NH communities rely on decentralized, unpredictable EMS system

November 09, 2009 03:34 AM

By Margot Sanger-Katz
The Concord Monitor

CONCORD, N.H. — At Concord’s Broadway fire station, the motto is “running like crazy,” because, most days, the alarm bells keep on ringing.

The emergency medical technicians who staff the Broadway ambulance are busy, responding to Concord’s many emergencies: falls, sickness, drug overdoses, domestic assaults, allergic reactions and heart attacks.

It is just one of three ambulances in the city that, combined, responded to 4,898 medical calls in the city last year. When the bell goes off, the EMTs are waiting in the station, and every ambulance boasts at least one paramedic, who can insert IV lines and breathing tubes and administer an array of medications at the scene of an emergency. The city doesn’t break out the cost of emergency medical care, but it spent a combined $10.6 million on fire and emergency medical services last year — and more than half the calls were for ambulances.

In Andover, where fewer than 200 calls come in a year, there’s no one at the station, and there’s no medic at the ready. There’s no rescue squad line item in the town’s budget. And, sometimes, there’s no one who can respond when a sick person calls 911.

In central New Hampshire, there are ambulances like Concord’s and Andover’s and nearly every variety in between. Some staff full-time ambulances during the day but rely on volunteers at night. Some pay stipends to their volunteers to compensate them for their time. Some contract with private, for-profit companies. Everyone who calls 911 talks to a dispatcher in the same, centralized system. But the individual rescue squads that respond to the calls differ in their size, budgets and local custom.

Do you know how your local service stacks up?

The state tells communities what equipment they need to carry to call their truck an ambulance. And it tells volunteers what training and courses they need before they can call themselves EMTs or paramedics. But there’s no rule that every community must have any sort of emergency medical service, no rule that says how many people each unit should have on staff, no rule that says whether communities need EMTs with advanced life-support certifications. No rule says an ambulance needs to arrive in eight or 15 or 30 minutes.

In characteristic New Hampshire style, the statewide system emphasizes local control, small budgets and volunteer service.

“This is a home rule state, so the way EMS gets delivered is decided by these communities, not by us,” said Sue Prentiss, who runs the state’s Bureau of EMS, which oversees the state’s many providers.

The Monitor spoke with 42 local EMS providers, reviewed state performance statistics and talked with consultants, experts and researchers in the field. What we found was:

- There are wide disparities in what towns pay for EMS, the training of their responders, the design of their system and departments’ reliability and speed at reaching patients’ sides.

- Small, rural communities often rely extensively on mutual aid from larger, urban departments with more resources. In all but a few cases, the larger communities are not paid for that assistance.

- Improving patient outcomes is more complicated than simply driving down response times. In fact, research suggests that too much emphasis on improving response times can cost communities lots of money without improving patient survival.

- Formal regional collaboration in EMS can be a cost-effective way to improve the quality of care across many towns. But it may not be embraced by many local leaders.

Prentiss thinks many New Hampshire residents are simply not aware how communities finance and manage their EMS operations. During her career in EMS, she has seen the quality and sophistication of the care EMTs can provide improve dramatically. But she said she’s been disappointed by how little many residents know - or care - about the performance of their local rescue squad. Homeowners tend to research the quality of local schools and whether the local crime rate is rising or falling. But until they have an emergency in their family, she said, many people just think they can dial 911 and expect an ambulance to appear.

Communities looking to explore their performance now have access to a new tool. New Hampshire was the second state in the country to submit data about all its emergency medical calls into a national online database. And the forms filled out after each call can give local governments - and researchers - troves of information about how calls are being answered and what care is being offered.

For towns like Andover with long volunteer traditions, volunteers try to do the best they can. They attend training sessions, meet up to wash the ambulance and raise money to cover their costs of operation. It’s one of a few departments in the state that still provides ambulance service without paying its members, costing taxpayers money or sending a single bill to the patients it serves. It runs on $15,000 in annual donations and the community spirit of 14 volunteers.

But that old-fashioned system is clearly under strain. Rescue squad Capt. Phil Hackmann readily admits that there are many calls that the small volunteer squad simply can’t answer. When Hackmann’s pager goes off and he’s teaching a high school class at Proctor Academy or reading his 3-year-old daughter a bedtime story, he can’t always rush to the station. About half the time, Franklin’s fire department sends an ambulance when an Andover resident needs one. Ambulances typically take more than 20 minutes to arrive. Franklin taxpayers foot the bill for whatever patients’ insurance doesn’t cover.

Volunteers for the department sound themes that are familiar to organizers throughout the region. People are busier than they once were, they’re more likely to work outside of town, and they’re more likely to have jobs that don’t take kindly to employees leaving for half the day to take someone to the hospital. Hackmann said the rescue squad plans to ask the town for help next year at town meeting.

“It has become very hard for the volunteers to keep up with all these things: continuing education, certifications, training and calls,” Hackmann said. “It’s hard, physically, to go on calls, and financially, to leave your job to go on a call.”

In many towns, the volunteer ranks have dwindled, and the departments rely on the extraordinary commitment of just a few members. Bob DeStefano, the EMS captain in Weare, said he’s left work, his recreational softball league and Christmas to tend to sick and hurt town residents. Last year, he was working a full-time job and attending paramedic school, but he said as tired or busy as he gets, he has a hard time ignoring his pager when he knows someone needs help.

“If I’m right there and I can fix somebody, I’m going to do it,” he said.

In recent years, Weare voters have rejected measures to pay members to be available during the day, to hire full-time firefighters trained in EMS and to hire a full-time chief.

“Considering there’s only 30 calls that went unanswered out of 650, no one thought that was really that bad,” DeStefano said.

The region’s urban systems are the most deluxe, featuring 24- hour full-time coverage, paramedic providers and ambulances spaced throughout the city to shorten response times. They also benefit from nearby hospitals. (Typically, the farther you live from a hospital’s emergency department staff, the less likely you are to receive paramedic-level care in the field.) City residents know that when they call 911, someone highly trained will come for them in under nine minutes. City residents also pay more in taxes to support that service.

Concord’s service is expensive, but not as expensive as it would be for a smaller town to provide similar coverage. Because the city is densely populated and generates a lot of medical calls, the city’s large staff of EMTs stays busy and the tax burden is spread more widely. It would be difficult to imagine taxpayers in a town like Canterbury, with a population of 2,300 and 50 square miles, footing the bill for similar staffing.

Especially because the Concord Fire Department often picks up the slack when nearby towns get strapped. Though Concord bills patients who require EMS care, that bill still falls far short of the true cost of operating the ambulance. Concord frequently helps its neighbors through its fire mutual aid system, though it rarely needs their help to cover its own medical calls.

According to a recent analysis by a Concord city councilor, the city provided medical mutual aid more than 330 times last year but never needed any from its neighbors.

“The statistics suggest that Concord has become an EMS crutch for surrounding communities,” wrote Fred Keach, in a report he presented to the council earlier this year.

The statistics also show a surprising trend. The bulk of those mutual aid calls aren’t to small towns such as Canterbury and Webster, where volunteers may be sparse but medical calls are few. Concord EMTs are most often leaving the city to help other full- time departments such as Allenstown and Bow.

Bradford addressed a volunteer crisis last year by offering small stipends to rescue squad members who responded to calls. Still, fire Chief Mark Goldberg said it can be a challenge to ensure adequate staffing.

“For a small town like Bradford, I don’t see how it could work any better. I think they use resources very well,” Goldberg said.

At the time, calls were going unanswered. A former Bradford EMT said in 2007 that she remembered hearing tone after tone go out about a patient in severe respiratory distress. Goldberg looked around at other options and didn’t see many good ones. Personnel with New London Hospital’s ambulance, which is staffed 24-7, said they were too busy to cover Bradford’s calls. A private ambulance company would have cost between $250,000 and $500,000 a year - in a town with a total annual budget of $1.8 million.

“If we had a better alternative tomorrow, I think we’d pursue it,” he said.

In other parts of the country, regional or county-wide EMS systems are the norm, but in New Hampshire, local control makes for a patchwork of systems.

Local EMS captains said they’ve seen another trend emerge: the combination department. Because few towns can afford to contract with a professional service or staff their own full-time ambulance, they hire career EMTs to work some of the time - usually during weekdays, when volunteers are hardest to find.

That’s the solution recently embraced by Canterbury. This summer, the fire department hired its first full-time employee, dual trained in firefighting and EMS care.

Prentiss thinks the state will move increasingly to combination departments as more towns experience crises like Bradford’s. But she said that EMS providers have a long way to go in educating taxpayers about what they do.

“Doing it the way we’ve always done it isn’t necessarily the right way or the best way anymore,” she said.