The following is republished from The Youngstown Vindicator as a part of The Center for Community Solutions' Health and Human Services Journalism grant.
By Jessica Hardin, Youngstown Vindicator Reporter
Health and Human Services Journalism Grant Awardee
jhardin@vindy.com
YOUNGSTOWN - Leslie Murphy recalls feeling helpless as she sat in the living room of a woman who thought she was having a heart attack.
Experiencing shortness of breath and already on oxygen, the woman had called 911 looking for assistance.
Captain Leslie Murphy and Lieutenant Michael Mahon talk about responding to emergency calls at Youngstown Fire Station 15 on Wednesday. Murphy had been dispatched, because the Youngstown Fire Department was warned an ambulance would not arrive promptly.
They passed time as “Law & Order SVU” played in the background.
After an hour, Murphy was prompted by her supervisor to ask the woman if she had a car.
“Never in my 21-year career have I been so ashamed to be a Youngstown firefighter,” Murphy said, her words dripping with bitterness and frustration.
So she sat in the back seat of the woman’s 2000 Chevrolet Impala keeping watch over the woman’s oxygen tank. A firefighter – who was an emergency medical technician, not a paramedic, like Murphy – drove.
Murphy turned to the woman and said, “Ma’am, let me tell you something. If something happens in this car, this will be my last day at YFD, and you and I are going to hyphenate the name of this city, because we’re going to own it.”
Problem
About half of those who die from heart attacks do so within the first hour after symptoms begin. Getting quick medical attention is paramount, but in Youngstown and surrounding communities, there are no guarantees an ambulance will be timely.
Joe Mistovich, chairman of the Health Professions Department at Youngstown State University, is blunt when discussing the state of ambulance service in Youngstown:
“We have no system in the Mahoning Valley” for emergency medical services, he said.
Ambulance service in the Valley is an uncoordinated patchwork of private companies and community-run ambulance services that operate out of local fire departments.
The primary private companies in the region are AMR and Lane Life Trans. Youngstown partners with AMR, and Boardman and Austintown work with Lane.
Ambulances are sparse, and, at any given moment, no one knows the locations of ambulances outside their own community. As a result, dispatching often doesn’t make sense.
If a student starts choking in the hallway outside Mistovich’s office at YSU, and there is a Lane ambulance next door at the Taco Bell and an AMR ambulance in Trumbull County, the latter will respond to the incident.
“We’re not sending the closest ambulance, because we don’t know who is closest.
The result is delayed care.
“If your house was burning down and you called the fire department, it would not be OK if it took 20 or 25 minutes for a firetruck to get there. You would have people marching downtown. If someone was robbing your house and you called the police, I don’t think any citizen would be OK waiting 30, 40 or 50 minutes.
“Yet when someone has to wait for an ambulance,” Mistovich said, “no one seems to care.”
Every day, about 165 people visit the emergency room at St. Elizabeth Youngstown Hospital. About 62 are transported by ambulance.
“This is a public health crisis,” Mistovich said. “We can’t get ambulances to the scene in a reasonable amount of time.”
Physicians contacted by The Vindicator would not comment for this story.
Dealing with delays
Delays are the result of a brutal resource squeeze: Demand is up, resources are down, and operating ambulance services is less profitable than ever.
There are many reasons for increased calls, said Tom Lambert, assistant chief of operations at Lane Life Trans.
“People find it easier to call 911, and they think they’ll get into a hospital quicker,” he said.
The city also is dealing with an increasingly older population and systemic poverty. Many city residents lack a means of transportation, and public health knowledge in Youngstown is mediocre at best.
Murphy recalled transporting patients with blisters and toothaches.
“I think we should hand out WRTA [Western Reserve Transit Authority] passes,” Murphy said. “Take that instead of an ambulance.”
Moreover, EMS services in Youngstown are still reeling from the opioid epidemic.
Overdoses “have not gone away,” Lambert said. “It’s a stress on our system.”
As call volumes have spiked, fewer ambulances are available.
One of the biggest pressures on ambulance providers is Medicare and Medicaid reimbursements.
Although Medicaid coverage has expanded, reimbursement rates have been stagnant for more than a decade, said Lauren Huddleston, executive director of Ohio Ambulance and Medical Transport Association.
OAMTA data estimate that in Ohio, basic life-support transfers cost $174.48, and advanced life-support transfers typically cost $232.64.
According to a recent survey conducted by OAMTA, ambulance providers, on average, lose $46.31 per advanced life-support trip and lose $71.11 per basic life-support trip for a patient on Medicaid.
“It’s not like they’re breaking even,” Huddleston said.
The region also acutely feels the nation’s paramedic shortage.
For the first time in the 35 years that Mistovich has worked at YSU, the department does not have enough applicants for an EMT class.
“Typically, we would turn students away,” Mistovich said.
At the moment, the profession is undesirable.
“They’re probably getting paid $12 to $15 an hour. Quite frankly, you can go to McDonald’s and make that money,” said Youngstown fire Chief Barry Finley.
For barely more than minimum wage, paramedics work grueling hours under immense pressure.
“What a paramedic sees in one shift, most people don’t experience in a lifetime,” Mistovich said.
Contracts
Mahoning County’s largest communities provide ambulance service through contracts with private companies.
The contracts stipulate guidelines for response times and often include measures to ensure that an ambulance is nearby.
Only 66 percent of ambulances called to Boardman in November 2018 responded within six minutes.
That number is not supposed to dip below 85 percent, according to a memorandum of understanding the township has with Lane. But Lane failed to meet this criterion for seven months in 2018, the last full year that statistics are available.
“[Pitzer] came to us. We corrected that problem. Our response times are less than six minutes now,” Lambert said this month.
Boardman’s contract states: “The Provider will have at least one fixed facility centrally located in Boardman Township located within the Township to ensure adequate response locations.”
In January, Boardman fire Chief Mark Pitzer responded to a medical call involving a child. It had been several hours since a call came into the department, so, by all accounts, an ambulance should have been available.
Boardman’s dispatcher checked on the status of the ambulance after firefighters waited on the scene for more than 15 minutes. Responders eventually learned the ambulance was at Mahoning Avenue and state Route 11.
“That tells me they were probably more than likely coming from a Trumbull County location, and that’s where our frustration is,” Pitzer said. “Even though they’re the contracted ambulance company, sometimes we feel there is [not] due diligence in locating a closer ambulance.”
Although the contracts outline disciplinary action for violations, municipalities have little to no leverage in enforcing these provisions.
When Finley took over as Youngstown’s fire chief, city council brought up the issue of ambulance delays and asked him why the contract couldn’t be enforced.
“If we [upset them] and they leave, what are our options?” Finley said. “No other private ambulance company can handle the call volume we have in this city.”
So he deals with it.
And he hates it.
“But I’m also a realist and realize that right now they’re the only game in town. So we need to tread lightly,” Finley added.
Coping
Chip Comstock, Western Reserve Joint Fire District chief, knew that something had to change in spring 2018.
Two Poland residents recently had experienced heart attacks and waited for ambulances for 30 minutes.
While both patients survived, he feared the next victim might not be as lucky.
So he pushed a 1-mill ambulance levy that would allow the district to purchase a backup ambulance.
His department is in a unique situation. It is smaller than communities such as Boardman and Austintown and thus lacks the call volume to be a priority for private ambulance companies.
But the community’s agreement with AMR does not prohibit the fire district from conducting ambulance transport.
One of the provisions in Boardman’s contract with Lane is that Boardman agrees not to provide ambulance transport as a result of calls to the police or fire departments.
Per the fire district’s new policy, if AMR estimates a response time of more than 15 minutes, it must let Poland know, and Poland will cover patient transport if it can round up volunteers.
“When we bought our ambulance, I projected that we would transport two patients a month, maybe at most one a week,” Comstock said this month. “Yesterday, we transported four times. We average one a day.”
What is happening in Poland has occurred in other communities with the resources to make the switch.
Canfield started running its own ambulance service last year after a car accident during the Canfield Fair put Chief Don Hutchison in the same position.
Witnesses swarmed the scene, and when ambulances failed to materialize for the five injured people, everyone demanded answers.
“There were people yelling at us, ‘Where are the ambulances?’” Hutchison recalled.
The Cardinal Joint Fire District started running EMS in July 2018. It has 24 paramedics and three ambulances. In the past year, the district has responded to more than 940 calls.
The communities that operate their own ambulances use a system known as “soft-billing.”
If a township or village resident calls an ambulance, the fire department writes off the remaining cost after insurance is applied.
For nonresidents, the department “hard bills,” or sends a bill for the remaining balance. This arrangement would be beneficial for retail hot spots that attract nonresidents, such as Boardman.
Though the single ambulance the fire district purchased after the November election is not enough to run all of the community’s calls, it’s a start.
Comstock would need to acquire two cars and staff EMS with four part-time people at a time.
He estimates that EMS service would cost $800,000 annually, or a 2.5-mill levy.
Running ambulances
Starting an ambulance service in large, less-wealthy communities is significantly more daunting.
To effectively respond to Youngstown’s call volume, Finley would need to purchase four ambulances and hire 24 paramedics.
He estimates the start-up costs would amount to $4 million.
Additionally, since Youngstown dispatches through AMR, switching models would require training dispatchers in emergency medical response.
Finley intends to ask council for a portion of the cost and write federal grants for the remainder.
“The one thing we have over privates is we don’t need to make a profit,” Finley said.
Boardman Fire Department has been talking about starting its own ambulance service for more than 10 years.
In 2008, the International Association of Firefighters Local 1176, the union that represents Boardman firefighters, drafted a proposal.
“We would like to be able to show you and the community that this is not about firefighters trying to make more money, but an attempt to provide better service,” the proposal said.
Former Boardman fire Chief James Dorman presented a feasibility study to township trustees in March 2009.
The Boardman Business Citizens Committee reviewed the study and gave findings to trustees in July 2010, saying the proposal looked “at best, a break-even” business, said Jim Rosa, who led the review.
In the intervening years, layoffs, personnel changes in leadership and union contract negotiations resulted in the plan being shelved.
“A lot has changed since then,” Pitzer said. “What it really boils down to is the taxpayers and what level of service do they want.”
And he warns it may not be the panacea some envision.
“Almost 33 percent of our calls in 2018 were overlapping,” said Pitzer. “Even if we ran our own EMS, and let’s say we have two ambulances like Lane does – when a third call comes in, what we are going to do?”
In that case, Pitzer would seek mutual-aid assistance.
In Youngstown, Finley said his ideal system would involve communities running their own ambulances and private companies providing backup.
“Even after we get our own ambulance, we still need them,” he said.
Mass casualty
In the Pittsburgh Tree of Life shooting in November 2018, 11 people were killed and seven others were wounded, including the suspect.
Without a tactical EMS response, the death toll almost certainly would have been higher.
“If you reach care within an hour, you have a much higher chance of survival. The earlier we can make contact, the better their chances. That’s really what it comes down to,” said Justin Sypolt, Pittsburgh’s paramedic crew chief and a member of the tactical EMS team that responded to the Tree of Life shooting.
Tactical EMS teams, like the one in Pittsburgh, accompany SWAT teams in active-violence situations. While SWAT isolates the threat, medical personnel can begin treatment.
Traditionally, paramedics enter only secure areas. But isolating a threat can take hours, and it takes only five minutes to bleed out.
An incident like this in Mahoning County could be much more deadly.
Seven Boardman firefighters are trained in tactical EMS. They have trained in tandem with the Boardman police to effectively respond to active violence in the township.
“Go back and listen to all these people that were interviewed on the news,” Pitzer said. “One of the first things they say is we never thought this would happen in our community.
“We can’t live that way,” Pitzer said.
While Lane also has a TEMS team, there’s no guarantee it would be prepared to respond in that situation.
“I don’t know what kind of training they have. I don’t know if they would be willing to do that,” Pitzer said.
Lambert is confident in the training of his paramedics, though he noted, “Nobody knows the communities like the fire department knows the communities.”
If Boardman ran its own ambulance, paramedics, firefighters and police officers could be trained in response to these crises that happen with increasing frequency.
“It’s not just about response times,” Pitzer said. “Now I am at the mercy of the private ambulance companies. If I go to an active-violence situation and I need five ambulances, I don’t know if they’re coming or not.”
The end
In the face of this EMS crisis, officials agree: It’s just a matter of time before the area’s ambulance system collapses.
Until then, what are residents’ options?
“The only thing they can do is call 911 and hope for the best,” Murphy said.
Local fire chiefs talk about starting their own ambulance service, but they need buy-in from political leaders and residents, who say they are already overtaxed.
In the meantime, many fear things will continue to fall apart. In some cases, they already have.
“There is a tsunami of EMS calls on the horizon that most elected officials do not see,” Comstock said. “We are in a crisis mode, which has not yet been acknowledged by either our residents or our elected officials.”
His work has taken him to nearby counties, such as Carroll, where delays can routinely run from 30 minutes to an hour. Residents there frequently drive themselves to the hospital in an emergency.
Comstock predicts communities with the means will run their own ambulances and that those that cannot could go without.
“They’ll resort to the days when ambulance service used the hearse to get people to the hospital.”
Murphy agrees.
“I think it will be status quo until it blows up.”
This report was funded in part by a grant from The Center for Community Solutions, a nonprofit, nonpartisan think tank in Cleveland. Learn more at communitysolutions.com.
