Fixing Emergency Response

A story published in The East Hampton Star on Nov. 27, “Lawyer’s Death Reveals System Failures,” about emergency medical services in the town following the death of Tom Twomey, illustrates the tip of the iceberg. Such stories have played out in the past and will continue to in the future until we implement better solutions.

Simply throwing more money into first responder programs is fiscally irresponsible. System design is a key aspect of turning financial resources into service. The problem lies in that each of the 101 ambulance and first response services in Suffolk functions independently.

Disturbingly, the lack of funding is often cited as a limitation in designing a better system and coordination at a regional level. Yet a 2007 New York State Office of the Comptroller report says that revenue collected by special districts is considerable.

Funding relies heavily on the tax base of the community and contributes to the already high property taxes in the region. This is ironic since insurance companies will often pay for emergency transport, yet all but one known not-for-profit ambulance company in Suffolk bills for its services. Fire districts are not permitted to bill for their services; ambulance districts can.

This excuse cannot be used to continue leaving money on the table that could go toward establishing a more economically efficient model. Excuses such that patients will be discouraged from calling 911 so they can avoid a co-pay are flawed. It would be expected that an emergency department visit would generate a co-pay, as would physician services.

Nor can we continue to hide behind the excuse of “home rule.” Home rule allows governance at the local level. Ambulance service governance is generally at the fire district and town level. Even at the town level, however, town councils generally do not take a role in providing oversight or coordination of the individual agencies.

The culture must change. Agency and political leaders must support systemwide modernization. Change that will capitalize on economies of scale, such as shared municipal services, is necessary to prevent future E.M.S. system failures. Metrics must be established, data collected, and ambulance services held accountable to performance standards.

Several agencies have proved their ability to serve their communities well, but may not have the strength in all three sides of the triangle that are essential measurements of an E.M.S. system: clinical sophistication, response time reliability, and economic efficiency. Many get two right, but achieving all three is the exception. Shortening one or two sides of the triangle may give a false appearance of competency when viewed from a favorable angle.

It may be better to look at each of these agencies not as micro systems, but as individual stations, part of a larger system. In many cases, it is not the individual station that has failed us, but the system as a whole. A well-performing system relies on all links in the chain to function well. We have a system with many broken links.

Lacking is the coordination among the very dedicated men and women who provide emergency medical services. It is time that we recognize a more efficient E.M.S. delivery model that includes improved agency coordination of first responders and ambulance response vehicles. Staffing could be done by both volunteer and career personnel, but integral to coordination is effective communications, command and control of vehicles, and human resources, among other key components.

Resource allocation needs to be managed based on demand, not availability. While change will not bring back Mr. Twomey or those who have died waiting for an ambulance, the little data we have demonstrates that we are better than we were in 2007. There has been at least a tripling of cases of individuals surviving to be discharged alive from the hospital after suffering an out-of-hospital cardiac arrest. Such accomplishments would not have been possible without the grassroots efforts of the thousands of dedicated volunteer and career E.M.S. personnel, emergency departments, and intensive-care units throughout Suffolk County. But major gaps still exist.

In October, New York State and Suffolk emergency agencies responded swiftly and collectively to the Ebola outbreak in answer to an order issued by the acting state health commissioner, Howard Zucker. While I am not minimizing concerns at home about the Ebola threat, we have not had one individual with Ebola in Suffolk County. We have a much bigger public health emergency regionally — a fragmented and inefficient E.M.S. system.

While protocols are in place to transfer a call to a neighboring ambulance service if a crew cannot respond, data are unavailable to measure compliance. It is essential that leadership at the district level be part of the process, but coordination must happen at a higher level of government.

This is a call for our leaders to come together at the district, town, and county levels to implement sweeping improvements in our E.M.S. system. Your life may depend upon it!

Carl S. Goodman is certified in emergency medicine and emergency medical services by the American Board of Emergency Medicine. A Mount Sinai resident, he has been both a volunteer and a paid E.M.S. provider in Suffolk County and elsewhere for 30 years.