45 Medics - Are 3 enough?

[ONEEYEDMIC 68]

Who covers the other half of North Castle?

37-M1(Mt Pleasant fly car) & VVAC!

[firedude 985]

Who covers the other half of North Castle?

North Castle is made up of Armonk, Banksville and North White Plains. Armonk and Banksville are covered by Armonk EMS and 45M1. North White Plains is covered by Valhalla VAC and The Mt Pleasant Medic (37M1).

[Ga-Lin 86]

It's not bad for Norwalk to get to Vista, as all they have to do is shoot up Route 123 to get into Vista. As long as a Vista ambulance has already rolled, the Vista ambulance can usually intercept with a Norwalk medic along route 123 in New Canaan. Now, if you're using Norwalk's medic as a transport unit, requiring them to actually get on scene, that may take a bit more time. However, Norwalk's response times are great and they tend to get into or near Vista within a few minutes. As for Wilton's medic, they wouldn't likely be called, as they have to cover Wilton, Weston, and parts of Georgetown and Redding. New Canaan's medic has been called before to respond into Vista, and Norwalk will then bring an ambulance to the New Canaan line or into New Canaan to backup their town. Wilton and Weston Medics are Norwalk Hospital Paramedics operating in town-owned flycars. At the end of the day, if Vista needs help and New Canaan and/or Norwalk are available, they are guaranteed to be merely minutes away. Norwalk has 24/7 ALS units and New Canaan has a 24/7 medic and at least one BLS ambulance (often more) fully staffed by volunteers in-house at all times.

Is Norwalk even certified to operate in NYS?

[firedude 985]

Is Norwalk even certified to operate in NYS?

They are alowed to operate in NYS but can't transport to a NYS hospital. WEMS Medics can operate in NYC and CT and can transport to both states.

Per Vista's SOGs (Available Online)

Edited November 1, 2011 by firedude

[Bnechis 3,961]

"The line between Westchester (NYS) & Conn was established by the King of England. Vista, being in Westchester never "used to be in CT". "

Actually Barry until 1700 The Towns of Rye (Port Chester, Rye Brook, Rye Neck, and all of Modern Harrison) and Bedford were Towns in the County of Fairfeild CT. Modern day Harrison was stripped from Rye and the "purchase" of Mr. Harrison, a man conected to the royal governor, was a way of repaying the "rebellious" efforts of the people of Rye to remain in Connecticut including their appeal to William III.

Yes, so the King of England Established it....and long before their was an FD. But nice info, thanks

[Medibart 55]

First some background info about the 45 Medic system and Westchester EMS in general. Westchester EMS is a not for profit organization and is part of the Stellaris Health Network which includes Lawrence Hospital, Northern Westchester Hospital, Phelps Memorial Hospital and White Plains Hospital. The 45 Medic program is a single consortium type contract with the 8 townships of Bedford, Lewisboro, Mount Kisco, New Castle, North Castle, North Salem, Pound Ridge and Somers. We generally have a meeting with representatives of all 8 towns on a quarterly basis. At those meetings we supply a huge amount of data, including response times, extended response times and times we were not available. Because of that, the town leaders are some of the most informed politicians in regards to EMS. They vote on a number of things, including the budget. The budget is audited every year and WEMS and Stellaris make no profit on it. The coverage area is 191 square miles (roughly 42% of the county) and 98,500 people (second largest population covered after City of Yonkers). Last year we responded to 4757 calls. This year call volume is running about 5% higher than last. We operate 3 single medic fly cars 24/7. We can add up to 3 more ALS units including supervisors and ALS ambulances). We've definitely had 5 medics running at once on a few occasions. I don't think we've had 6 out yet. This really is a unique example of a regional solution to EMS. I don't know of any other consortiums of this size in our area. RPS's contracts are with each town with the exception of North Rockland where 2 towns share one truck.

For the first two quarters of 2011 response times averaged 8 minutes. Obviously this is a average and some response times are much longer given the distances involved. This average has held up for the last 6 years or so, even as the volume has increased by 17%. Mutual aid was called for 3 calls (0.1% of total volume), only 1 of which went ALS. The 45 Medics were dispatched 20 times mutual aid to other areas. Vista does use the Norwalk medics whenever 45M3 is on a call rather than having 45M1 or 2 respond from their areas. Given the size of the area, I'd say that the system is working pretty well.

Different 4th medic scenarios have been presented to the towns. Obviously with any decision like that, cost is a factor. Personally, I think tiered systems provide the best coverage for the money. BLS first resonders, whether FD, PD or VAC, are really the key in my eyes for a good EMS system. More medics is the most expensive solution and per medic call volume becomes an issue, I think, if you want to keep their skills up. Obviously this is the problem that every rural(ish) emergency service faces. Low call volume along with large area is always problematic to deal with.

At the end of the day it is up to the towns, with input from their own emergency services to decide when a 4th medic is the best solution.

I'm happy to answer any other questions about the system or Westchester EMS in general.

Scott T. Glaessgen

Paramedic Supervisor

Westchester EMS

[INIT915 1,119]

First some background info about the 45 Medic system and Westchester EMS in general. Westchester EMS is a not for profit organization and is part of the Stellaris Health Network which includes Lawrence Hospital, Northern Westchester Hospital, Phelps Memorial Hospital and White Plains Hospital. The 45 Medic program is a single consortium type contract with the 8 townships of Bedford, Lewisboro, Mount Kisco, New Castle, North Castle, North Salem, Pound Ridge and Somers. We generally have a meeting with representatives of all 8 towns on a quarterly basis. At those meetings we supply a huge amount of data, including response times, extended response times and times we were not available. Because of that, the town leaders are some of the most informed politicians in regards to EMS. They vote on a number of things, including the budget. The budget is audited every year and WEMS and Stellaris make no profit on it. The coverage area is 191 square miles (roughly 42% of the county) and 98,500 people (second largest population covered after City of Yonkers). Last year we responded to 4757 calls. This year call volume is running about 5% higher than last. We operate 3 single medic fly cars 24/7. We can add up to 3 more ALS units including supervisors and ALS ambulances). We've definitely had 5 medics running at once on a few occasions. I don't think we've had 6 out yet. This really is a unique example of a regional solution to EMS. I don't know of any other consortiums of this size in our area. RPS's contracts are with each town with the exception of North Rockland where 2 towns share one truck.

For the first two quarters of 2011 response times averaged 8 minutes. Obviously this is a average and some response times are much longer given the distances involved. This average has held up for the last 6 years or so, even as the volume has increased by 17%. Mutual aid was called for 3 calls (0.1% of total volume), only 1 of which went ALS. The 45 Medics were dispatched 20 times mutual aid to other areas. Vista does use the Norwalk medics whenever 45M3 is on a call rather than having 45M1 or 2 respond from their areas. Given the size of the area, I'd say that the system is working pretty well.

Different 4th medic scenarios have been presented to the towns. Obviously with any decision like that, cost is a factor. Personally, I think tiered systems provide the best coverage for the money. BLS first resonders, whether FD, PD or VAC, are really the key in my eyes for a good EMS system. More medics is the most expensive solution and per medic call volume becomes an issue, I think, if you want to keep their skills up. Obviously this is the problem that every rural(ish) emergency service faces. Low call volume along with large area is always problematic to deal with.

At the end of the day it is up to the towns, with input from their own emergency services to decide when a 4th medic is the best solution.

I'm happy to answer any other questions about the system or Westchester EMS in general.

Scott T. Glaessgen

Paramedic Supervisor

Westchester EMS

Scott, what is the approximate call volume breakdown percentage-wise by truck?

[PFDRes47cue 653]

Not entirely, the fact remains, even an ALS unit not tied up on BLS-ride-ins will still have long response times to outlying areas of the district. It's just a fact.

This is true, even when not tied up, the response distance/time can be lengthy. This can be fixed by intercepting with the Medic. This is common practice in parts of New York where ALS is 20+ miles away. There is nothing wrong with notifying dispatch and the Medic of the nature of the patient, which hospital you will be transporting to and which route you will be taking allowing for an intercept point to be established. I'm not saying this is the best way, but if money is the issue, then this is a way of utilizing the Medics that you have.

[Medibart 55]

Scott, what is the approximate call volume breakdown percentage-wise by truck?

Medic 1 - 39%

Medic 2 - 35%

Medic 3 - 25%

That's by responses, not PAR.

[INIT915 1,119]

Medic 1 - 39%

Medic 2 - 35%

Medic 3 - 25%

That's by responses, not PAR.

Hypothetically, if funding wasn't an issue, what would be the optimal location for a 4th or even 5th unit for a more comprehensive coverage of the district?

[Remember585 815]

Medic 1 - 39%

Medic 2 - 35%

Medic 3 - 25%

That's by responses, not PAR.

Scott,

Would it be feasible to have a Medic assigned to Somers in place of one of the EMTs WEMS provides? This way the 3 Fly-Cars could possibly be re-positioned to decrease their response times? Just a thought I had one night.

I give the WEMS Medics a lot of credit, the Medics monitor the radio and will post centrally while their partners in the other fly-cars are tied up on calls.

[Medibart 55]

Hypothetically, if funding wasn't an issue, what would be the optimal location for a 4th or even 5th unit for a more comprehensive coverage of the district?

Personally, I'd say somewhere in the Bedford Village Fire District. This could improve response times to Bedford Village, Armonk, Banksville and Pound Ridge. Obviously, it would depend on finding a place to house it. Again, a decision like that would be up to the towns.

[Medibart 55]

Scott,

Would it be feasible to have a Medic assigned to Somers in place of one of the EMTs WEMS provides? This way the 3 Fly-Cars could possibly be re-positioned to decrease their response times? Just a thought I had one night.

I give the WEMS Medics a lot of credit, the Medics monitor the radio and will post centrally while their partners in the other fly-cars are tied up on calls.

Again, that's really up to the towns to decide.

[efdcapt115 1,511]

Medic 1 - 39%

Medic 2 - 35%

Medic 3 - 25%

That's by responses, not PAR.

I'm entirely impressed that someone in a position of leadership would actually take the time to show up here and be responsive to members questions. Well done sir...Bravo!

[sympathomedic 383]

Wow! Only ONE mutual aid call IN went ALS and I got to do it!

Barry: I think the Journal News did a piece about how after WWII Vista was moved from CT to NY. I recall it said there still CT evidence in Vista- scout troops still affiliated with CT not NY and some other left-overs. Or maybe I read that in The Star, after the Elvis article.

Bill

[efdcapt115 1,511]

Wow! Only ONE mutual aid call IN went ALS and I got to do it!

Barry: I think the Journal News did a piece about how after WWII Vista was moved from CT to NY. I recall it said there still CT evidence in Vista- scout troops still affiliated with CT not NY and some other left-overs. Or maybe I read that in The Star, after the Elvis article.

Bill

And it is no small feat to pick up an entire community and move it across state lines! (I read that Star article about Elvis, the following story was about how to construct your own aluminum foil hat without using tape. It worked fantastically!)

[Guest alsfirefighter]

I have a side question while everyone is debating about the 45 medics....and perhaps adding a 8 hour car or 2 during the day would help offset cost and add coverage to high volume call times.

How is the BLS response in the area? And a few things to keep in mind...when running low on resources the best treatment you can give your patient after initial actions like oxygen...is movement. Get them moving towards the hospital and call for or coordinate an intercept while your MOVING! But do it immediately if you feel they need imminent treatment. Far too often we get called for intercepts but when we meet up the hospital is so close it doesn't make sense or is it prudent to start initiating ALS care or interventions instead of just keep moving to the hospital. You can limit the response time by starting to bring the patient closer..or just making it to the hospital.

And a soap box item since I keep reading all over about traffic etc. We all deal with traffic...some more then others systemic instead of main roads like many of you. Will it slow you down some..yes..but patience is the key...and when transporting to the hospital..traffic is not a justification for use of L and S.

[Medibart 55]

I'm entirely impressed that someone in a position of leadership would actually take the time to show up here and be responsive to members questions. Well done sir...Bravo!

All the information comes from the report given at the September township meeting. These regular meetings are attended by Town Supervisors, other town officials, police chiefs, town OEM officers, VAC officers, hospital administrators, physicians and Stellaris and WEMS management. I'd rather pass along that information than have people state incorrect information.

[ny10570 745]

If BLS was faster and more reliable triaged dispatching would be more viable and free up the medics from many of the BLS calls they're sent on. However when you can't guarantee a timely response from BLS the risk of a incorrectly triaged call resulting in serious harm or death is too much.

[Guest alsfirefighter]

If BLS was faster and more reliable triaged dispatching would be more viable and free up the medics from many of the BLS calls they're sent on. However when you can't guarantee a timely response from BLS the risk of a incorrectly triaged call resulting in serious harm or death is too much.

True..but statistically incorrect triage is usually at a very low percentage. Trust me I understand this is a debate I've been having for a few years with my agency to enhance BLSFR use and scale back the use of ALS units on low priority calls. Even with a lapse in BLS response I think there always is a dispatching procedure to help with that situation as well.

[ny10570 745]

Its not to say that something can't be done, but that begins to complicate things on the dispatch end. If you were going to implement BLS only response for certain calls then there has to be back up. After x-number of minutes the medic get assigned or only do BLS solo when the vac has a rostered or even better, on site crew. How complicated can the dispatch algorithms at 60 get?

[PEMO3 523]

EMD algorithms should not be that complicated. Simple flow sheet - If yes to "a" then "b" and if no then "c". Initial dispatch should be based on algorithms not the particulars of a individual VACs staffing unless they are out of service. Dispatch BLS if algorithm says BLS and ALS if it says ALS regardless of if there is a crew in house, on roster or on pager. Criteria would have to be tight as far as how long before mutual aid is assigned following the first tones. To build into the plan that a call will go ALS regardless of EMD triage after x minutes sort of defeats the purpose. In order to work effectively 3 things would have to happen: 1) EMD would have to be well executed with algorithms everytime, 2) BLS would need to understand that if they get a BLS job it is theirs and they will not have ALS running to help with response time, if they fail to respond they are the ones accountable, no ALS on site waiting for the initial bus then the mutual aid bus, and 3) quarterly if not monthly reviews would be needed to look at response time, EMD rating vs true call type, and percentage of jobs up-triaged to ALS after initial EMD triage. It can be done but as with everything requires a change in mindset and would meet resistance.

[ny10570 745]

At this point point EMD is fairly simple to implement and I believe 60 already offers this option. To say agencies have to respond is nice, but doesn't acknowledge the reality of the system as it is right now. We already have agencies that have trouble at times getting crews out the door. That is an issue for one of dozens of other threads about getting ambulances on the road and hiring staff. While you're banging out the second round of tones or the third mutual aid bus for the injury that due to caller error is actually an arrest/CVA/whatever, the patient is dying. Other systems address BLS shortages by sending ALS units, but they often still have gaping holes.

An example you're familiar with, NYC. No BLS available and ALS are assigned high priority BLS jobs. But what about when BLS is greater than 10 minutes away and ALS is around the corner? The system doesn't address it. ALS greater than 10 minutes and BLS closer gets an automatic response from the system.

My point is, we know that there will be times when BLS cannot get on the road in a timely manner. While we wait for the agencies to address this is there a compromise between sending ALS on everything and a straight triaged system where the medics can still be used to fill the gap?

[helicopper 1,050]

Its not to say that something can't be done, but that begins to complicate things on the dispatch end. If you were going to implement BLS only response for certain calls then there has to be back up. After x-number of minutes the medic get assigned or only do BLS solo when the vac has a rostered or even better, on site crew. How complicated can the dispatch algorithms at 60 get?

Sending 33% of your available ALS resources to a soccer game for a broken ankle is a waste of resources. The BLS level of the system has to operate effectively and efficiently too.

[PEMO3 523]

ny10570 I understand where you are coming from but if we keep putting a band-aid on the response issue with sending ALS on low priority BLS calls then we give no push for these problem agencies to address the problem head on. To strain you ALS resources with back to back jobs because your BLS resources can not meet the goals set forth under their individual certificates of need is not a solution. It is the equivalent of turning a blind eye to the problem. You are correct that in NYC ALS units are assigned to high priority BLS jobs but two issues exist here: 1) we are comparing apples to oranges and 2) they are assigned to just that "high priority" BLS jobs not the "I've fallen and I can't get up" calls. The second is the real issue that can tax your ALS resources and burn out a good medic fast.

Edited November 2, 2011 by PEMO3

[x635 4,066]

As several people have pointed out, MEDICAL PRIORTY DISPATCHING, a component of EMD, has been shown to effectively select the right resources and send them in the right response mode, according to local medical direction and protocol, if you have a tiered system.

The ONLY answer to this is a single, County based dynamic Careeer ALS (dual Medic) ambulance system. Solves everything. Just need a good salesperson.

To assist in funding, also do ALL the transfers in the County, like BLS takehomes.

For instance, this system is in a County comprable to Westchester in size. It is a model nationwide, has won numerous high profile awards and accredetations, and is always being looked at as a model for EMS agencies around the nation.

http://www.wilco.org/CountyDepartments/EMS/tabid/453/language/en-US/Default.aspx

And, you can have the best EMS system in the world, but if you don't have the best people and retention rates, it's nothing. The above agency starts at $60,000 a year, 23 year retirement, and an entrance exam in which only 8% pass the first component. And your job is also based on performance, and poor customer service is NOT tolerated in any manner. Burnout is a personal issue, not an agency issue, since it was you that chose the career and place to work. Don't like the job anymore, leave. You are not doing anyone any good. And if you take care of your agency, the agency will take care of you. There is no punitive discipline or supervisor is after you mentality or actions. You go out there, do your best and give every call your all, you will have a succesful career.

So your not only getting a ride to the hospital, but the best quality of care from people who actually want to do the job no matter what the call is and have an interest in making the system the best.

[Goose 188]

Nothing is going to change until the BLS agencies have their feet held to the fire by their respective communities or some county/state entity if they ever grew the stones.

Now, let's not forget that the issue is generally compounded by the silly agency specific mutual aide agreements, which are often based more on politics than patient care & geography.

I agree that EMD works and priority/tiered dispatching (ie: how Putnam & Dutchess do it) works....it just won't work here because the ALS flycars are the only guarenteed EMS resource to arrive in a reasonable time frame.

[ny10570 745]

The band-aid is already in place. Whether it takes 5 or 25 minutes to get an ambulance on scene do the agencies suffer? There's already a cop or 4 and the medic on scene. The patient, family, and any witnesses see a very fast and substantial response and assume that all is well. Kind of like a big red fire truck with one firefighter.

[ONEEYEDMIC 68]

The band-aid is already in place. Whether it takes 5 or 25 minutes to get an ambulance on scene do the agencies suffer? There's already a cop or 4 and the medic on scene. The patient, family, and any witnesses see a very fast and substantial response and assume that all is well. Kind of like a big red fire truck with one firefighter.

You weren't serious with this were you? I guess you haven't been on many calls waiting with the family whether ALS or BLS waiting for an ambulance to get there. Not saying it happens all the time, but I get tired of saying, "well they are volunteers and it takes time to get here". That is just BS! Patients and their families don't understand the concept of time when someone they love is hurt or sick. All they want is their loved ones to get to the hospital, and the only way that happens, is if AN AMBULANCE IS ON SCENE!

I am gonna stop now because I see this getting me HOT!

[ny10570 745]

You weren't serious with this were you? I guess you haven't been on many calls waiting with the family whether ALS or BLS waiting for an ambulance to get there. Not saying it happens all the time, but I get tired of saying, "well they are volunteers and it takes time to get here". That is just BS! Patients and their families don't understand the concept of time when someone they love is hurt or sick. All they want is their loved ones to get to the hospital, and the only way that happens, is if AN AMBULANCE IS ON SCENE!

I am gonna stop now because I see this getting me HOT!

Easy there. I'm not defending that kind of delay. Far too often regular civilians and yes even the family that had to wait those extra 20 minutes are later praising all of the responders(volunteer ambulance included). You may very well be the only one laying blame on the system rather than making up excuses for the delay.