By Margot Sanger-Katz
Concord Monitor
STEWARTSTOWN, N.H. — Chief Harry Brown goes everywhere with a packet of maps. There’s the map that shows the 911 addresses assigned along every snowmobile trail in the North Country. There’s the map that shows where bags of medical supplies have been stashed with first responders. There’s a map with town boundaries and fire stations. One shows the spots where helicopters can land near heavily wooded areas.
The maps, stuffed in a sack and pinned on the walls of a trailer, show the territories covered by the North Country’s new ambulance service, the 45th Parallel. The territory is massive: 1,200 square miles. The area is dominated by more snowmobile trails than paved roads and includes 10 communities in two states.
Named for a line of latitude running through Stewartstown - said to be the halfway point between the equator and the North Pole - the 45th Parallel is unlike most EMS providers in the state. It’s a true regional system, where a group of communities developed a shared plan, came up with a budgeting formula and helped fund an independent nonprofit organization to provide round-the-clock ambulance coverage to their small, rural communities.
“You can’t get anywhere from here,” Brown said recently, gesturing toward one of his many maps. Yet these communities now have something that many of Concord’s rural neighbors lack: a full- time, advanced life-support ambulance.
It’s a model that experts say is popular nationwide, even in areas far less rural than northern New Hampshire. But regional ambulance services have failed to take root in New England, where clashing community cultures and a tradition of volunteer ambulance services keep most service local.
Up north, local leaders say the advantages of the new system are clear: more reliable service, better-trained staff and stable costs to many towns. But selling the plan politically was a long and fraught process.
“If we could make it happen up here in the northernmost part of New Hampshire, where I think the definition of damn Yankee pride came from - if we can make it happen, I think anyone could make it happen,” said Louise McCleery, the CEO of Upper Connecticut Valley Regional Hospital in Colebrook, a leader in the effort to develop the 45th Parallel. “But you have to have a few people willing to take risks and stick their necks out on the line.”
As it awaits construction of its new building in Colebrook, the 45th Parallel operates out of a trailer behind the hospital. It’s a small building filled with comfortable chairs. In one corner are two twin beds for the overnight crew.
Working for the ambulance means a lot of waiting. Unlike a busy city department, the North Country doesn’t have many medical emergencies. In the organization’s first year of operation, it responded to 843 calls - about two a day.
But the staff finds plenty of ways to keep busy. Brown and Michelle Hyde, the deputy chief, manage billing, apply for grants and monitor the progress of the building project. The shift EMTs train, exercise and frequently wash their ambulances. Brown, a North Country lifer, also likes to pass the time by telling stories about particularly grisly snowmobile wrecks and watching internet footage of his son, Chris, a professional snowmobiler, who specializes in death-defying tricks.
But though the alarm sounds less frequently than it does in the city, the full-time structure of the department means there’s always someone at the ready when it does. Every shift includes at least one intermediate-level EMT, who is able to provide some advanced life- support techniques.
The 45th Parallel was born in crisis. The hospital, which had long subsidized Colebrook’s volunteer ambulance, said it could no longer afford to pay. Volunteerism was waning as locals got busier and had to travel farther for work. On average, it took more than 10 minutes between the time someone called 911 and the time an ambulance even left the station in Colebrook or Pittsburg, the two local towns with volunteer ambulances.
And that was the average.
Often, “there would be three, four, five, six tones trying to get a crew together,” Brown said.
In communities where distances are significant, that time is about all crews can control. There’s not much ambulance crews can do to speed the trip between Colebrook and Errol on a wintry day. But by bringing in a full-time staff, the 45th has cut that time to under two minutes. A call comes in, and staff members hop right into an ambulance and leave. For injured snowmobilers in the woods, it could be the difference between 40 minutes and an hour of waiting.
McCleery said she remembers one case when it took more than 90 minutes for a crew to reach a suspected heart attack patient in Pittsburg. National standards suggest heart attack patients should be in a catheterization lab within 90 minutes to have the best possible outcome.
For years, the hospital had subsidized the operating deficits of the Colebrook ambulance, but the hospital was facing its own financial challenges and decided it could no longer afford to offer the same degree of assistance. That decision meant that the nearby towns that had long benefited from those subsidies suddenly needed to rethink their approach to EMS care.
The North Country has unique challenges - such as the lack of cell phone coverage and the frequent use of sled rescues - but the big problems for the North Country were not that different from those facing many communities farther south: The towns had limited call volumes and limited tax revenue but still wanted a reliable, professional EMS service. Local leaders say they embraced an unusual solution because their options were more limited. With their small populations, few of the individual towns could run their own services; the equipment costs alone would have been crippling. And because of their geographic isolation, there were no neighbors with excess capacity to pick up the slack.
“I think the reality is that the local towns could not afford to do it on their own,” said Gregory Noyes, a selectman in Canaan, Vt., who sits on the organization’s board of directors. “So that kind of puts you in a position of coming up with a solution.”
McCleery led the way, giving local leaders a deadline and securing grant funding to hire a consultant. A board was formed with representatives of each town.
Bruce Baxter, the EMS chief in New Britain, Conn., and a professional EMS consultant, said he presented the communities with a set of options. Ultimately, they chose to run a full-time staff with at least one intermediate-level EMT working each shift. Billing would pay for some of the costs of doing business, but the towns would need to pony up a combined $200,000 a year to make the organization run.
The group needed to decide where the ambulances should be stationed. Though the hospital continued to offer space to the group, the members voted to build a facility at the geographic center of the region. Brown said they hope to break ground next year.
The funding formula was where the project got difficult. Smaller communities wanted the funding split to focus on population. Poorer towns wanted an emphasis on property valuation.
“That took probably five or six knockdown, drag-out meetings,” Brown said.
Ultimately, the steering group agreed to a formula divided equally between three considerations: the number of medical calls, the number of residences and each town’s population. Property valuations were left out of the formula.
Then Brown and the board went on the road, making presentations in more than a dozen towns. Organizers had determined that the 10 key communities all needed to approve the plan - with its price tag - to make it work. Other communities were optional.
The plan went before 10 town meetings last year and was approved in all of them.
Organizers worried about what would happen if any community said no.
“Basically, the answer was, no pay, no play,” Brown said. “The state of New Hampshire, by law, does not require towns to have an ambulance service.”
The 45th Parallel deals with realities that would likely be unacceptable in more densely populated areas. They don’t staff any paramedics. They often contend with response times of an hour or more. Patients frequently get airlifted to hospitals far from their homes.
But when a patient calls an ambulance, one comes. And the towns have a predictable and affordable budget come town meeting time.
It’s a system that could be a model for the rest of the state, Brown said. But after decades of working in EMS systems, he knows regionalization is a tough sell to many communities, which take pride in having their own fire department, police department, high school and ambulance service, regardless of size.
“What we’ve done here makes so much sense all over the state, but you have to get over the ownership B.S., the turf,” he said. “It’s the pride. It really is.”
In the Concord area, no one is talking much about a regional solution to the area’s EMS problems. Larger departments tend to cover for smaller ones but rarely through any formal relationship. At Tri-Town Ambulance, one of the area’s longstanding collaborative systems, Hooksett recently decided to leave the group and staff its own ambulances.
“I’d like to be able to tell you that I think it’s going to be more regionalized, but I don’t think that will happen,” said Steve Carrier, the chief of the Tilton-Northfield Fire Department, which has contacted several neighboring communities to see if they’d like to pool resources. “I think there’s a perception that if they regionalize, there will be less control.”
According to experts, a regional system could work well in parts of New Hampshire because it could spread out the big costs - ambulances and full-time staff. But an ideal system could still make use of local volunteers. Local “fast squads” could respond immediately to medical calls to provide CPR or other first aid so patients on the outskirts of the system could still get speedy care.
A regional system could also make the best use of paramedics, Baxter said. By staffing just a few paramedics - perhaps in collaboration with a hospital - and reserving them for the calls that require their services, communities would need fewer of them, and the medics on call would get lots of experience.
“It is one way in which you can gain cost-effectiveness, by serving a greater population of people with some shared resources,” Baxter said.
Sue Prentiss, who runs the state Bureau of Emergency Medical Services, said she thinks more regionalization in New Hampshire is “very realistic” but would be a paradigm shift. She said the tough budgets in the next few years may encourage towns to think more creatively.
“A change is hard for everybody,” she said.
Several chiefs in struggling towns agreed.
“I have a million dollars worth of equipment. Sutton has a million dollars worth of equipment. Newbury has a million dollars worth of equipment,” said Bradford Fire Chief Mark Goldberg, who supports a regional EMS model but said he’d probably be “dead and buried” before one gained wide acceptance. “And nobody knows if they can get it out during the middle of the day.”
Copyright 2009 Concord Monitor