An Examination of the Trumansburg Fire Department Volunteer Ambulance Service
Six years ago a decision was made by the Village of Trumansburg to move to a system of paid EMS providers during the day while maintaining volunteer coverage at night. The intent of the system was to provide high quality pre-hospital emergency care for patients while operating at the lowest cost to taxpayers. The stated reason for implementing this system was the decline in the numbers of trained EMS volunteers available in the village or its environs during the daytime hours. Currently, the fire department claims thirty-three certified EMS providers within its membership. This is more than at any point in the history of the department and far more than most volunteer fire departments in the area.
Trumansburg Fire Department certified EMS providers include: 5 - CFR (Certified First Responders) 21 -EMT (Basic Emergency Medical Technicians) 1 - EMT-1 (Advanced) 5 - A-EMT-P (Advanced EMT-Paramedics) I - CCEMT-P (Critical Care EMT Paramedic)
Professional crews were nevertheless hired to staff the Fire Department's ambulance weekdays from 06:00 to 18:00 hours. Nighttime hours were to continue to be covered by fire department volunteers. This system has since proved to be problematic. The number of volunteers that are now willing or able to cover the evening shifts has fallen far short of what is needed. The task of shift coverage has fallen to a core group of about six to eight individuals.
A Task Force established by the Village recommended that a fee based operation be instituted in order to offset the cost of providing ambulance service with paid crews. As a result of the concerns raised by the residents of the fire and ambulance protection district, the fee-based proposal was temporarily tabled.
Over the past few weeks a survey of Trumansburg volunteer EMS personnel has been conducted to determine why more of them were not willing to volunteer to cover nighttime shifts. The survey also attempted to identify problem areas within the EMS delivery system as a whole and sought suggestions for improvement.
This report was prepared by Jim Mason, Life Member and former EMT with the Trumansburg Fire Company. Ron MacLean assisted with survey data analysis. The report summarizes the information collected through the survey in addition to that gleaned from one-on-one interviews with volunteers, meetings with Fire Department members and officers and others involved in the delivery of emergency medical services throughout the area. This report also includes a recommendation as to the direction the Village should take for delivering pre-hospital emergency medical services within the protection district.
Summary of Survey Responses
Seventeen of the thirty-three Trumansburg EMS providers (approx. fifty percent) responded to the survey. The following is a summary of their responses:
The survey found that nearly fifty percent of the respondents were involved in the delivery of EMS in other agencies, including paid service with Bangs Ambulance of Ithaca. Ten of the respondents have been involved in EMS more than seven years, some as long as fifteen years.
The primary factors keeping them from volunteering for more shifts were: - Already volunteering at the level they want - Work or family commitments - Burned out
Problems within the organization. - Problems with ENO (Emergency Medical Dispatching).
• The four issues identified as critical for the success of our volunteer ambulance service
were: - Patient service - Conflict management within the Department - Communication between leaders and volunteers - Volunteer retention
• The four most valuable volunteer benefits desired were:
- Excellent squad level training - Reimbursement for training - Having a role in planning - Recognition within the Department and Receiving a property tax break for service. (Tie) Note: Receiving reimbursement for fuel expense was also listed by several respondents.
The idea identified as having a negative impact was: Adding one paid crew member to all volunteer shifts. Using paid crews was perceived as having a negative impact on motivating volunteers.
• Of particular note were the concerns expressed about EMD (Emergency Medical Dispatch) protocols. - Unless Trumansburg has submitted a roster for each night's coverage, the county dispatcher automatically dispatches Bangs without giving T-Burg the opportunity to "scramble" a crew. This creates a "why bother" mentality among volunteers who might otherwise respond. - IEMD analyzes the call for its response level and automatically dispatches Bangs if the call is ALS and T-Burg is staffed at Basic.
EMD protocols require dispatchers to dispatch Bangs if T-Burg has not responded to a second tone activation. Second tones are given 4-5 minutes after the first tone. Some dispatchers are sending Bangs at a second tone even if the T-Burg crew is actively assembling and has reported this to dispatch.
Other issues raised:
The staggering training requirements being mandated by New York State on volunteer EMS providers is a significant issue. To become ALS certified, an individual must undergo classroom and practical training that is equivalent to that needed to acquire a college level Associates degree. A series of continuing education courses are then required to maintain certification and individuals must re-certify every 24 months! Average tuition for a paramedic course runs between $3,500 and $4,000. Most individuals seeking ALS certification today are doing so in order to seek employment in the EMS field, not to serve as volunteers. While certification for Basic EMT is somewhat less onerous, it still requires hundreds of hours of formal training in a classroom and hospital environment.
Over a recent five month period the Trumansburg ambulance provided emergency medical services to approximately 264 patients. Of these, sixty three, or about twenty-four percent, were determined by the dispatcher as requiring ALS coverage. On the average, only two ALS calls per week occurred on "Paid" time. The remaining calls were dispatched as requiring BLS response. Twenty-five ALS calls (less than two per week) were dispatched on "Volunteer" time. Data is not available as to how many of these calls were actually covered by volunteer ALS providers.
There are currently six ALS qualified volunteers in the TFD. Of these, only three are active. That number is now down to two because of illness. It is impossible to provide ALS coverage with only two active volunteers. Bangs is therefore frequently called upon during "volunteer" time to respond into the Trumansburg district to provide ALS coverage.
From the taxpayer's standpoint, if Basic Life Support crews were available, there is no justification for having "paid" crews for twelve hours a day at a cost in excess of hundreds of thousands of dollars per year. The approximately ninety ALS calls per year could be covered by the fly car from Bangs, with Trumansburg providing transport. There are simply not enough ambulance calls in the Trumansburg Protection District to warrant full time paid crews.
Problems Identified:
The Trurnansburg Fire Department is currently operating with limited volunteer ALS staffing. The ability to continue to deliver even Basic Life Support services is also a significant concern. Of the twenty-one certified BLS providers currently in the Fire Department, seventeen must renew their certification by May of 2009. Several of these have indicated they will not be renewing their certification because of their dissatisfaction with the current system and its administration. Without these individuals, the future of the Trumansburg Fire Department volunteer ambulance service is in serious jeopardy.
Recommendations
The Trumansburg Fire Department should revert to a fully volunteer ambulance service providing Basic Life Support and transport only. On the occasions where an ALS response is required but not available, Bangs should, and would, be automatically dispatched just as they are under the present nighttime system. This would have minimal impact on patient care beyond what is currently provided. Patient care might actually improve and volunteer response could potentially go up when the volunteers feel they were again playing a key role in the system.
Such a system would however generate a dramatic savings/or the taxpayers in the Trumansburg Fire/EMS Protection District. Only those requiring ALS would be billed, and that would be the responsibility of the commercial service, not the Village.
Two calls (or less) per day can not financially support a fee-based ambulance service. Little if anything over what is currently in place would be gained by such a system, and the loss of our volunteer's service would be devastating. As one survey respondent asked, "does the Village of Trumansburg really want to be in the EMS business? Staffing, training, insurance, uniforms, vacations, liability, all for less than one or two calls per day, half of those at night when the volunteers are the primary responders?" It was also pointed out that for the Village to bill for the services provided by volunteers would be ludicrous at best.
Should the Village decide to implement a fee-based ambulance service, any ciffiliation with the
Trumansburg Fire Department must cease. The ambulance could not in any way reflect identification with TFD, and should be clearly separated from TFD's administration and budget. It would be a separate department, much like the Police Department or the Public Works Department. Even now, the public is being mislead by the Village in using paid, non-firefighters, to operate a Fire Department vehicle twelve hours a day.
We are very fortunate that most of the Trumansburg Protection District is within 10-15 minutes of the hospital's Emergency Department. In most situations, the patient could be transported to the Cayuga Medical Center under basic EMT care in less time than it takes Bangs to respond to the district. Getting the patient to the Emergency Department in the shortest possible time should be our first priority. Under the current system, more time is often spent attempting to treat the patient in the field than it would take to transport them to the hospital!
The Trumansburg Fire Department has provided the community with exemplary volunteer ambulance service for over thirty years. If the Department, for whatever reason, can not effectively continue to operate this service with volunteers, the Village should revert to a "Rescue Response" operation. Ambulance service should be provided by a privately operated "fee-based" commercial service, not the Village. Other rural townships in Tompkins County, some of them much more remote from the hospital than Trumansburg, depend solely upon fire department rescue response supplemented with ambulance service from Bangs. There is no evidence that patient care is any less effective, yet the municipalities do not incur the expense of having a taxpayer supported service. Under this type of system, only those who use it, pay for it. The Village would not have any affiliation with this service, thereby eliminating hundreds of thousands of dollars in annual cost to its taxpayers.
The challenge before us is to maintain our current EMS volunteers and increase their numbers. Aggressively addressing the concerns expressed by the survey respondents is the first step. I would then encourage the Village to seriously consider implementing some, if not all, the desired benefits for volunteers listed in this report. The cost of doing so would be insignificant in comparison to going to a paid, professional ambulance service operated by the Village.
Respectfully Submitted:
James A. Mason December 9, 2008
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