BONITA SPRINGS, Fla. — An effort by the Bonita Springs fire district to provide its own ambulance service was dealt a recent blow by Lee County commissioners.

During their Jan. 31 meeting, Commissioner Ray Judah made a motion to move forward with a public hearing, which is part of the district's request for a certificate to operate an ambulance transport service. However, the motion died without another commissioner seconding it.

"This board has voted no twice," said Commissioner Tammy Hall, who does not support the fire district's application. "I don't see the benefit to the community or the fire department."

The Bonita Springs Fire Control and Rescue District filed an application with Lee County in May 2010 for its own ambulance transport service.

Currently, Lee County EMS provides ambulance services to Bonita Springs. But Bonita Springs fire officials believe they can use their 44 emergency medical technicians and 36 paramedics to provide a better service at less cost for taxpayers.

Bonita Springs officials say they would provide four 24-hour ambulances compared to Lee County EMS's two 24-hour and one 12-hour ambulances.

"We could provide a more efficient service by doing it ourselves and augment the county in relieving some of their obligations in the Bonita area," Bonita Springs Fire Chief P.H. Kinsey Jr. said.

However, both Lee County and the fire district have conducted studies on the issue, and their numbers don't line up. Some commissioners believe it would cost more for Bonita Springs to run its own ambulance service.

In October, the commissioners voted refused to grant or deny the Bonita Springs fire district a certificate to operate an ambulance transport service. Instead, they unanimously agreed to hire an independent public hearing officer to present an unbiased recommendation. The $20,000 cost would be split evenly between the county and the fire district.

But the county also requested a financial review of the fire district's budget, the cost of which would have also been split by the two sides. That turned out to be a deal breaker for Bonita fire officials who, according to Kinsey, don't want to "help the enemy."

"We need a forensic auditor for answers," said Commissioner Frank Mann. "I think it's important to include and critically important Bonita share (in the cost of a forensic audit)."

Judah, who thought both sides were on the way to resolving their issues through hiring the public hearing officer, said the bottom line is Bonita Springs made the request and necessary information on what is at stake needs to be on the table.

Since Judah's motion failed, there will not be a public hearing with an independent third party. The fire district's initial request for an ambulance certificate will go back before commissioners for a vote.

A date for that vote has not been set.

Copyright 2012 Collier County Publishing Company
All Rights Reserved

When I went to nursing school, few EMS professionals were considering nursing as an additional opportunity. Male EMS professionals were even less likely to take the big step. Today, things are quite different. In fact, since I completed nursing school only a short six years ago, I have heard from countless EMS colleagues considering the option. I guess once they saw that this dope could pull it off, anyone could!

In this economy, EMS professionals seem to be considering some of the same factors. They generally want the following out of a nursing program:

• To continue to work while attending school. This could mean that the option of attending courses part-time or on weekends and evenings is important. A predictable and consistent schedule is vital because convenience and scheduling are a top concern.
• Affordable education
• Value on clinical experience
• Credit for previous education, no matter when courses were completed. Many colleges and universities require major science courses to have been completed within the past five years. This could be an issue for the EMS professional who completed A&P or microbiology several years ago and has just now decided to pursue further education.
• To get 'er done! They expect to work hard and dedicate themselves, but they don't want to take two years to do it.
• Avoiding "death by PowerPoint" with focus on applying new clinical skills and the nursing process. EMS professionals tend to gravitate to programs that include clinical simulation, computer simulation, group learning and frequent computerized testing.
• To pass the NCLEX the first time. Therefore, a program's reputation and use of computerized test preparation is valuable.
• A different clinical experience from that of entry-level nursing students. EMS professionals don't want to spend much time in the ED or OR, but they want to branch out from their comfort zones by spending time in the ICU, pediatrics and OB.
• Respect from the nursing staff. They want to avoid any gender or professional (anti-paramedic) bias. I recall before I went to nursing school being told by my male nursing mentors, "Don’t tell the nursing faculty you are a paramedic!"

One of the all-around best choices is a paramedic-to-ADN "bridge" or "transition" program. These are typically facilitated by community colleges or universities and are usually more cost-effective than private colleges. Unlike traditional programs, there are relatively few real bridge programs across the country. The benefit of a true bridge program is that it articulates previous paramedic education into completed credit hours. This saves the student time and money.

For example, our institution started the first paramedic-to-ADN bridge program in our state and articulates 29 college credit hours for paramedic graduates from a state- or nationally accredited program. In addition, bridge programs often offer hybrid courses — part in-class, part online.

Those looking to maximize convenience with an online or distance program have two great choices to consider. I may be revealing a little personal bias here as I am a graduate of Excelsior College, but I would still keep this college on the top of my list of choices. Although tuition will be more than your local community college, you can’t beat the convenience. Excelsior College has been awarded the National League of Nursing (NLN) Education Excellence Award twice. It shares this honor with only one other educational institution.

In addition, Excelsior College cares more about what you know than when you learned it. So you will likely receive credit for those old courses you took 10 years ago. The downside is that its ADN program is not a bridge program, so you still have to take the complete load of nursing credits to graduate.

The flexibility of the program is very attractive, though. You can generally progress as slowly or quickly as you want. I took three months off in the middle of my coursework to deal with a family crisis and then started again when I could. Try that with a traditional program! It still only took me 16 months to complete my ADN program with Excelsior College.

Another top pick would be The College Network. It is well-known for its excellent academic support, resources, friendliness and convenience. Partnering with a variety of top national educational institutions, it offers online and distance learning and guaranteed financing. Many students value the "at your place, at your pace" philosophy.

Designed with working adults in mind, the Network has developed comprehensive learning modules to help nursing students succeed. Content from each course has been condensed and organized, making learning efficient. I wish I could have benefited from this resource when I went to school. The College Network also gives a 10 percent tuition discount for NAEMT members.

Hopefully, I have shed some light on some nursing programs that offer opportunities for EMS professionals. We wish you success in your future endeavors.

PINELLAS, Fla. — Only a few months after Pinellas officials hiked property taxes 46 percent to pay for the emergency medical services system, they are talking about raising the rate again if costs don't go down.

They've also broached the possibility that the cost of an ambulance ride could go up for the third year in a row.

The news came as part of an early forecast of county expenses for the 2012-13 fiscal year that showed officials expect the EMS fund to be in worse shape than expected next year. The reasons are low property values and expected increases in the cost of providing both first response and ambulance service.

That combination of factors is expected to result in a $5.9 million shortfall next year and a further $4 million shortfall in 2013-14. Meanwhile, the 18 fire departments that provide first response EMS service are expected to see costs increase by 4 percent per year through 2020. The costs for ambulance service are projected to increase by 6 percent annually through 2020.

At that rate, the EMS reserve fund - held for emergencies - would be out of money by the 2014-15 fiscal year.

The county increased ambulance fees - paid mostly by private insurance and federal and state taxes through the Medicare and Medicaid programs - 10.15 percent in 2010.

Last year, the county boosted the cost of an ambulance ride by 3.3 percent. A basic ambulance trip rose from $521.81 per person to $539.03.

The cost for mileage also went up from $11.79 a mile to $12.18 a mile.

County Administrator Bob LaSala declined Friday to project how much taxes might increase and said that's a decision for the County Commission, which last year said it would not raise EMS taxes again. LaSala said his job is to present the commission with a balanced budget.

That could be done by increasing revenue, decreasing spending or some combination, he said.

The projections are very preliminary. More will likely be known next month when the fire districts submit their budgets.

The woeful EMS budget forecast was no surprise. The fund has been in trouble for several years. Last year, LaSala proposed changing the funding model by reducing the number of firefighter/paramedics and equalizing pay across the county.

But cities and districts objected, saying the proposal would shift a countywide tax obligation to local taxpayers and would lessen the level of service by eliminating vehicles and paramedics.

Three firefighters proposed two separate plans for having firefighters take patients to the hospital. The authors of both plans said the county would save millions by changing to a fire transport system rather than paying a private for-profit company for the service.

An EMS transportation study committee was established by state Sen. Jack Latvala, R-Clearwater, to hire a consultant to analyze the LaSala plan and the Sanford-Millican fire transport plan, proposed by Lt. Scott Sanford of Palm Harbor Fire Rescue and Capt. Jim Millican of the Lealman Fire Department. Under Sanford-Millican, firefighters would transport both emergency and nonemergency patients.

The other plan, written by Lt. Rick Koda of the Seminole Fire Department, suggested firefighters transport emergency patients only, leaving the non­emergency transport to a private company.

At least two members of the committee, County Commissioner Karen Seel and St. Petersburg Mayor Bill Foster, thought studying the LaSala and Sanford-Millican plans was too limiting and would not enable officials to make an informed decision about the best solution for Pinellas EMS.

The committee decided, at Friday's meeting, to somewhat expand the scope of the study to include an analysis of the cost of emergency-only fire transport.

Copyright 2012 Times Publishing Company
All Rights Reserved

As I mentioned recently, EMS needs to evolve fairly rapidly just to keep up with the speed of change that is quietly but definitely moving through the house of medicine.

In this case, the EMS system involved in the study worked on multiple fronts to reduce the number of unnecessary transports by their units, which in turn reduced the number of admissions to the local emergency departments.

These changes were implemented with relatively little cost and by using existing staffing.

The result was a gain in financial and operational efficiency — a great measure by any means.

Not all systems can implement these configuration changes. Reviewing the article, it is clear that there needs to be multidisciplinary support for the concept and an array of resources to implement and monitor.

Yet any system can take a few ideas and modify them to address their particular needs. These types of efforts can really sharpen an EMS system's management of its local community, no matter how big or small.

What They Did | Did It Work" | How They Did It | Adoption Considerations

Summary
The Area Metropolitan Ambulance Authority (more commonly known as MedStar), an emergency medical service provider serving the Fort Worth, Texas area, uses advance practice paramedics to provide in-home and telephone-based support to patients who frequently call 911.

Working as part of MedStar's Community Health Program, these paramedics conduct an in-depth medical assessment, develop a customized care plan based on that assessment, and periodically visit and/or telephone the patient and family to support them in following the plan. Support generally continues until they can manage on their own.

A separate, similar program serves individuals with congestive heart failure, and the same concept is being tested with hospice patients and may later be expanded to serve those with other chronic conditions. The program significantly reduced 911 calls, leading to declines in emergency medical service and emergency department charges and costs, and to freed-up capacity in area emergency departments.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of 911 calls from program participants, along with estimates of the cost savings generated and ED capacity freed up as a result of the reduction in calls.

Developing Organizations

Area Metropolitan Ambulance Authority
Fort Worth, TX

Date First Implemented

2009

Patient Population
The program serves those who frequently call 911 in situations not considered to be an emergency.Vulnerable Populations > Medically uninsured; Insurance Status > Uninsured

What They Did

Problem Addressed
Inappropriate calls to emergency medical service (EMS) providers and unnecessary use of the emergency department (ED) occur frequently, with a handful of "super users" accounting for a disproportionate share of the problem. These individuals generally lack health insurance and a medical home and face multiple barriers to accessing care, causing them to repeatedly turn to EMS providers and local EDs with problems that could have been prevented and/or do not require immediate care by EMS or ED staff. The net result is higher costs and the diversion of valuable resources away from true emergencies.

• High utilization, dominated by a few (often uninsured) users: A few "super users" often account for a disproportionate share of 911 calls and ED visits. In 2009, MedStar found that 21 patients had been transported to local EDs a total of 800 times over a 12-month period, generating over $950,000 in ambulance charges and even larger ED expenses. Most of these individuals did not have health insurance and relied on EMS and local EDs for health services. Other cities have found similar problems. For example, the Tucson Fire Department identified 50 individuals who accounted for more than 300 nonemergency 911 calls over a 12-month period.¹
• Often for nonurgent needs or those ED not equipped to handle: Various studies have found that between 11 and 52 percent of 911 calls come from individuals who do not face serious health problems.² Many ED visits by super users are for conditions that should be treated in a primary care setting, including acute upper respiratory infections, viral infections, otitis media, and acute pharyngitis. Super users also routinely call 911 and visit the ED with exacerbations of chronic conditions that could be avoided with adequate ongoing care and for psychosocial problems that cannot be effectively treated in the ED, such as alcohol or drug dependency and depression.
• Leading to high costs, diverted resources, little lasting value for callers: Handling nonemergency calls raises the costs of providing EMS and ED services and diverts scarce resources away from true emergencies, leading to longer response times. In addition, although those who respond to these cases can resolve the immediate problem(s) at hand, they lack the resources and knowledge to educate the individual about appropriate self-management and the many community-based resources (e.g., home health care, behavioral health services, public health clinics, substance abuse services) that could better address their needs in the future.

Description of the Innovative Activity
An EMS provider uses advance practice paramedics (APPs) to provide in-home and telephone-based support to patients who frequently call 911. The paramedics conduct an in-depth medical assessment, develop a customized care plan based on that assessment, and periodically visit and/or telephone the patient and family to support them in following the plan. Support generally continues until they can manage on their own. A separate, similar program serves individuals with congestive heart failure (CHF). Key program elements are described below:

• Identifying eligible individuals: MedStar identifies eligible individuals in various ways, including internal analysis (a monthly report lists those with 10 or more 911 calls in the past month) and referrals from ED case workers at local hospitals, other first-responder agencies, and MedStar employees working in the field. Currently, the program serves those who have called 911 at least 15 times in the past 90 days. (Those close to this threshold may be tagged as someone to monitor for enrollment at a later date.) For the CHF program, staff at local cardiac intensive care units (ICUs) identify and refer patients who are at risk for bounce-back to the ED within 30 days and/or could benefit from ongoing support; these patients need not meet the 15-call threshold.
• Brief enrollment visit: Anyone deemed eligible for the program receives a phone call and/or visit from an APP, either at home or in the hospital. The APP explains the benefits of the program to the patient and his or her family members and other caregivers. Those interested sign a release form authorizing the sharing of relevant information with appropriate parties.
• In-depth medical assessment: An APP conducts a 1.5- to 2-hour in-home visit with the patient, family members, and caregivers. The visit includes a full medical assessment, including checking vital signs, blood glucose levels, oxygen saturation levels, and other key indicators. During the visit, the APP reviews the following:
  o Current medication use, making note of any potential problems (e.g., taking two medicines for the same condition, potential drug-drug interactions) to be discussed with the prescribing physician(s).
  o Any chronic conditions the patient may have, focusing on appropriate self-management of those conditions and related comorbidities.
  o Existing support and resources available to the patient and family, including financial resources, insurance coverage, and access to non-emergency medical care (including primary care and home health), mental health services, transportation, and other relevant social services.
• Individualized care plan based on assessment: The APP who conducted the review works with the patient and family to develop an individualized care plan that outlines their needs and responsibilities related to managing health and health care on an ongoing basis.

As part of this process, the APP may talk with other providers who serve the patient (as identified in the assessment), including primary care clinicians and mental health providers. The resulting plan includes concrete steps to be taken by the APP to help in accessing needed resources, such as securing insurance coverage or other financial resources and linking the patient and family to county hospital-affiliated clinics and other local agencies and resources that serve low-income and uninsured individuals (e.g., transportation, home health, hospice, Meals-on-Wheels).

The plan also includes mutually-agreed on goals for the patient and family to manage their health, such as checking their own blood pressure and/or blood glucose levels, eating an appropriate diet, exercising more regularly, taking medications appropriately, and scheduling and attending needed appointments. Patients and family members receive a copy of the care plan, and the plan is also entered into the patient's electronic medical record (EMR) where it can be accessed by APPs and other authorized providers as appropriate.

• Ongoing support via home visits and phone calls: Based on the needs identified in the care plan, an APP conducts periodic 30- to 60-minute home visits with patients, with the frequency of visits determined by need. (The same APP may not conduct each visit, but all have access to the patient's information, and most know all patients enrolled.)

Visits initially occur two or three times a week, with the frequency tapering off to one or two visits a week over time. As warranted, the APP may conduct telephone calls instead of in-person visits if the patient is making adequate progress. Visits provide an opportunity to ensure the patient and family are following the plan. As appropriate, the APP will intervene, providing referrals and support in accessing needed services.

For many patients, visits also provide an opportunity for much-needed social interaction. All APP contacts with patients get entered into the patient's EMR, including current vital signs, medications, and other relevant information. Patients are also given a 10-digit phone number to call to request an APP home or phone visit as an alternative to calling 911.

• Special protocols for CHF patients: Going forward, APPs who work with CHF patients will be able to take point-of-care blood values (e.g., potassium levels) at the patient's home and use standing-order protocols to adjust doses of diuretic medications based on a patient's weight gain and other indicators. The APP will immediately notify the patient's primary care doctor and/or cardiologist whenever an adjustment occurs.
• Multiple paths for leaving program: At some point, patients receiving services (designated "active" patients) formally leave the program. This process can occur in several ways, as outlined below:
  o "Graduating" from program: Most patients successfully "graduate," which occurs when the APP believes they can effectively manage their own health and health care without proactive support. Graduation typically occurs in about 30 to 60 days, with the shortest time being 2 weeks and the longest time being 6 to 8 months. Graduates can call a special 24-hour nonemergency number that will trigger an APP or ambulance visit within an hour to check on their well-being and intervene as necessary. Before graduating, some individuals may be placed on "watch" status, which means they are almost ready to graduate, but their 911 use remains elevated or has recently ticked up, suggesting they still need some support.

o Designation as system abuser: Those who do not change their habits and continue to call 911 repeatedly may be terminated from the program. These individuals are either designated as "pending system abusers," meaning they do not have any medical issues that require ongoing care, or as "system abusers," meaning they have ongoing medical issues. If a pending abuser calls 911, the APP goes to the house (in addition to the regular response team) to conduct a full medical evaluation and then works with the medical director to determine the right course of action. System abusers get assigned to a designated home hospital, and whenever they call 911 the ambulance takes them to that facility so they can be monitored by providers familiar with their condition.

• Regular case discussions with hospital caseworkers: Once or twice a month, MedStar's Community Health Program coordinator meets with hospital, ED, and cardiac ICU case workers to discuss patients enrolled in the program. The caseworkers provide information on recent ED visits or hospitalizations, including diagnoses, treatments and tests performed, medications prescribed, and discharge and follow up instructions.

This information, which gets entered into the EMR, helps APPs determine the appropriate level of ongoing support and identify those who may be abusing the system by seeking care (e.g., medications) at multiple facilities. The Community Health Program Coordinator also shares relevant information with hospital-based caseworkers about recent contacts that APPs have had with patients.

• Ongoing monitoring via electronic database: The coordinator regularly reviews an electronic database to check on the progress of individual patients and update classifications as appropriate. This information is regularly shared with the associate medical director.

References/Related Articles
Mitchell M. In Fort Worth, MedStar's Community Health Program cutting costs, improving patients' well-being. July 9, 2011. Fort Worth Star-Telegram. Available at: http://www.star-telegram.com/2011/07/09/3209806/in-fort-worth-medstars-community.html#tvg

Johnson K. Responding Before a Call Is Needed. The New York Times. September 19, 2011. Available at: http://www.nytimes.com/2011/09/19/us/community-paramedics-seek-to-prevent-emergencies-too.html"_r=2
Contact the Innovator
Matt Zavadsky
Associate Director of Operations
Area Metropolitan Ambulance Authority
551 E. Berry St.
Fort Worth, TX 76110
(817) 632-0522
E-mail: MZavadsky@medstar911.org

Did It Work"

The program significantly reduced 911 calls, leading to declines in EMS and ED charges and costs, and to freed-up capacity in area EDs.

• Significant decline in 911 calls: Between the formal launch in July 2009 and August 2011, the volume of 911 calls from the program's 186 enrollees fell by 58 percent, from an average of 342.3 monthly calls during the 6-month period before enrollment to 143.3 monthly calls afterward.
• Corresponding declines in EMS and ED charges and costs: The decline in calls has led to a corresponding drop in MedStar's charges and costs, with annualized EMS transport costs for these patients falling by over $900,000 (from $1,577,472 to $660,128) and charges falling by over $2.8 million ($4,929,600 to $2,062,899).

Based on information provided by area EDs, MedStar estimates similarly large declines in ED charges and costs for patients transported by MedStar to area EDs, with charges falling by nearly $9 million and costs by over $1 million. (The large difference between charges and costs stems from the many uninsured patients being served and the low rate of reimbursement by public payers, particularly Medicaid. Consequently, full charges are set at a level that allows adequate collections to cover costs.)

• Freed-up ED capacity: MedStar estimates that the decline in patients being transported by ambulance has freed-up more than 14,000 bed hours at area EDs, allowing these capacity-constrained facilities to better serve those facing real emergencies.

How They Did It

Context of the Innovation
The Area Metropolitan Ambulance Authority, also known as MedStar, operates as the sole provider of emergency and non-emergency ambulance service for 15 cities in Tarrant County, Texas, including Fort Worth. More than 880,000 residents live in this area, making roughly 10,000 911 calls a year that are handled by a fleet of 54 MedStar ambulances.

The impetus for this program came from MedStar's current medical director (associate director at the time), who in preparing for another busy summer season in 2009, began thinking about how the organization could better serve 911 callers who repeatedly use the system for nonurgent situations. He knew many of these individuals personally and felt the current approach did not serve them or the community well.

Planning and Development Process

Key steps included the following:

• Quick analysis to document problem: To test his theory, the then-associate medical director ran a quick analysis and found that 21 patients accounted for more than 800 calls in 2008, with the vast majority being for primary care and other nonurgent needs.
• Pilot test with subset of patients: MedStar reviewed information on the 21 identified individuals and enrolled 9 of them in a 60-day pilot test of the program. These individuals had a long history with and were very familiar to MedStar staff. During the trial, two paramedics on "light duty" (due to recovery from an injury) who had experience in primary care served as the APPs. The test proved quite successful, leading to a 77-percent reduction in monthly 911 calls.
• Funding plan to support rollout: Because home visits and other services provided as part of the program are not eligible for reimbursement by third-party payers, MedStar lacked a funding source to cover the costs of shifting paramedic time from their traditional duties to program activities. To address this issue, MedStar leaders decided to "marry" the Community Health Program to a new critical care transport program, a service not previously offered by MedStar that involves transporting critically ill patients from facilities that cannot adequately care for them (usually in outlying areas) to those that can (often tertiary facilities in urban areas).
• Paramedic training: The medical director and associate medical director developed a 16-day program, delivered 1 full day a week, to train existing paramedics on how to provide Community Health Program services (which was covered in three sessions) and how to conduct critical care transports (the focus of the remaining 13 sessions).

The community health portion emphasized how to assess patients for long-term, chronic conditions, in contrast to the paramedic's traditional approach of identifying and addressing life-threatening issues. Specialists from the local mental health authority provided in-depth education on common mental health issues facing this population, including schizophrenia and bipolar disorder. Training also focused on how to intervene with patients, and how to access community-based medical and social services that can help them.

• Forming partnerships with community-based organizations: MedStar leaders forged partnerships with community-based organizations serving the same population, including hospitals, EDs, the county health department, the local Medicaid office, mental health organizations, home health and hospice agencies, and Meals-on-Wheels. They first met with organizational leaders to explain the program and gain their buy-in, and then discussed how the APPs could coordinate with them on an ongoing basis, including how each party should make referrals to the other.
• Expansion to CHF and other chronic patients: In September 2010, the program expanded to serve CHF patients. The CHF program continues to evolve, as MedStar leaders have been working with local cardiologists to develop the aforementioned standing-order protocols that will allow APPs to adjust medication doses. Once the CHF model has been "perfected," MedStar leaders hope to use the same basic approach to support those with other conditions that frequently lead to EMS and ED use, such as chronic obstructive pulmonary disease, asthma, pneumonia, and diabetes.
• Pilot test with hospice patients: In partnership with local hospice agencies, MedStar is conducting a small pilot test where APPs support patients and families receiving in-home hospice care who call 911. Traditional first responders lack the time and training to play this role, which requires patience and compassion as family members deal with stress- and panic-inducing episodes in loved ones who are terminally ill. Often, these events lead to a decision to abandon hospice care, triggering a painful end-of-life scenario that includes multiple hospitalizations and ED visits.

Resources Used and Skills Needed

• Staffing: To date, the program has not required additional staff. Existing paramedics serve as APPs, and MedStar managers (e.g., medical directors, operations managers) participate in program-related duties as part of their regular job responsibilities. One APP is on duty at all times (7 days a week, 24 hours a day), with individuals serving 12-hour shifts. APPs, however, do not spend all of their shift time on the Community Health Program, as some time goes to critical care transports and other duties. For budgeting purposes, 4.5 full-time equivalent staff have been allocated to the Community Health Program, but MedStar has been able to reduce its budget for non-APP paramedics by a similar amount due to the reduction in call volume generated by the program.
• Costs: The program required an upfront outlay of roughly $46,000 to buy and equip a response vehicle for the APPs. This vehicle houses specialized equipment and computer technology, including monitors. Other upfront costs include the time spent by paramedics in training, while ongoing costs include uniforms and supplies for the APPs.

Funding Sources
Area Metropolitan Ambulance Authority
The program is funded internally by MedStar.

Tools and Other Resources
More information on the program can be found at www.medstar911.org/community-health-program.

Adoption Considerations

Getting Started with This Innovation

• Consider financial implications: This program can present financial challenges, because it provides services (e.g., in-home visits) that are often not covered by payers and, if successful, eliminates some EMS transports that potentially would have been reimbursed. MedStar has thus far found revenue losses to be fairly minimal, because most people served by the program lack insurance or are covered by a payer that either does not reimburse or pays very little for ambulance transports in non-emergency situations. As noted, MedStar leaders decided to couple the program with a new revenue-producing one (critical care transports) to make the finances work.
• Identify community needs: The population served by this program will have different needs in every community. Consequently, potential adopters need to survey the local environment to understand the situation faced by heavy users of 911 services and the community resources available to serve them.
• Begin with small pilot test: Test the program with a small group of patients, using the testing period as an opportunity to build relationships with patients and potential community partners. Over time, the various organizations serving these individuals will come to realize that they can and should depend on each other.

Sustaining This Innovation

• Continue investing in partnerships: Ongoing communication based on transparency, honesty, and respect is critical to keeping partners together. In particular, the various organizations must honor their commitments to each other. MedStar has forged good relationships with virtually all key stakeholders, including four competing hospitals that have a tense relationship with each other but freely share data and collaborate with MedStar.
• Approach payers about funding support: Third-party payers may be interested in supporting the program once they understand how it can benefit them. To that end, MedStar leaders plan to meet with representatives of the three largest payers in the area to find out what aspects of the program would be most meaningful and beneficial to them (e.g., its ability to reduce EMS transports, ED visits, and hospitalizations). MedStar will then hire an independent party to evaluate and document the program's impact on these metrics, and share that analysis with the payers as part of a conversation about reimbursement.
• Prepare for reimbursement changes: As accountable care organizations, pay-for-performance, and other new payment and care delivery programs become a reality, health systems and other large provider organizations will increasingly take responsibility for covering EMS transport services (rather than traditional insurers). Consequently, those adopting this program should consider partnering with organizations that plan to participate in these new initiatives.

Use By Other Organizations

Approximately 10 other EMS programs have visited MedStar to learn more about the program.

References

1. Referred services and alpha trucks: Norma Battaglia leads Tucson Fire Department toward response efficiency. JEMS. 2009 Apr;34(4):4-5.
2. Dale J, Williams S, Foster T, et al. Safety of telephone consultation for "non-serious" emergency ambulance service patients. Qual Saf Health Care. 2004;13:363-73. [PubMed]

TOKYO — A telephone service in which people call #7119 to speak to medical staff about whether they need emergency treatment has failed to gain traction nationally.

The around-the-clock service was introduced to reduce requests for emergency care for people with illnesses or injuries that do not require immediate treatment. Ambulance response times have been slowing in part because of the growing number of unnecessary emergency requests.

But due to staff shortages and budget problems, only Tokyo, Osaka and Nara prefectures introduced the system.

Medical experts say for the system to proliferate, frameworks covering wider regions are necessary.

The counseling service is free, although callers are charged for the phone call. It is jointly operated by local governments, doctors associations and firefighting authorities.

Callers describe symptoms or conditions to doctors and nurses. If they are judged to require urgent treatment, medical staff will ask firefighting stations that operate ambulances to provide immediate care.

When the situation is less serious, the medical staff will recommend a range of nearby facilities such as hospitals that can be visited for treatment.

The Tokyo Fire Department in Chiyoda Ward, Tokyo, has a counseling center for the #7119 service, which is called frequently.

"My child has fever and he looks painful," a recent caller said. Another caller said, "My baby fell off the bed and hit her head."

Replies from the medical staff included, "Has the child been knocked unconscious"" and "Did the child vomit""

In a recent case, a phone counselor said, "If conditions do not worsen, it'll be OK to go to a hospital tomorrow," causing the panicked caller to become calmer.

A nurse working on the phone service said, "In many cases we can help relieve the callers by discussing the symptoms."

The number of ambulance dispatches throughout the nation reached a record high of about 5.46 million in 2010, according to Fire and Disaster Management Agency statistics.

During the first half of last year, the number of calls rose 6 percent from the same period a year earlier, an increase due to the nation's aging population. The national average length of time for ambulances to reach a hospital after collecting a patient has grown by nine minutes during the last 10 years.

Firefighters say patients with light injuries and mild illnesses account for about half of the call-outs.

To counter this problem, the agency implemented the #7119 service as a trial for six months from October 2009.

The Tokyo metropolitan government had already created a similar system that resulted in the number of ambulance dispatches falling from about 690,000 in 2007 to about 650,000 in 2008 when the service was fully implemented.

The percentage of ambulance call-outs to people with light injuries or mild illnesses fell from 2008 to 2010.

Tokyo's system proved that the service can be effective in reducing the number of unnecessary emergency requests. Osaka and Nara prefectures implemented the system in fiscal 2010. But the agency said the only other area thinking of introducing the phone service is the city of Sapporo.

An agency official said the service has not become popular nationwide because "local governments do not have sufficient number of doctors and nurses to create the system."

At least 10 doctors and nurses are always on hand at the center in Tokyo, with the metropolitan government allocating 440 million yen annually for the service.

A Saitama prefectural government official who visited the center said: "Our firefighting stations have a different system to that used by the Tokyo Fire Department, which covers most of Tokyo. Our budget is smaller so it's currently difficult for us to start this service."

Another issue is how this system can effectively coexist with another phone service that was introduced nationwide by the Health, Labor and Welfare Ministry in 2004. This nationwide program allows people to call #8000 and speak about their sick or injured child to medical staff who evaluate whether emergency treatment is needed.

The Aichi prefectural government implemented the #7119 service in a six-month trial from October 2009 but it was discontinued.

A government official said: "We have the #8000 service and the prefecture's own system to tell patients about suitable hospitals. So administering these systems [in conjunction with the #7119 service] is difficult."

Prof. Futoshi Iwata, a medical safety expert from Sophia University, said: "The number of medical practitioners who can work as counselors in this system is limited. So it's difficult for small local governments to introduce the service.

"It would be better to develop a system where centers in urban areas can receive phone calls from rural areas," he said.

NEW YORK — EMS Assistant Chief John McFarland, who served the EMS Command for more than 28 years and led many innovations that changed nationwide emergency medical services, died on Feb. 6 after battling a brain tumor.

"The things that stand out to me were his leadership qualities as a visionary and patient advocate," said former Chief of EMS Robert McCracken. "He always looked into technology to improve performance and patient care."

Chief McFarland joined EMS as an EMT in 1983. He studied to become a paramedic in 1985 and was assigned to cover Manhattan. Four years later, he was promoted to lieutenant. He worked in Operations and Training before being promoted again, to captain, in 1997.

He held different positions both at FDNY Headquarters and the EMS Academy before being promoted to Deputy Chief in 2001. He then served as Chief of the Academy and Chief of Division 4. He then became Queens Borough Commander in 2003, followed by Deputy Assistant Chief of Field Operations in 2004. He retired in 2011.

In his time with EMS, he responded to many notable incidents, including the World Trade Center terrorist attacks of 1993 and 2001, US Airways Flight 1549 that landed on the Hudson, two plane crashes at LaGuardia Airport and the steam pipe explosion in Midtown Manhattan.

"He was a pioneer, striving for top-quality medical care that anyone could provide on the street, as well as the most up-to-date medical care," said FDNY Chief Medical Officer David Prezant. "He wanted to make sure that the FDNY EMS Command was the best in the world."

He added that Chief McFarland was always pushing for the FDNY to make use of the latest innovations and technologies, including STEMI and hypothermia therapy. He also never forgot what it was like to work as a paramedic or EMT on the streets, and always strived to find ways to make their lives easier.

"He really viewed EMS as a lifeline for the people of NYC," Dr. Prezant said.

While Assistant Chief John Peruggia lauded Chief McFarland's emphasis on patient care, he also remembered how much he loved his family. including his wife, EMS Captain Jo Ann, and children Katherine, 28, Megan, 24, Rebecca, 7, John, 5, and Joseph, 4.

Chief McCracken said he was deeply saddened by the passing of his longtime colleague and friend, but said he was happy he had the chance to know such an innovative thinker and kindhearted man: "It was an honor and pleasure to know John, and I can't say enough about him. I'm just happy that the last time I saw him that he still had that great smile and positive outlook on life, his family and job he loved."

GRANTS PASS, Ore. — A few years ago, John Rachor painted his helicopter orange and yellow, so it would be easier to spot if he ever crashed and became the target of a search and rescue operation in the rugged forests of southwestern Oregon.

Over the past six years, he has been the one doing the spotting.

On Saturday, Rachor found three members of a Gold Beach family after they got lost while picking mushrooms. The family spent six nights without food, slept in a hollow log, and considered killing their dog for food. Rain showers left them damp and cold as they fought through wet brush. Without a lighter, they couldn't start a fire to ward off cold nights when temperatures dipped into the 30s.

It was a similar story in 2006, when Rachor spotted a San Francisco mother and her two daughters who had been lost more than a week in the same rugged region of the Klamath Mountains, where steep ridges covered with loose rocks, brush and tall Douglas fir trees make the going tough, and a maze of abandoned logging roads can get people without a map and compass hopelessly lost.

In between he has found several others, he doesn't keep track of how many, who didn't get as much attention.

"He's crazy good," said Sara Rubrecht, search and rescue coordinator for Josephine County. "I have a picture of the area he found the subjects (on Saturday). When you talk about a needle in a haystack, that's an understatement."

She said Rachor has something that can't be taught in a classroom, a "natural ability to see things from the sky."

"He's flying a helicopter at the same time," Rubrecht said. "He obviously is a good multi-tasker."

Good eyesight
Rachor attributes his success to good eyesight, an ability to spot things out of the ordinary, a willingness to think outside the box, and the efforts of the scores of other people involved in a search.

"I like to think of it as a knack" more than luck, he said. "It wasn't me. There are a lot of people that put a lot of effort into it."

Rachor, 63, is a fourth-generation Oregonian. The son of a log truck driver, he went to a technical college to study diesel mechanics. He served as a mechanic in the Navy Seabees in Vietnam, and was married with two kids and working for a truck distributorship when he got a chance to buy a Burger King franchise. He eventually built 13 of them, but has since sold them and been elected a Jackson County commissioner.

He first learned to fly an airplane about 35 years ago, and switched to a helicopter so he could fly to his remote vacation home, where a grassy field is long enough for a small plane to take off, but not without flying under a towering steel bridge. The home is in Agness, a remote and tiny settlement about 30 miles up the Rogue River from the southern Oregon Coast that lives off sport fishing and whitewater rafting. It is just a few miles from where he found the mushroom pickers.

His four-seater Robinson R-44 used to be painted white, with flames on the sides.

"I painted it bright orange and yellow so it would be visible in case I ever crashed, they could find me in the snow," he said.

Rachor joined Jackson County search and rescue as a ground-pounder and snowmobile driver several years before he started volunteering with his helicopter. He had to quit when he was elected because having authority over the budget was a conflict of interest.

"But if there is a 4-year-old boy in there, all bets are off," he said. "I'm going in there anyway."

Hunting for trees
In 2006, he was with his family at Diamond Lake, hunting for Christmas trees, when he read about the Kim family disappearing while driving from Portland to a lodge outside Gold Beach. Familiar with the lay of the land from frequent flights to his vacation home in Agness, he figured they might have made the bad decision to drive a one-lane logging road in winter through the Rogue River-Siskiyou National Forest. A popular shortcut for whitewater rafters in summer, it is not plowed of snow in winter, and people frequently get stranded.

He checked in with the Josephine County search headquarters for likely areas, and went looking on his own. He spotted Kati Kim waving her umbrella. Unable to land, he directed another helicopter that picked her up with her two daughters. James Kim got lost trying to hike out for help, and died of hypothermia in a creek.

Since then, Rachor has volunteered his helicopter for about a dozen searches, for the living and the dead, and delivered medicine to people snowed in at remote cabins.

He regularly trains with Curry County search and rescue. Though the state reimburses for fuel and federal timber funds help offset search and rescue operations, cash-strapped counties like Curry depend on volunteers who can help out for free, Sheriff John Bishop said.

"Any time we can get a helicopter in the air it gives us an advantage," Bishop said.

Rachor was planning to join the search for the Conne family last Friday, but had a cold, and waited a day.

He and Sheriff's Lt. John Ward had been flying about two hours when Rachor decided to go outside the search area. He knew from experience that when people get lost, they don't always go where you expect.

Rachor spotted a movement, something out of the ordinary on such a calm day. A man in tan bib overalls was waving his arms.

Two ground teams were within several hundred yards, and probably would have found them the same day, said Bishop and Rubrecht. But they were happy Rachor beat them to it.

"We kind of laugh about it now, after he found these folks," said Rubrecht. "I felt like, `All right, next time somebody needs to call him earlier.'"

MIAMI — U.S. Postal Service officials in Miami say an employee died when he tumbled into a storm drain while searching for his cell phone.

Postal Service spokeswoman Debbie Fetterly says the accident happened early Tuesday at the Miami Processing and Distribution Center in Miami.

Police identified the man as 70-year-old Shelby Wing of Miami. Authorities say it appears Wing drowned after falling into the drain.

The Miami Herald reports he had worked for the postal service for more than 25 years.

No further details were immediately available.

NEW YORK — The medic charged with misconduct for callously failing to help a dying pregnant woman is still banking city paychecks — more than two years after getting suspended from active duty.

Melisa Jackson, 25, has raked in about $39,000 annually since the death of Eutisha Rennix, on Dec. 9, 2009.

"She's still on restricted duty — no patient care," said FDNY spokesman Frank Dwyer. "We have to wait till the criminal case is done and see how that plays out."

While Jackson gets paid for doing clerical work and stacking office supplies, the Brooklyn DA's Office continues to build its case.

But for two years, that case has been mired in motions and postponements. Jackson's attorney, Benjamin Heinrich, is scheduled to be in court March 5 to ask for an adjournment.

Heinrich did not return calls from The Post.

Copyright 2012 N.Y.P. Holdings, Inc.
All Rights Reserved

CHICAGO — "Thank you for saving my life."

That's what Thomas Lewickyj, 34, wants to say to the half-dozen police officers who carried him and his wheelchair down six flights of stairs to safety after a fire broke out in his Lake View apartment building Friday night. They even went back and rescued his dog.

One of the officers, Julio Mercado, was hospitalized for smoke inhalation, along with four others — including a 3-year-old girl in critical condition — after the fire began at 8:40 p.m. in a kitchen in the second floor of the building at 2303 N. Clybourn, fire department officials said.

Firefighters Luis Aguayo and Nelson Camacho went to the second floor where the fire started.

"We noticed the fire up in the ceiling in the kitchen," Aguayo said. "We got the fire out. Right after that, I heard a faint noise." That's when they saw the girl and her mother by a window in the living room.

"I asked [the mom], 'Are you OK"' I grabbed the child and said, 'Follow me.' And then I ran out of there with the child. ... I had her close to my coat so she wouldn't breathe a lot of the smoke in the apartment."

She was taken to Children's Memorial Hospital in critical condition.

Lewickyj, 34, said he smelled smoke while he was in his sixth-floor apartment, then he heard fire alarms.

He began knocking frantically on the inside of his door, and a few minutes later, Mercado knocked back, and screamed, " 'We got to get you out! We got to get you out!' " Lewickyj said later, as he waited outside in the cold.

Mercado picked him up along with his wheelchair and carried him to a stairwell, where other officers brought him to safety.

Copyright 2012 Sun-Times Media, LLC
All Rights Reserved

NEW YORK — Ailing Ground Zero responders are finally getting their last checks from a settlement with the city, but many are crestfallen that the payments are less than touted when they took the deal.

"We didn't get what they told us we were going to get," one put it.

One main reason for the lower-than-expected payouts: The dollar value of each point awarded workers for the type and severity of their illnesses was just recently set at $7.36, a figure based on the money to be divvied up.

That's below the $7.50 to $9.19 range first estimated.

"Obviously, it was a big mistake. They miscalculated the total number of points awarded, so the value dropped significantly, " said a lawyer in the case.

More than a year ago, 95 percent of 10,000 cops, firefighters, hard hats and other Ground Zero workers accepted the city's $680 million offer.

The sickest are now getting the final 60 percent of their payments. The WTC Captive Insurance Co., which manages the city's 9/11 settlement funds, did not immediately comment.

Adding to the disappointment, the payments have been slashed by tens of thousands of dollars in unexplained legal expenses deducted from the awards, in addition to a 25 percent attorneys' fee. The expenses are listed in lump sums, with no itemized list.

In one case, a former NYPD detective with asthma and other ailments signed on to the settlement in September 2010 after the main law firms in the litigation, Worby Groner Edelman and Napoli Bern, estimated his city payout at $532,826 to $650,267.

His city award came to $115,480 — but after fees, he received $79,292.

The huge reduction stemmed from a rejected claim filed on his behalf. At first, his lawyers claimed 60,000 points for his asthma. But his disease was deemed less severe, and downgraded to 7,500 points.

Also, more than $9,750 in legal costs, in addition to the 25 percent fee, ate into his entitlement.

Paul Napoli, a partner in the firm claiming the costs, would not give a breakdown. His spokeswoman said the court-appointed Garretson Resolution Group, based in Cincinnati, approved all expenses allowed by the judge.

In another inflated estimate, the Napoli firm first informed the detective he would get a disability payment of $76,738 to $92,998 as part of his settlement.

But his disability award came to $55,465. He got a check for $41,599, after the 25 percent lawyers' fee.

ON THE MINUS SIDE

A former NYPD detective suffering from asthma and other ailments after working at Ground Zero received far less than he was originally told to expect when he signed on to the city's $680 million settlement with 10,000 responders. Here's the breakdown:

Payout first estimated when the detectivewas asked to accept the settlement in September 2010: $532,826 to $650,267

He accepted, but his ailments were later deemed less serious, and with lawyer fees, his final payout was less than onefifth of the original estimate.
INITIAL PAYMENT

• Award: $3,250
• Law-firm costs deducted: $134.84
• Attorneys' 25% fee deducted (after costs): $778.79
• Check to client: $ 2,336.37

DISABILITY PAYMENT

• Award: $55,465
• Attorneys' 25% fee deducted: $13,866
• Check to client: $41,599

INTERIM PAYMENT

• Award: $24,291
• Law-firm costs deducted: $3,771.77
• Attorneys' 25% fee deducted: $5,129.81
• Check to client: $15,389.42

FINAL PAYMENT (delivered this week)

• Award: $32,474.44
• Law-firm costs deducted: $5,851.06
• Attorneys' 25% fee deducted: $6,655.84
• Check to client: $19,967.54 $532,826 to $650,267

TOTAL AWARD: $115,480.25

• Total law-firm expenses deducted: $9,757.48
• Total attorneys' fees deducted: $26.430.44
• Total paid to 9/11 responder: $79,292.33

Copyright 2012 N.Y.P. Holdings, Inc.
All Rights Reserved

PACIFIC GROVE, Calif. — A Pacific Grove man was killed when his car ran off Holman Highway, down a hillside and crashed into a tree Sunday , the California Highway Patrol reported.

The accident occurred in the early morning, said CHP Officer James Eagleman, when a red 2002 Honda Civic, driven by Brian Henderson, 24, westbound on Holman, ran into an embankment on the right side of the roadway, rolled on its side, and skidded across the eastbound lane and down a hillside, striking several trees.

The car came to rest on its roof about 30 feet below the roadway near the S.F.B. Morse Gate to Pebble Beach, Eagleman said.

The wreckage was spotted shortly before 2:15 p.m. from the highway by a man driving a truck, he said, and the driver called authorities.

Patrolmen and firefighters from the Pebble Beach Community Services District responded and found Henderson dead in the vehicle, Eagleman said, adding that no one else was in the car and Henderson was wearing his seatbelt.

Henderson's body was recovered by firefighters and released to the coroner, Eagleman said, and an autopsy is scheduled today.

Copyright 2012 The Monterey County Herald
All Rights Reserved

OAKLAND, Calif. — Four people are recovering in a hospital after being wounded in a shooting Friday night, police said.

The victims' injuries are not considered life-threatening, authorities said.

About 10 p.m., officers responded to a call reporting multiple gun shots fired in the intersection of 45th Avenue and International Boulevard, Officer Kevin McDonald said.

The victims were taken by ambulance to an East Bay hospital, police said.

Police did not provide a suspect description.

Copyright 2012 San Jose Mercury News
All Rights Reserved

RALEIGH, N.C. — Police charged a man with threatening city firefighters and Wake County emergency medical service workers with a machete Friday when they answered a call in a parking lot at 1823 Capital Blvd.

Grady Lee Smith, 55, of 1420 S. Wilmington St. in Raleigh, was charged with carrying a concealed weapon, being intoxicated and disruptive and going to the terror of the people.

Details of the call, to which dispatchers sent fire department first responders and paramedics, were not available.

Full story: Man charged with machete threat against Wake emergency workers

CHEROKEE COUNTY, Texas — A head-on collision in Cherokee County killed a Texas couple late Sunday morning. The couple's 2-month-old son survived the crash, according to Lt. Jay Baker with the Cherokee County Sheriff's Office.

The baby, transported to Children's Healthcare of Atlanta at Scottish Rite, suffered a traumatic brain injury, according to Cherokee County Fire and Emergency Services. The baby's right leg also was broken in the crash.

Police identified the dead couple as Rick Dean Headen, 48, and Charlotte Ann Sedtal, 40, of Sour Lake, Texas. They were the parents of the baby who was in the rear of the car, police said.

The accident happened about 11 a.m. on Knox Bridge Highway about five miles west of Canton.

Headen and Sedtal were heading eastbound in a Ford Focus and appeared to have veered into the other lane, hitting a pickup truck, according to Baker.

"It appears they were driving through Georgia on their way to another state," Baker told the AJC. "A family member from another state is currently on their way to the hospital. That relative will have temporary custody of the child when he is released from Scottish Rite," Baker added.

The couple died at the scene. Two adults in the pickup truck were injured but their injuries do not appear to life-threatening.

They were transported to WellStar Kennestone Hospital.

The accident is under investigation.

Copyright 2012 The Atlanta Journal-Constitution

CLEARWATER, Fla. — A Clearwater fire truck was responding to an emergency when it had to screech to a halt because a big concrete rock slammed into the windshield. And it was no accident — someone deliberately threw it.

"We're not talking about a pebble here, we're talking about a large chunk of concrete," said Elizabeth Watts with the City of Clearwater. Watts said the emergency call was halted by the flying chunk of concrete. "Big enough to fill the palm of your hand, so he got some momentum going," she said.

It happened during a busy Friday morning commute, in the 2300 block of Gulf To Bay Boulevard around 7:20 a.m. Clearwater Fire Rescue #49 was responding to a call, with their lights and sirens blaring.

Full story: Concrete shatters ambulance windshield

Concrete shatters ambulance windshield: MyFoxTAMPABAY.com

SAVANNAH, Ga. — Authorities say a Georgia man is recovering after accidentally shooting himself in the leg at a Savannah gun show.

Police say 26-year-old Charles Lake was leaving the gun show at the Savannah Civic Center around 5:10 p.m. Sunday when he discharged a round into his leg while re-loading his pistol.

Savannah-Chatham police spokesman Julian Miller says Lake bought the pistol at the gun show on Saturday and had returned Sunday to purchase another gun. Police say he was re-loading the pistol in the parking lot because loaded guns weren't allowed inside the gun show.

The Savannah Morning News reports Lake was taken to Memorial University Medical Center with an injury not considered life-threatening. No other injuries were reported.

Savannah-Chatham police are investigating the incident.

GOLD BEACH, Ore. — Three mushroom pickers whose disappearance in an Oregon forest prompted a ground-and-air search were found alive Saturday, authorities said.

The Curry County Sheriff's Office said Belinda and Daniel Conne, both 47, and their 25-year-old son Michael, who have been living in an RV trailer while scoping out a place to live in Gold Beach, hadn't been seen since about noon Sunday at a Huntley Park campsite along the Rogue River.

About 100 law enforcement officers and others took part in the search for the three family members, the newspaper said.

Deputies found signs of the family along a logging road at the western edge of Rogue River-Siskiyou National Forest, and about 11:30 a.m. Saturday a helicopter crew spotted the trio.

The parents were hungry, somewhat dehydrated and cold, and their son had a sprained ankle and frost bite on his feet, authorities said.

Authorities said the family, who had taken shelter in a hollow tree, had seen and heard the aircraft in the area previously but couldn't get their attention because of the thick vegetation. They were found Saturday after they moved to a clearing.

The Connes were airlifted out of the ravine about 2 p.m. and transported to a hospital.

Copyright 2012 U.P.I.

PHOENIX — A small plane crashed and burst into flames shortly after takeoff Saturday in an eastern Arizona mountain community, killing a well-known rural Arizona auto dealer and his wife and seriously injuring the couple's son and daughter-in-law.

The son was pulled from the burning plane by firefighters, while the daughter-in-law was found near the wreckage. Both were flown to Phoenix-area hospitals in critical condition.

The single-engine Cessna 206 crashed just before dawn and caught fire moments after taking off from the Show Low airport en route to Las Vegas.

The four onboard were affiliated with a series of automobile dealerships in eastern Arizona mountain towns, Show Low police Sgt. Shawn Roby said.

The dead were identified as Gerald Hatch and his wife, Ruth Hatch, of Snowflake-Taylor. Both were 66.

Gerald's 38-year-old son, Gunther "Rob" Hatch, was pulled from the flaming airplane by firefighters, Police Chief Jeffrey Smythe said. His 36-year-old wife, Mikelle "Kelly" Hatch, was outside the plane when firefighters arrived. She was badly burned and had a broken femur.

Gerald Hatch was the primary owner of dealerships in Show Low, Winslow and Snowflake, Smythe said. They included two Ford dealerships.

Rob Hatch also worked for the dealerships, as did other family members.

It was foggy and cold at the time of the wreck, but it wasn't known if that contributed to the crash, Smythe said. A Federal Aviation Administration investigator was at the crash site, and one from the National Transportation Safety Board was headed to the town about 150 miles northeast of Phoenix Saturday afternoon.

The loss will be felt through the small communities, Smythe said.

"Clearly they've been here for decades and decades in the Snowflake-Taylor area," Smythe said. "That's where they all lived primarily is Snowflake-Taylor, but as businessmen here in Show Low they were very well-known and well-respected, and it's going to be a big impact."

The police chief said Rob Hatch owed his life to the firefighters.

The battalion chief was first to arrive at the scene and used a hand-held fire extinguisher to keep the flames away from Rob Hatch while crews got a hose running, he said.

"They didn't know how much fuel was left in it, and yet they stood right there by that plane and extricated Rob and got him out and absolutely saved his life," Smythe said.

"Which is what they get paid to do, yeah, but I don't think the average person can recognize the idea of intentionally running up to a flame ball and dragging a person out to save their life, and that's what these guys did this morning."