Though wounded, Kristopher Pride was “alive and talking,” according to a witness, when Buffalo police and fire officials arrived to help him July 17 on Keystone Avenue, where he’d been shot while riding a bicycle.
But the witness said Pride lay bleeding for 25 more minutes before an ambulance arrived and took him to Erie County Medical Center. He was later pronounced dead. Witnesses thought the 25-year-old Pride could have been saved if the ambulance had come sooner.
It took so long because Rural/Metro Medical Services, which normally provides ambulance service in the city, experienced a “huge spike in volume” – probably because of the mid-July heat wave, a spokesman said – and Twin City Ambulance, which serves the Northtowns, was called for help.
The incident was an example of how Buffalo, like many other cities, sometimes faces ambulance shortages as 911 call volume continues to rise and hospitals become overcrowded.
But state health officials and Rural/Metro administrators are talking about a possible solution, copied from other communities or cities.
It’s called community paramedicine, a new approach to emergency health care that expands the role of paramedics far beyond transporting patients to emergency rooms.
A complex system
When Pride was shot, Rural/Metro ambulances were responding to 11 different “hot,” or high-priority, calls in the City of Buffalo alone. Twelve of its ambulances were stalled at area hospitals, waiting for spots for patients in emergency rooms. Five more “cold,” or lower-priority, calls were also waiting to be answered in the city. Calls included a cardiac arrest, three reports of “shortness of breath” and a diabetic attack, among other medical issues.
Emergency responders have contacted The Buffalo News to complain that ambulances sometimes cannot respond to true emergencies because they are too often picking up “frequent fliers,” or people who repeatedly call 911 for non-emergencies and often don’t have to pay for the ambulance service they get. That does happen, Rural/Metro and county officials said, but the problem is not so simple.
When somebody in Buffalo calls 911, many county and city agencies become involved.
First, the call is answered by Erie County’s Central Police Services. If the incident is police- or fire-related, the call is forwarded directly to those respective agencies. If the incident requires an ambulance, the call is forwarded to another county agency – Ambulance Dispatch and Inspection, or ADI.
An ADI dispatcher then asks the caller a series of questions to determine the level of care required. If an ambulance is needed, Rural/Metro is notified, and the company sends paramedics to the scene. Rural/Metro can also be called by police or fire officials, or by patients directly.
Rural/Metro has 12 locations where ambulances are “posted” in the city, and some of these ambulances are often responding to other calls. Rural/Metro also covers many suburban areas; officials said the company posts about 50 ambulances systemwide per day.
The Fire Department is called, as well, and firefighters – who are trained as EMTs – often beat ambulances to the scene because the department’s 19 firehouses are usually closer.
The firefighters arrive and treat the patient to the extent they can. If the patient wants a ride to the hospital, the firefighters can’t leave until an ambulance arrives. The patient, at any point, can “sign off,” or decline a ride to the hospital, which Rural/Metro general manager Jay Smith said happens about 35 percent of the time over the approximately 55,000 calls the company receives annually in Buffalo.
If an ambulance arrives and the patient still wants a ride, Rural/Metro must transport the patient, no matter how exaggerated the symptoms might seem, and the ambulance cannot respond to another call until the patient is “cleared” into an emergency room.
But when things are busy, that can take an extremely long time.
Ambulances are sometimes lined up eight-deep as they wait for space to become available at area emergency rooms, Smith said, and clearing a patient can sometimes take up to two hours – 90 minutes longer than the state’s recommended maximum waiting time.
Smith said the three busiest hospitals are Buffalo General, Mercy and ECMC, which collectively average a turnaround time of 50 to 54 minutes. At two local hospitals, Smith added, the average turnaround time has gone up by eight minutes over the past three years.
“It’s not a criticism of the hospitals directly,” Smith said. “They do work with us to try to figure out ways to make it quick.”
Smith also acknowledged that hospitals are also dealing with walk-in patients and ambulances from other agencies.
Brendon Reilly, a University at Buffalo medical student who worked as a scribe in the emergency room at Mercy Hospital for three years, said it “wouldn’t be uncommon” for him to report for a night shift and see eight stretchers of patients waiting for beds.
Melanie Griffis, a spokeswoman for the Catholic Health System, of which Mercy Hospital is a part, said the Mercy emergency room in 2010 underwent a 46,000 square-foot expansion and added 32 private treatment rooms to decrease turnaround time.
She said over 70 percent of patients arriving to Mercy by ambulance are in a bed within 15 minutes, and she stressed that Mercy’s turnaround time doesn’t vary “in any significant way from regional or national norms.”
Reilly said some in the emergency room aren’t there for legitimate reasons.
“It’s definitely not an emergency every time,” Reilly said. “People have called the ambulance for ridiculous things.”
‘Abuse’ or ‘misuse’?
There’s no question some people who frequently call 911 are not always for emergencies.
In Buffalo, one man called Rural/Metro a whopping 313 times in 2009, and two others called over 180 times that year.
One Buffalo firefighter who didn’t want his name published said he and other firefighters tell jokes about some of the “nonsense” calls they respond to. He said a 19-year-old once called because of a pimple.
“I’ll go my whole life, hopefully, without having to call 911,” the firefighter said. “And we get some of the same people, over and over again, calling 911.”
Smith acknowledged that frequent callers do present a challenge to Rural/Metro’s ability to serve the city, but he said the stories like the firefighter’s are mainly “anecdotal” and was reluctant to blame the frequent callers, who often tend to be poor.
“I have always liked to use the words ‘misuse the system,’ ” Smith said. “Because ‘abuse’ is pretty harsh on someone who doesn’t have access to health care, doesn’t know not to call 911, doesn’t know that he has the ability to get services in another way, may have societal problems, whether it’s alcoholism or some type of mental incapacity.”
Studies in four states that were published last fall concluded that most frequent fliers often call 911 for legitimate medical reasons, according to the American Medical Association’s news website.
The studies showed that while those patients do take up a disproportionate amount of space in the hospitals – in one California study, 3.1 percent of the patients accounted for 16.5 percent of the visits to the emergency room – they also tended to recurrently suffer from mental or physical illness, substance abuse or other health problems.
The patients also tended to be poor and live in environments not conducive to treating their health issues, with relatively little access to health care.
Smith wants to dispel the notion held by Rural/Metro’s detractors that the company seeks calls from the frequent fliers. They have to respond to every call, but it’s often bad for business, he said.
Many of the callers are on Medicaid, which Smith said reimburses Rural/Metro for only $187 for each transport – far below the company’s cost structure. A single ambulance can cost almost $100,000 before it is stocked with a $30,000 heart monitor, a $3,000 stretcher and ever-expensive fuel. And that’s also before labor and maintenance costs.
Uninsured callers often can’t and don’t pay the ambulance bills, which can get expensive – even insured customers sometimes face co-pays of over $1,000. It’s “bad debt” for Rural Metro, Smith said.
The Medicaid reimbursement hasn’t risen in 10 years, according to Smith.
“If somebody calls for a cardiac arrest, our paramedic – with all that training and background, all that equipment and technology that we invested in – gets there, is able to save the person’s life, monitors them on an EKG on the way to the hospital; to Medicaid, that call is worth $187,” Smith said.
The Wall Street Journal reported on Wednesday that Rural/Metro’s national parent is considering filing for bankruptcy. Erie County officials have said that they are monitoring the situation and will step in if needed to make sure all 911 calls are responded to normally.
A possible solution
So how to solve the problem?
New York State is looking into a new idea in emergency medicine called “community paramedicine,” according to Steve Kroll of the Healthcare Association of New York State. He also sits on the state health department’s Emergency Medical Services Council.
In an effort to reduce costs and the volume of 911 calls, cities such as San Diego and Washington, D.C., have implemented community paramedicine, which gives paramedics more responsibility than they have now.
Since many frequent 911 callers do not have great access to health care and have chronic conditions, “community paramedics” visit them periodically to check on their health and administer medicine – preventing expensive 911 calls before they clog the system.
Rural/Metro spokesman Brian Lawson envisioned a community paramedicine scenario in which EMTs respond to a 911 call that turns out not to be an emergency, but medical attention is still needed. The paramedics could use their skills to diagnose the problem, contact a doctor and perhaps bypass the emergency room.
“What you’ve done is take a person who could potentially be transported to the hospital, wait in line at the emergency room and take up a bed in the emergency room. … You’ve treated that patient already and you’ve relieved a little bit of that stress [on the system],” Lawson said.
There are hurdles. Right now, Rural/Metro only gets reimbursed for services if a transport is made, so there is a question about who would pay for community paramedicine, even though it might eventually lead to cost savings. Still, Kroll said the state Department of Health is examining a way to implement such a program.
“I think it’s very possible,” Kroll said. “I think there needs to be some legislative and regulatory things that need to happen to support it. And it can be a very important part of the future.”