Putnam ALS Provider Empire Ambulance may quit

[helicopper 1,050]

Maybe they should have bought Fords instead of the Hummers! And so it begins...

Putnam's paid ambulance service ready to quit contract

By SUSAN ELAN

THE JOURNAL NEWS

(Original Publication: July 27, 2007)

CARMEL - The company that provides ambulance service to Putnam County says it can't afford to do the job at the current rate and has announced it will opt out of its contract on Oct. 1.

"It's strictly financial," Robert McMahon, the county's commissioner of emergency services, told a legislative committee last week. "The cost of ALS (advanced life support), like everything else, has gone up. They are continuing to lose money."

The news couldn't have come at a worse time for Putnam officials. County Executive Robert Bondi is in the midst of preparing the 2008 county budget and has already warned that property taxes could increase by more than 20 percent.

Bondi, an ambulance volunteer in Mahopac for 15 years, said he would not allow the paid service arrangement that has reduced response times to lapse, a stance that could lead to a renewed showdown with legislators over county spending. Some have already said the plan initiated a year ago may be a luxury Putnam cannot afford.

It cost Empire State Ambulance Corp. $1.8 million to provide the service, Robert Cuomo, the county's emergency medical services director, told the Legislature's Protective Services Committee. Putnam paid Fishkill-based Empire $485,000 for one year for advanced life support and paramedic services.

"They thought transport would bring in revenue, but they didn't get the transport," Cuomo said, referring to payments from patients' or their insurance providers for taking people to the hospital.

Empire spokesman Dan Roberts said the company was still in talks with county officials.

Empire was to receive $504,000 in the second year of its contract. Its original bid did not take into account the number of canceled calls for transport, Roberts said.

Legislator Regina Morini, R-Mahopac, said some of her constituents have told her they can't afford Empire's transport charges.

Patients carried to the hospital by an Empire ambulance get billed for the trip. Those taken by a volunteer ambulance do not pay for transport, but are billed for any paramedic service.

Under the contract, Empire replaced two paramedic-staffed "fly cars," which carry medical equipment but do not transport patients, with two fully staffed ambulances in eastern Putnam. It provides the service only during the day and only if volunteers are not available. If volunteers can be mustered to transport a patient, Empire still provides a paramedic.

Western Putnam continues to have coverage from two fly cars and to provide volunteer ambulances for transport.

The service was initiated in September to reduce response times during business hours, when there is a shortage of volunteers. From 2002 to 2005, response times of more than 20 minutes rose from 8 percent to 25 percent; responses of more than 30 minutes went from 0.6 percent to 6 percent.

Cuomo said Empire response times range from 8.4 to 12 minutes. It also provides better care than "basic life support," he said.

"ALS has made a difference," Cuomo said. "It's the standard for care in the state."

Anita Somers, 74, of Brewster said prompt ambulance service is not something she as a taxpayer considers discretionary.

But Legislator Sam Oliverio, D-Putnam Valley, and others have balked at the idea of paying the full cost that Empire reports.

"In the current financial environment, with so much controversy over everything, I don't know where we would get the $2 million," he said.

Legislator Tony Hay, R-Southeast, said towns and villages or neighboring communities should chip in.

"We should look for a regional solution," he said.

[Guest Orpi442]

Well actually the hummers are cheaper than the tahoes for flycars. Actually I think is a better ride. I am working Medic 2 tonight. Stop up if you want. It would be good to see you.

As far as the contracts Putnam as well as everybody else is getting a sudden shock of what Westchester & Rockland already knows

[jps385 0]

Those numbers seem a bit high but the fact is putnam is just experiencing what pawling did a few months ago. EMS costs Money!! Maybe if the days of low ball bids from the privates are at an end we'll start to see a few more municipal services come into existence. This would be better for both the employees as well as the public as we may start to see the experience level increase if people stay medics for more than a few years.

[x635 4,066]

Some have already said the plan initiated a year ago may be a luxury Putnam cannot afford.

ALS A LUXURY???? Are you kidding me? ALS is needed more in Putnam then some areas of Westchester, considering hospital transport times!

This should be a signal to Putnam to step up and run their own ALS system, like how they run their own Sherriff's Department, 911, etc. Just another reason EMS shouldn't be handled by "For Profit" companies. We wouldn't contract out for FD or PD, so why EMS????

I don't blame Empire at all, they are just trying to do business. They're not to blame if this venture is losing them money due to the practices in PC, obviously, the county doesn't want to spend the money on ALS that it should, or doesn't use it properly.

[Guest Orpi442]

Thanks for saying that. You are also might I add a 100% correct about how we need to run EMS. The company just like in Pawling is attempting to make money & provide service. Putnam has been talking about running there own system for a while now. We have seen other services doing just that but at a smaller scale. ie Blooming Grove for example. & soon to follow is New Windsor with there own Medics. As one of the medics working the system I feel bad that we may pull out at the same time looking to who may come in to continue working a system that I enjoy being in hummer or no hummer.

People like the two that was quoted just do not understand what we do or provide. I as a good medic that is leaving the system down to part time really wants something perm. "WHY CAN'T WE ALL GET ALONG!!!! Working medic 1 right now

[RWC130 594]

Just curious...

How come the Hummer ALS Fly Cars don't say:

PARAMEDIC UNIT

or

ADVANCED LIFE SUPPORT

They say "Empire State Ambulance" on the rear windows, "Putnam 911" over the rear tires

and "Our Passion Is Caring" in the center of the vehicle.

I would think ANY company would want to promote they are an ALS provider, No?

I really like the Hummers, I hope Empire can keep ALS going!

[JetPhoto 626]

"ALS has made a difference," Cuomo said. "It's the standard for care in the state."

Yes ALS makes a difference but it is a tool that you use when needed it is not the "standard of care". On average, actual ALS calls is prob. 35 - 40%. EMT's are the standard and medics are used when needed.

[Guest alsfirefighter]

Having ALS is the standard of care, the percentages of what call volume are ALS is a seperate topic.

Someone mentioned how Putnam has talked for a long time about having their own ALS. And they kept talking, and talking and talking and talking and talking and now they will talk, and talk and talk and talk. Why because most of them do not get it, they don't understand it, don't want to understand it whether you explain it to them or not. A luxury they can't afford? Nice. Where will we find two million dollars? Its there find it, create it, start a tax district, do something. If you sell it they will like it. I know I would never complain about increased taxes for increased emergency response. Add money onto county and local permits that goes towards EMS funding only. If not...go back and tell the town's or fire districts they have to pick up the tabs and see if the cost gets any easier. Putnam learning a lesson? What hasn't been there to learn from the beginning with the Sloper, Alamo contracts that every year they wanted more. Now a company comes in, with not the greatest reputation to being with and its a shock? Right.

Many may not agree with my thought process, but I honestly feel that if you can't fix or organized your BLS services, ALS might not work as well either. After all it all starts with BLS, whether you need transport or to be a good paramedic, you need to be a good BLS provider.

[PVFD233 68]

who picks up the contract now for Putnam ALS? Transcare has been rumored and Alamo has been there...

Edited July 27, 2007 by SPFC56-233

[RWC130 594]

All of the EMTBravo Paramedics are going to VOLUNTEER and handle Putnam ALS!

[helicopper 1,050]

Yes ALS makes a difference but it is a tool that you use when needed it is not the "standard of care". On average, actual ALS calls is prob. 35 - 40%. EMT's are the standard and medics are used when needed.

Advanced Life Support is a standard of care. It is much more than just a tool. BLS is the standard of care for BLS emergencies and ALS is the standard of care for ALS emergencies. If you're having a heart attack or other cardiac event, ALS may save your life. Outcomes in many other medical emergencies are also influenced greatly by early ALS intervention. The statitics you cite are probably accurate 65/35 BLS to ALS but for those 35 percent of the patients, ALS is the standard that they should receive. When you consider the taxes that residents in the Hudson Valley pay, there should be no question that they receive the highest level of care available - and that's ALS.

Orpi, I was just joking about the Hummers. I'm glad to hear you enjoy the ride - I'm surprised there aren't dubs on them!

It is time for Putnam, like so many other communities, to recognize that "doing it cheap" and expecting the commercial provider to eat the losses is unrealistic. To call ALS a "luxury" is patently absurd and that's someone who obviously has NO clue about EMS or medical care.

Maybe the system would benefit from using the alphabet soup dispatch levels to triage calls - that's what EMD's are for. STOP sending ALS on the twisted ankle on the ball field so ALS isn't criss-crossing the county from one BLS call to another. STOP using the ALS units to cover for the inability to get a BLS squad out the door - if they can't do it, put a commercial BLS ambulance in their town. Don't deprive a person in need of a paramedic, the service because the medic is transporting a BLS job AGAIN!

EMS isn't a luxury and it isn't a game. It can and should be taken seriously and now is a golden opportunity for Putnam to step up and do the right thing!

From the American Heart Association:

EMS

The American Heart Association and the EMS community are vital partners in emergency cardiovascular care management. Both work towards the goal of saving lives. The AHA is committed to providing state-of-the-art training in Advanced, Basic, and Pediatric Life Support to healthcare professionals. AHA works closely with a variety of national organizations that include: ACEP, NAEMSP, NREMT, NASEMSD, NAEMSE, and EMSC in developing education and training programs and materials for the EMS community.

As healthcare professionals we are all committed to the “chain of survival”. The “chain of survival” concept was first introduced in the American Heart Association’s Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care published in 1992. The chain of survival is a metaphor that illustrates a series of related interventions that will improve the outcomes of victims of cardiac and respiratory emergencies. Each link in the chain identifies an early intervention: early access (call 9-1-1), early CPR, early defibrillation, and early advanced life support. Each early intervention requires the training of persons ranging from the lay rescuer, to the first responder, to EMTs, to the emergency room physician. This training is delivered through the American Heart Association’s Emergency Cardiovascular Care (ECC) training network.

[helicopper 1,050]

All of the EMTBravo Paramedics are going to VOLUNTEER and handle Putnam ALS!

You crack me up!!!

[Goose 188]

You really can't make this stuff up. What a joke.

[RWC130 594]

You crack me up!!!

I try to add a few much needed LOL's to the board. Life is too short.

BE SAFE BROTHER!

[ckroll 101]

ALS in conjunction with timely BLS is, or ought to be, the standard of care. In defense of those who manage EMS in Putnam, it is not an easy county to manage. That said, it is not impossible to craft an EMS system here that takes into account level of care, response times, and affordability, but it continues not to happen.

So long as leadership responds to single driving forces and what should be tertiary concerns --'what is the cheapest solution', 'how do we keep costs out of the county budget', ' how do we get re-elected or keep the legislators happy', 'what can we do that doesn't upset local fire departments'-- then we have scant hope of ever having an EMS system that meets its primary function, which I think ought to be to establish a consistent standard of service across the county that provides appropriate access to ALS and useful response times. I think it is also incumbent upon a county or its towns to address public health issues and craft a system that is responsive to its residents' needs.

Standard of care: I think every patient should be assessed by a paramedic.

Geography drives staffing levels in Putnam, not call volume, so we have the resources in place to send medics to all calls --with the caveat that they can be diverted or reassigned. [if PD/SO are EMTs, BLS calls can be left in their competent hands pending arrival of BLS transport units if there is another true emergency prior to arrival of BLS.] How serious a fractured ankle, or why an elderly woman is not feeling well is best served by a provider who knows how to do a proper assessment and does it often. Cardiovascular issues can be subtle. Given the 3 to 5 minutes wasted by 911 dispatch on data entry and over the phone evaluation, I think the time and resources much better spent with automatic dispatch of ALS. ALS doesn't need to go lights and sirens, but it ought to go.

Quality of care: I think ALS early brings professional care to bedside and ought to be the goal of any EMS system.

Any patient who will be admitted to a hospital or will need blood work and treatment is well served by that care starting as early as possible and continuing until transfer to hospital staff. Can most of our patients live without it? Yes, but it is a level of service that can save medical costs in the longer run and brings comfort to both patient and family.

Time to service: The county or towns need to set a standard for time to service. ALS, BLS and transport.

We don't have it and we can't plan without it. time <=> quality + resources <=> expense. It's a dynamic equation. Set standards, review and evaluate both standards and compliance. Decide what we want, what we need, and strike a balance for what we can afford.

Who pays for it: I think a system ought to be primarily user funded with reasonable upper limits, the balance covered by taxes.

OK, it's all user funded. We pay for insurance, or through taxes or directly. If a county 'saves' $500,000 by outsourcing EMS, the residents will still be paying the same. The bill will come in a different envelope. One of the fundamental purposes of central government is reallocation of resources. It is like insurance. If residents pay the county and/or town every year, then the resident doesn't get as badly soaked when he has an emergency. If the user sees some of the cost, there is incentive to control those costs by using it carefully. Public health is better served if people are not so burdened by the cost that they cannot/ do not call for aid when they or a family member needs it.

How do we control costs: I think towns or counties ought to have direct control over how the cost of EMS is allocated.

For the most part, we cannot control what the costs of EMS are. We can control how the costs are allocated, and in doing so, we actually can have some minor impact on overall cost. Contracting out to a for profit EMS provider and walking away is like selling a child into servitude. Yes, care will be provided, but at what cost? I think the county and some towns have abdicated the role as overseers of how care is billed. This is good role for government and it is not being addressed.

Who should provide the service: After the county and/or towns decide what service is appropriate, the provider who can provide that service at the least price should do it.

Who provides the service is not an issue. If volunteers can do it, great... but they have to do it. If a for profit company is the best bargain, then that is great as well. There is nothing wrong with making money at EMS. There is nothing wrong with asking users to pony up for services. Roads, lawn care, refuse removal, plumbing, carpentry all cost money and we pay for it and pay the provider decent profit for his work. Health care is no different. If the county can provide the service for less, then the county should do that. If the private sector is the best choice, then do that. Expecting, even allowing, private sector to subsidize EMS is questionable management practice, at best.

Every year fire departments and ambulance corps and Indian Point and Putnam County put out pamphlets telling residents how to plan for that eventual emergency. Know what to do, plan ahead, know what you need, stock what you will need, plan for how you are going to get together and where you are going to go. Keep some extra cash on hand as well...

Then county officials and our elected representatives go back to their offices look aghast when there is a knock on their door and the county needs an EMS system and now it is an emergency. They never saw it coming. As a resident, as a volunteer BLS provider and as a paid paramedic, I am completely discouraged by how much we pay for management in this county and how little we are getting for our money.

[Guest alsfirefighter]

All of the EMTBravo Paramedics are going to VOLUNTEER and handle Putnam ALS!

RIIIIIIIIGHT......I'LL BE THERE TOMORROW.

CKroll, I believe that I remember you saying in a few of your other posts that you believe all patients should be evaluated by a Paramedic. When you say all...do you really mean...."all?"

I'm not challenging you, just interested in your concept of this. I think its probably obvious that I do not believe this and feel that ALS providers are over utilized, which leads to "medic" dependance by BLS providers and often puts them in the position to be improperly used as crew fillers.

Edited July 28, 2007 by alsfirefighter

[RescueKujo 130]

I don't understand why it is so hard for our elected officals and other public servants, who generally will never pass up a pay raise, to understand that public safety is never something you can fudge on. Unfortunate as the costs are, proper coverage of EMS, Fire abnd local law enforcement is a necessary cost. In the end, if you do not appropriately cover public safety, you will end up spending much more for nothing as you pay a family for a death that could have been avoided.

As for every patient being evaluated by a medic, that's not a proper use of resources. Emergency Medical Dispatch or programs like it, while flawed (try getting info from a untrained civilian) most of the time gets the proper resource for the complaint. A paramedic response is not appropriate for a foot injury, for example, while EMTs aren't appropriate for a shortness of breath patient.

There are ways to manage the system. And while I am not familiar with the specifics back east, the basics are generally the same in every system.

Remember, air goes in and out, blood goes round and round. Either of those stops, it's a very bad thing. And that's why we're doing what we do.

Here endeth the lesson.

Edited July 28, 2007 by RescueKujo

[Danger 160]

Enter: Alamo. There's no money to be made in Putnam. Muni makes sense, but it's a world away.

[STAT213 332]

See, I am of the opinion that paramedics on every bus and fly car are the way to go. Its not that EMT's are adequate, they certainly are. Its that things change. You turf off a borderline patient to BLS because its a strong crew, or whatever reason and things go south. Now what? The patient who was supposed to have ALS now doesn't.

There is a reason that companies like Eastern Paramedics (sadly sold to R/M in the 90's) and Fire Departments staff only at the paramedic level. (And, I am a union FF, so the whole job justification doesn't work on me. if that were true, we would use basics and have the same arguement.)

Now, I understand that there are shortages of medics around. Ever notice that the fire departments aren't short medics and EMTs?

Regardless...EMS costs money. Plain and simple. So does plowing the roads. I hate taxes as much as the next guy. So...Let those who won't pay for it go without for a while. That is an ok choice in my book. NYS Law requires municipalities to provide FD and PD, but not EMS ( I am pretty sure about this one, but as always might be wrong.) Let them find their own way to the hospital for a week. You don't want to pay for it, you vote it down, great. No more services. Somehow I bet the schools will remain open and the roads will be plowed.

The priorities of the public are fascinating, aren't they?

[ckroll 101]

RIIIIIIIIGHT......I'LL BE THERE TOMORROW.

CKroll, I believe that I remember you saying in a few of your other posts that you believe all patients should be evaluated by a Paramedic. When you say all...do you really mean...."all?"

I'm not challenging you, just interested in your concept of this. I think its probably obvious that I do not believe this and feel that ALS providers are over utilized, which leads to "medic" dependance by BLS providers and often puts them in the position to be improperly used as crew fillers.

In Putnam county, well, yes, I do, and maybe that's because it's a low volume system. In high volume situations resource allocation makes sense. In a rural system where time to scene can be 15 minutes, waiting for BLS to get on location and decide it's worse than it sounded delays ALS or puts it out of reach. Patient evaluation is only as good as the person who does it. Mostly, I'd like to see evaluations done by a provider who is paying careful attention and has the experience to make a good decision.

An ALS evaluation that includes the EMT is also a teaching opportunity. Explain to the EMT what one is looking for, what one found and why BLS is the right level of service and what would have made the call deserving of ALS. One way to tackle medic dependence is to show the EMT that patient evaluation is not rocket science, but it needs to be done well. My experience has been that on average-- but by no means all the time--one gets better BLS out of an ALS provider than a BLS provider. I think you are correct that the foundation of any system has to be good BLS.

And yes, I agree medics are over utilized for care by medic dependent providers, but that is a different issue.

[Guest partyrock]

An ALS evaluation that includes the EMT is also a teaching opportunity. Explain to the EMT what one is looking for, what one found and why BLS is the right level of service and what would have made the call deserving of ALS. One way to tackle medic dependence is to show the EMT that patient evaluation is not rocket science, but it needs to be done well. My experience has been that on average-- but by no means all the time--one gets better BLS out of an ALS provider than a BLS provider. I think you are correct that the foundation of any system has to be good BLS.

Thats great, so now you have a well trained EMT who will NEVER use his skills because the medics do everything. Truth be told most of the interventions we perform in the field outside of the most serious respiratory distress and cardiac emergencies are not necessary for patient survival. It can often wait until the paient gets to the ER. They improve the comfort of the patient and help to prevent the patient from turning south on us. For full cardiac arrest, when looking at meaningful recovery the two greatest factors are early CPR and early defibrillation. Get those EMT's on scene quickly and get the shock box on the patient. Medics can get a heartbeat out of piece of veal but rarely get a real recovery.

[ckroll 101]

Thats great, so now you have a well trained EMT who will NEVER use his skills because the medics do everything. Truth be told most of the interventions we perform in the field outside of the most serious respiratory distress and cardiac emergencies are not necessary for patient survival. It can often wait until the paient gets to the ER. They improve the comfort of the patient and help to prevent the patient from turning south on us. For full cardiac arrest, when looking at meaningful recovery the two greatest factors are early CPR and early defibrillation. Get those EMT's on scene quickly and get the shock box on the patient. Medics can get a heartbeat out of piece of veal but rarely get a real recovery.

I didn't follow that all. As someone who was an EMT-B 15 years before crossing over to EMT-P, I value BLS. Good assessment is the bed rock of good care. Those in the field have the unique opportunity to see the patient in their natural environment. The pre-hospital provider can have a large positive impact on care if they have done a careful and thorough assessment. As a BLS provider, I agree that a majority of outcomes will not be changed by ALS pre-hospital. As an ALS provider, I see the opportunity to educate, to reduce time to definitive care, and to improve outcomes in the process. Not everyone benefits from ALS, but many do. That's why I favor ALS assessment when available, and that's why I became an EMT-P.

[Guest partyrock]

sorry ckroll, I mistakenly thought you had also been the person advocating ALS assessment for every patient.

I was trying to say putting ALS on every call is a waste of valuable resources and marginalizes the skills of EMTs

[PC415 1]

Chris192

Putnam County uses the National Academy EMD Protocol - the "Alphabet Soup" system

[ckroll 101]

sorry ckroll, I mistakenly thought you had also been the person advocating ALS assessment for every patient.

I was trying to say putting ALS on every call is a waste of valuable resources and marginalizes the skills of EMTs

I do advocate ALS patient assessment as I find EMD does not adequately triage patients. I assume following assessment that the majority of those calls will be turned over to BLS for treatment and transport. I assume that where EMT-Ps and EMT-Bs know each other, that a good 'P will trust the work of a good 'B and that a good 'P can help the new or hesitant 'B to improve his or her skills.

I remember being an EMT-B called for a fellow who appeared near death to me and the family. The EMT-P politely gave the call back to BLS, pointing out key signs and symptoms of vertigo/ear infection, which it was. If, as a 'B your skills have been marginalized by your paramedic, then that is wrong and you are owed an apology.

The purpose of system management, and EMD is to allocate resources to best advantage while letting as few calls as possible end up underserved, that is, receiving BLS when ALS is appropriate. In busy systems, where calls wait for resources, then the advantage falls to conservative allocation of ALS. In slow systems when the unassigned medic will likely not be assigned another call, then the advantaqe falls to more liberal use of ALS with diversion as necessary. Each system is different and needs to be managed for its own quirks and eccentricities. Originally, the issue was the Putnam system and my comments apply to it. I would refrain from judging a system in which I had not worked.

[irishfire2491 24]

RIIIIIIIIGHT......I'LL BE THERE TOMORROW.

Tom you are empire volunteer medic for the BLS crew when they need a medic when the hosptial is 2 mins down the road and they wait 5 mins and call for a medic. So why not move in to putnam county

[EJS1810 7]

I think that was a shot....................................