance patients when people like my sister are having a stroke?” David Tate said. “Maybe that’s why I’m here doing this interview today so this doesn’t happen to anybody else in the future.”

Blalock, Tiffany Tate’s longtime boyfriend, remembers her cooking and her smile, trips they would take to Lambeau Field, all the good times.

“I miss her. I just miss her,” he said. “She was just gone too soon.”

Family photo Tiffany Tate and boyfriend Alvin Blalock.

Their son, Alex, is now 5. He started kindergarten this year.

Alex has questions.

“Only thing I got are pictures,” Blalock said. “Everybody else’s mama is around. All I can teach him is with the pictures."

It helps, he said, that “Little Al” is going to Sunday school now and learning about heaven.

That’s where his mama is, his father tells him.

He tells him that a lot.

Kevin Crowe and Cary Spivak of the Milwaukee Journal Sentinel staff contributed to this report.

We want to hear your story about ambulance diversion The Milwaukee Journal Sentinel is investigating the issue of ambulance diversion including the consequences when people don't get timely care from hospitals. We are looking for information from patients, paramedics and other health providers across the country.

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How to file a complaint

To file a complaint about care by a hospital, doctor or other provider, go to the U.S. Centers for Medicare and Medicaid Services webpage.

How we reported this story

For this article, a Milwaukee Journal Sentinel reporter reviewed more than 7,000 pages of medical records covering the care of Tiffany Tate on the day of her stroke and the months that followed. This was done with the consent of Tate’s family.

Also reviewed: Reports from the Wauwatosa Fire Department, Medical College of Wisconsin Public Safety Department and the Medical Examiner’s Office, court records and dozens of studies on ambulance diversion, hospital overcrowding, and stroke care.

The Journal Sentinel also analyzed five years of data from a state of Wisconsin system used by hospitals to alert each other of their status. The WI Trac system is voluntary. Not all hospitals participate; those that do sometimes do not send in data about closures. Thus, the findings reveal a minimum amount of time the hospitals are on diversion.