Two weeks ago, an elderly woman living in North St. Louis County called 911 and reported she was having chest pains.
Both of the Northeast Ambulance and Fire Protection District’s ambulances were on emergency medical service calls. Chief Medical Officer Brian Fields responded with a crew in a fire truck.
When they arrived, Fields said she was having a heart attack.
“She was in desperate need of being transported to the hospital, but by us being in a fire truck, we couldn’t transport her,” Fields said.
A private ambulance service, Gateway, arrived in seven minutes, he said. Had it been the district’s ambulance, it could have been there in about three minutes, Fields said.
In cases like these, Northeast teeters on the edge of disaster when it comes to emergency medical service, Fields said, because Gateway and other agencies don’t always have units available.
“We’ve been lucky to a point where we’ve not had a critical incident,” Fields said. “But if it continues, it’s just a matter of time where we do.”
This district has two ambulances to serve about 50,000 residents and to cover nine square miles in several municipalities. The district has the busiest emergency ambulance service in St. Louis County. In March 2009, the district implemented a plan for a third ambulance.
Yet this March – just when Fire Chief Angelia Elgin was about to get the new ambulance schedule running in full force – St. Louis County Circuit Court Judge John Ross ordered that the district only run two ambulances.
After a restraining order imposed on the district last year, the court intervened in administering the Northeast district and appointed two of the current three board members.
Now the district’s emergency medical service is under State investigation.
On Monday, Greg Natsch, bureau chief of EMS in the Missouri Department of Health and Human Services, told the Northeast board that he had heard a number of recent cases where the district had four to six calls at once and had trouble getting backup.
Natsch recommended to the board that they put the third ambulance in place.
Chief Elgin said she wonders why Judge Ross didn’t consult Natsch, the district’s medical director or herself before making a decision about the ambulance.
“Who did he get his expert testimony from, and what training do these people have?” she said.
At the same Monday meeting, board members approved a budget to present to Judge Ross – a step towards regaining control of their district.
The budget did not include the third ambulance. Overtime costs took the main focus of discussion, and some citizens and administrators alleged that the costs were a result of the third ambulance.
Elgin, who was out of town for Monday’s meeting, wrote The St. Louis American in an email Tuesday, “We did not staff the third ambulance with overtime. We staffed it with part-time employees which did not create overtime. This excuse is used to justify taking the third ambulance out of service.”
How Northeast EMS works
When a person calls 911 for medical assistance within the Northeast district, the first unit to respond is the district’s ambulance 4717.
This ambulance averages approximately 14 to 18 calls per day, making it the busiest ambulance in St. Louis County. The second ambulance runs about eight to nine calls a day.
If there is a third call, the district will send a fire truck, which can’t transport people to the hospital. From there, the 911 dispatcher calls a private ambulance service.
If a resident of the Northeast district calls 911 and a private ambulance responds, that resident will get a bill for about $1,000. If a Northeast ambulance responds, it’s free.
“Taking any typical week here, you’ll see how soon we run out of ambulances and depend on outside help,” said David Tan, emergency physician at Barnes-Jewish Hospital and the medical director for the fire department.
“When we had three ambulances for about three months, we certainly did not need to rely on outside agencies to answer our own medical calls. Patients were able to be delivered in a more timely fashion.”
Plan for a third ambulance
Before Elgin became fire chief, she was the chief medical officer with the highest credentials in the district’s 40-year history. She is the only firefighter in the U.S. who sits as an advisor to Federal Emergency Management Agency. Eight hundred applicants vied for that position.
In 2009, she devised a plan to use a third ambulance as a backup and mutual aid to other districts. The plan Elgin started to implement was to divide the district into two parts and have the two ambulances respond to their own areas. Then the third ambulance would act as a backup.
“The crew liked [the plan] because the primary truck was not being exclusively used to run EMS calls,” Fields said. “The wealth was spread around. Right now the primary truck has three times the mileage as the second truck.”
How an ambulance gets paid
In the Northeast district, all residents do not pay out-of-pocket to ride in district ambulances*, with an exception of a few cases. The fire district forgives the out-of-pocket costs that occur after the district receives revenues from residents’ insurance companies.
The district gets its revenue from people who live outside the district, who find themselves needing an ambulance while passing through the district.
With the third ambulance, the district could provide more mutual aid to other districts, which would bring in more dollars. It costs about $1,900 a day to run the third ambulance, or about $57,000 a month, Elgin said.
When the third ambulance was taken out of service, the district EMS insurance revenues decreased about $30,000 to $50,000 per month, Elgin said. For example, February’s net revenue was over $114,000. When the third ambulance was taken out of service, it decreased to $90,000.
Currently, the district’s EMS does not provide mutual aid to other districts, nor do other districts’ ambulances aid Northeast. That is, unless it’s an extreme case where the district is desperate for help.
One of those cases occurred at a March 28 fire. University City Fire Department had to bail out the district, according to the fire report. Elgin’s plan would be the first step towards developing a mutual aid system with other districts.
Many districts don’t write off the ambulance costs for their district residents. Because Northeast does, it has to come up with a strategy to keep dollars coming in, Fields said.
Board Chairman and District President Derek Mays said he proposed to start charging district residents for the ambulance rides, but the board decided on other cost-saving actions.
“We have to think about our fiscal situation seriously,” Mays said. “We have to make tough decisions.”
Mays said the board decided not to run the third ambulance until they know they can continue to operate the district without financial failure.
Trending is telling
The Missouri Department of Health and Senior Services gives licenses to ambulance services. However, it does not regulate how many calls per day one ambulance can respond to. It doesn’t regulate the number of hours an ambulance crew member can work either. That’s all left up to the agency, said Greg Natsch, state bureau chief.
“I know from experience that 15 calls with two people in one 24-hour shift, that’s a lot of work and a lot of wear and tear on the vehicles and on personnel,” he said.
One of the most telling statistics is trending, he said. In 2007, Natsch looked at the number of times Northeast had three calls come in simultaneously. It was 200 times per year. From March 10 to 26 alone, this happened 26 times, according to records.
“Those are significant numbers,” he said, “and if you’re running two crews, that’s a lot of turnaround.”
Burnout has not yet hit the Northeast crews, even when last fall’s turmoil caused the district to halt payment to employees for a few consecutive pay periods.
“We all need money. We have bills to pay, but we still have a duty to provide service to the community,” said Lavell Slaughter, an EMT and a resident of the district. “We got in this field because it’s what we love to do.”
In other Northeast news
– The approved budget includes $250,000 for overtime; last year’s overtime cost was estimated at $243,000. Already in 2010, overtime costs total about $110,000. Chairman Derek Mays said the board will be carefully monitoring the sick leave, the primary source of overtime abuse. If the district continues with relaxed sick-leave enforcement, it will face a $900,000 shortfall at the end of the year, according to a report given by accounting consultant James Rose on Monday.
– In the budget, Fire Chief Angelia Elgin’s base salary will be $96,000. She has been working at a court-mandated $80,000 salary, which is less than some of the officers beneath her.
– On April 26, Judge Ross will hear the case of former board member Robert Lee, who wants to get back on the Northeast board. Last year, he was pulled off the board because he was employed with St. Louis County government, which is not allowed for board members. If Ross agrees to place Lee back on the board, Rhea Willis, the first African-American female* board member in the district, will lose her position.
*CORRECTIONS MADE April 13, 2010