http://www.philly.com/mld/dailynews/news/local/14581707.htm

City EMS: Dying for attention
By DAVE DAVIES
daviesd@phillynews.com 215-854-2595

WHEN RICHARD BADWAY heard that former Philadelphia School Board President Rotan Lee died after waiting nearly 20 minutes for an ambulance, he just shook his head.

Badway's 22-year old son, Ricky, died last October after he collapsed in a Roxborough apartment, and it took 22 minutes for a Fire Department ambulance to arrive.

National standards call for an eight-to-nine-minute response time for ambulance service.

"I was sad to hear it happened to somebody else," Badway said in an interview last week. "But honestly, it didn't surprise me."

Richard Badway wonders if a quicker response would have saved his son, an apparently healthy young man who experienced an irregular heart rhythm.

"Nobody knows if he could have survived," Badway said. "But my son didn't have every chance he should have had, and it is a hard thing to live with, because I don't know if he could be living today."

In both Rotan Lee's and Ricky Badway's cases, a fire engine arrived relatively quickly with cardiac defibrillators and other basic medical aid.
But both men had longer waits for ambulances with paramedics who could render more advanced care - and take the patients to the hospital.

City Fire Commissioner Lloyd Ayers said he isn't happy with 20-minute response times for ambulances, but he said that they're unusual and that most calls are answered quickly.

But there's growing evidence that the city's EMS system is struggling to keep up with the increasing volume of 911 calls, and City Council members are questioning the Fire Department's management of the system.

"It's apparent there aren't enough medic units to cover the city adequately," Councilman Jim Kenney said in a recent interview. "That's clear from information we're getting about how long it takes to respond."

Ayers faced tough questioning from Kenney and other Council members in budget hearings this spring, and he admitted that at times the system is stressed.

"Sometimes during the day, every unit is out," Ayers told Council during his testimony. "They're running, they're crisscrossing. They're going all over the place."

Ayers told Council that he thinks coming improvements will help the system.

But Dave Kearney, the recording secretary of the local firefighters union and a 14-year paramedic, said in a recent interview that things in the EMS system are worse than they've been in years.

"People are waiting 20 minutes for a medic unit every day," Kearney said.
"People are dying waiting for ambulances."

"It's frustrating for me and other paramedics to watch this," he said. "It's hard when you look at a person who's very sick and say, 'I should have gotten here earlier.' "

Kearney believes that as 911 medical calls have increased in the last few years, the Fire Department hasn't planned to keep up with it, and that the system has reached a crisis point.

The Fire Department's deputy commissioner for operations, Ernest Hargett, said in an interview that 20-minute response times "are not the norm. They are the cases that attract attention. And they're the ones people like to point out as the weaknesses within the system.

"But there are thousands of people that are well-served by the system."

A Daily News review of challenges facing the city's EMS system found:

. Plans by the Fire Department to add eight new ambulance units last year are still on hold, primarily for budgetary reasons.

. The department is plagued by a shortage of paramedics, and bureaucratic bungling has delayed the hiring of more for weeks.

. The department's response-time statistics don't measure the actual waiting time that patients experience, and make it hard to tell how well the system is performing.

. A significant part of the problem is public abuse of the 911 system, which has flooded switchboards with calls for routine medical problems.

Rotan Lee's family issued a statement after his death last month, praising the "timely and sensitive response" of the Fire Department.

But Ayers said Lee's physician got into an argument with the firefighters who arrived first about why it was taking so long to get an ambulance there.

Ayers said two days after Lee's death he would issue a full report on the incident. Nearly three weeks later, no report has yet been released; the department says it is forthcoming.

Awaiting reinforcements

The city's EMS system consists of ambulances, known as medic units, and fire companies whose firefighters are trained as EMTs - emergency medical technicians. These EMTs are capable of administering what is known as Basic Life Support, including CPR and cardiac defibrillation. They can't take a patient to the hospital.

Almost all of the 42 medic units are staffed with paramedics, personnel with at least two years of training who can deliver what's known as Advanced Life Support services, including IV medications. Their ambulances can transport patients to hospitals.

When a medic unit isn't immediately available, a fire company - in a fire truck - is dispatched to a 911 medical emergency as a "first responder."

Of the 42 medic units, only 28 are available around the clock. Fourteen others operate primarily during the day, leaving coverage stretched thin at times.

Medic Unit 22, which responded to Ricky Badway in Roxborough, is based near Broad and Cambria streets in North Philadelphia.

The Fire Department has planned to add eight Advanced Life Support medic units since last summer, but the move is on hold until a legal dispute is resolved with the firefighters union over plans to close five fire companies.

Structural fires have declined sharply in recent years while 911 medical calls have risen, so the department sees the closing of fire companies and adding of ambulances as a sensible shift of resources to meet needs.

The union sued to stop them, and the case is now before the state Supreme Court.

When asked why the department didn't go ahead and add the medic units while awaiting the court decision on fire companies, Hargett said, "It's a budgetary constraint that keeps us from adding the eight."

But there's another problem.

Paramedics Wanted

The department doesn't have enough paramedics to staff the ambulances it has now, and it recently downgraded four units to Basic Life Support - meaning they're staffed with EMTs, not the more highly skilled paramedics - just to keep them running.

And it emerged in Council budget hearings this spring that, even though Fire Commissioner Ayers said his department was short "about 40" paramedics, somehow the city's personnel department hadn't been told to start the hiring process.

"I have not received the request [from the Fire Department] for approvals for these positions," city Budget Director Diane Reed told a clearly annoyed Councilman Frank Rizzo.

Fire Department officials insist they're not to blame for the snafu, and since then the personnel department got the hiring process going by publicly advertising the city's interest in certified paramedics.

But despite doubling the normal application period to four weeks, the city received only 47 applications, fewer than the 63 vacancies Fire Department officials say they now have.

And it's unlikely those applications will result in 47 hires, since applicants must take an exam, go through background checks, then decide if they still want the job.

The department says about 240 paramedics are on staff now, and union official Kearney says too many are leaving. Some apply to become firefighters, one of the most dangerous professions, rather than deal with the stress of constant ambulance runs in Philadelphia.

"It's a very tough job," said city Personnel Director Lynda Orfanelli - "a burnout job."

Ayers so far has refused to consider a step that might increase the pool of applicants - relaxing the residency requirement that limits the jobs to city-dwellers.

Hargett said a program to develop interest among Philadelphia high-school students in Fire Department careers should eventually generate a stream of trained and qualified city residents for the positions.

In the meantime, Kearney said, the department's refusal to confront the personnel issue is only driving more paramedics out of the department.

"At best, they're guilty of terrible planning," Kearney said. "The volume of calls has been growing, and they haven't expanded resources to keep up."

Response-time roulette

Despite the staff shortages, the Fire Department points to response times that are within the National Fire Protection Association standard of eight minutes for an Advanced Life Support response.

But the numbers don't tell the whole story.

When someone in Philadelphia calls 911, that person reaches a police operator, who asks some questions and, if it's a medical emergency, transfers the call to a Fire Department switchboard, where more questions are asked and help is dispatched.

In Philadelphia's response-time stats (and in the NFPA standard), none of the call-processing time is counted. Response time is from dispatch of an ambulance until arrival on the scene.

Jay Fitch, a nationally recognized EMS consultant, said response time ought to measured the way a patient experiences it.

"We recommend a real measure of response time," Fitch said, "from the time that call hits a phone console until an ambulance arrives on the scene."

Kearney said he thinks there's another problem with Philadelphia's response-time stats: Sometimes a medic unit will be dispatched on a call, then after a few minutes it may be transferred to another unit, or even a third.

In such a case, Kearney said, the Fire Department counts the response time from the dispatch of the last unit until it arrives on the scene, discounting the time other units were on the call and understating the true response time.

Greg Schaffer, an Atlanta-based EMS consultant and writer, said that is a weakness in many cities' EMS response-time stats. "Times can be skewed if a call is dumped from one unit to another. You want to be able to look at the time from the first call to arrival on the scene."

Deputy Commissioner Hargett said Philadelphia's stats count response time from the first dispatch to final arrival.

But the Daily News asked Hargett about a recent call in Northwest Philadelphia in which an elderly patient and her family waited 34 minutes for an ambulance.

Although the city has medic units based in Roxborough and Mount Airy, the one that eventually responded was Medic 22 from North Philadelphia, the same unit that responded to Ricky Badway.

The patient died of an apparent heart attack. The Daily News is not publishing that patient's name, at the request of the family.

Hargett said Fire Department records showed a 23-minute response on that call, representing the time from the dispatch of Medic 22 until its arrival at the scene.

When the Daily News pointed out that those records left 11 minutes unaccounted for, Hargett said in an e-mail that his 23-minute time was from an EMS report, not the department's official response-time data.

Another issue is that Philadelphia reports "average response time," a simple average of the dispatch-to-arrival for all medic runs. But the NFPA standard
- and, experts say, a better measure - is how quickly an EMS system responds 90 percent of the time.

Hargett said the Philadelphia department's data don't permit it to track that number, but that a new 911-dispatching system expected to go on line this summer should yield better data.

Too many calls

And then there's a problem over which the department has no control:

If the city's EMS system is overwhelmed, part of the reason is the dramatic increase in 911 calls in a city with declining population.

"The public has to understand they have to stop abusing 911," Kenney said.
"They have to understand it's not a taxi service. You don't call for a ride to the hospital."

Hargett said that for increasing numbers of people, a 911 call is their entry point to the health-care system.

"More people lack insurance," Hargett said. "They stay home and get sicker, and rely on the 911 system a lot more than they did a few years ago."

Kearney acknowledged that that's true, but said management has to be proactive. He noted that in the 1990s the department was expanding the number of medic units.

"I think we probably peaked around 2000," Kearney said. "We were doing pretty well, we were going in the right direction. But they didn't plan for the future."

In 2006 for this to be happening is INCREDIBLE