By Meghan Foley
The Keene Sentinel
CHESHIRE COUNTY, N.H. — It was Friday the 13th. Then it got worse.
With just one call, Cheshire County’s strained emergency medical response system found itself exposed that sunny July morning in a way that had those monitoring and working the incident nervous.
“That stretched EMS in our area right out,” Marlow Fire and EMS Chief Sean Brewer said. “If anybody below Keene had any medical emergency, they would probably have been calling mutual aid from Troy or Fitzwilliam, or Keene Fire.”
It was just after 9 a.m., and the region’s dispatch service, Southwestern N.H. District Fire Mutual Aid, received an emergency call about a two-car crash on Route 10 in Marlow, just north of the town’s village area. There were reports of multiple injuries, entrapment and one person who was unconscious.
The first card to fall was when Brewer told the dispatcher that there were no medical personnel available to staff his department’s ambulance. The only person who could respond was Marlow’s EMS captain, and she went directly to the scene, Brewer said.
“That forced us right out of the gate to call for a second ambulance,” he said.
State law requires two licensed providers per ambulance, with at least one person licensed at minimum as an EMT.
Five minutes into the call, three ambulances had been toned out from the town’s backup ambulance provider, R.J. DiLuzio Ambulance Service. The private company is based in Keene and provides primary and secondary EMS transport coverage, as well as paramedics to intercept calls, to several communities in Cheshire County.
Paramedic intercept is when a paramedic is sent to meet up with another agency’s ambulance to tend to a patient needing a higher level of care than someone with a basic or advanced EMT certification can provide.
Of those injured in the July 13 crash in Marlow, two were reported to be severely hurt, according to a recording of the call. Two helicopters from Dartmouth-Hitchcock Medical Center in Lebanon were dispatched to landing zones near the scene, and two more ambulances — one each from DiLuzio and Walpole — would also respond.
There were seven patients with a range of injuries, Brewer later wrote on the Marlow Fire and EMS Facebook page. Two were flown to Dartmouth-Hitchcock, two were taken by ambulance to Cheshire Medical Center, and the remaining three declined to be transported, Brewer wrote.
Then the second card fell. An emergency medical call being handled by Alstead Ambulance needed a paramedic, according to the dispatch audio. The only ones available were with Golden Cross Ambulance in Claremont, and that wouldn’t work, as Alstead Ambulance was heading south to Cheshire Medical Center, not north to Claremont.
“Any incident like that is tough,” Alstead Ambulance Chief Jesse Moore said.
And it’s an example of why area ambulance providers need to continue to discuss the region’s EMS system, he added.
“Any given day, an incident like that can occur, and that affects the entire collaboration.”
Sounding the alarm
Nearly 17 months ago, The Sentinel published a three-day, six-article series about the strain the region’s emergency medical services system faces.
Since then, some area EMS providers have tried on their own to improve their staffing levels and response times. But a system-wide solution remains elusive.
“As we see it, certainly things haven’t gotten any better,” Joe Sangermano, chief of Southwestern N.H. District Fire Mutual Aid, said.
Call volume continues to increase as does the difficulty in having agencies able to respond, especially during the day, he said.
In 2017, Mutual Aid, which covers 77 communities in New Hampshire, Vermont and Massachusetts, dispatched 19,953 emergency calls. Of those calls, 12,040, or about 60 percent, were medical, and 1,299, or about 7 percent, were for motor vehicle crashes, according to agency data.
The year before, Mutual Aid logged 19,670 calls.
When “Sounding the Alarm” ran, the system was reaching a breaking point, due to the increase in call volumes coupled with funding challenges and a drop in volunteers and personnel who are paid per call, according to area fire and EMS officials.
The problem has some services struggling to stay afloat, while others are being stretched thin trying to cover their calls and the calls other providers are unable to fill. This has resulted in patients, some of them critically ill or injured, having to wait longer for ambulances.
Worsening matters, officials with area ambulance services say, is the fact that Medicare, Medicaid and private health insurance reimbursements don’t adequately compensate the care they provide. As a result, ambulance agencies have had to rely on contributions from the towns they cover, grants, fundraising and donations to stay in the black.
They can also bill health insurance companies or the patient only when the patient is transported to a medical facility, regardless of whether care is provided at the scene.
Another complication is that, unlike area fire departments, local ambulances services don’t have mutual aid agreements.
So while they often help each other covering calls, an ambulance service called to respond as a backup agency can decline to go if it doesn’t have a contract with that community.
Mutual Aid’s board of directors has continued to discuss the problem, Vice President Harry Boynton said, and its officials are seeking to have the private ambulance companies that cover the agency’s member towns sign on with Mutual Aid.
The municipal ambulance services are already covered as they are under the fire departments of member towns, he said.
The agreements would be specific to allowing the private ambulance companies to use Mutual Aid’s radio frequencies during emergency calls, he said. The companies have been using the frequencies for years, he said, but without a written agreement that outlines rules.
However, that doesn’t solve the main problem — which is that the region needs more emergency medical personnel, he said.
It also doesn’t guarantee that a town requesting a backup ambulance from an agency it doesn’t have a contract with will get one.
“This change is not all of a sudden going to ease the burden on all EMS departments,” Boynton said. “For that, I don’t know what the answer is.”
In response to The Sentinel series, Mutual Aid officials hosted a meeting with area ambulance services in late March 2017 to discuss possible mutual-aid agreements and the future of the EMS system in the region. But there hasn’t been a meeting since.
Planning for that second meeting is still in the works, according Sangermano, who noted the challenge of finding a meeting time feasible within every agency’s schedule.
Sangermano hopes such a meeting can happen in the fall.
In the meantime, getting data needed to quantify the problem remains a challenge, according to James C. Suozzi, associate medical director and EMS director at Cheshire Medical Center.
Last year, Suozzi and other EMS officials were trying to collect more accurate figures from Mutual Aid to quantify the strain on the region’s EMS system. At the time, Suozzi had data from hospital records and anecdotal information, but they didn’t paint a complete picture. He believes detailed dispatching data can do that.
“The lack of data I think is really harming us and keeping us from knowing exactly what is going on. We know there is a problem. We are all feeling it. But we don’t know the numbers and details,” Suozzi said.
He added that “sometimes it’s a hope and a prayer” that there’ll be enough ambulances and crews left when there’s a call like the one in Marlow.
“In general, I think the big need is still staffing. There just aren’t enough volunteers to staff the system currently, specifically in the small communities,” he said.
The agencies that are able to answer calls and provide backup to other communities are becoming increasingly busy, and that causes additional challenges, he said.
Moore agrees that the biggest problem is human capital, which is also a problem the region’s fire service is facing, as fewer people are available to volunteer.
That’s why the regional conversation must continue and why he and other area EMS personnel are still waiting for Mutual Aid to hold a second meeting on the topic, Moore said.
“Everybody clearly knows what the problem is,” he said, “but I don’t think anybody has a really good answer to the problem.”