Lives on the line
Portland spends a lot on medical calls, but it pays off
Ever see this spectacle in your neighborhood?
A fire engine races down the street with horn blaring, trailed by an ambulance with siren roaring and lights flashing. Four Portland firefighters and two ambulance paramedics jump out and race into a nearby home or building, only to depart quietly minutes later when the emergency turns out to be no big deal.
Residents who have observed this scene decry it as a waste of resources, and theyre not the only ones.
An outside consultant took the Portland Fire & Rescue to task a year and a half ago, saying it was the only fire bureau among its peers that sends a full fire engine and ambulance staffed by six firefighters and paramedics to every 9-1-1 call. The Fire Bureau also is getting political heat from Mayor Charlie Hales and City Commissioner Dan Saltzman the newly appointed fire commissioner who are pressing it to use more two-person crews driving SUVs for lower-level medical calls, instead of four-person fire engines.
But before bashing the Fire Bureau, critics might want to talk to Dr. Jon Jui.
Jui, the medical director for Multnomah Countys emergency medical services system, sets the medical-response standards used by 9-1-1 dispatchers as well as city firefighters and ambulance paramedics.
There is no question in my mind that you need an emergency response with six people, Jui says.
It someone had a heart attack, you need all six of those professionals providing aid, he says. If we dont respond and the person dies, that is a worse scenario than over-responding. We tend to over-triage intentionally.
The trick is, 9-1-1 dispatchers arent medically trained and cant easily tell over the phone if someone is having a heart attack or a stroke, or if a severe tummy ache is acute appendicitis.
The city and county could try sending just one rig on cases that appear to be low-acuity, Jui says. But communities that have ratcheted back emergency responses to those calls experience higher mortality and morbidity on life-threatening diseases, he says.
For every 20 of those low-acuity calls, Jui estimates, one turns out to be a real emergency that warrants a full six-person response, and thats about 300 to 400 people a year.
Its against my moral and ethical framework to stop going to those kinds of calls (with a full rig), Jui says. What about those 400 people who are going to die?
Jui also sets high standards for American Medical Response, the ambulance company serving Multnomah County. AMR is required to have two paramedics in each rig, while peer counties often allow one of the two ambulance staff to have lesser training.
If hes wrong, Jui is causing a waste of money, though perhaps not as much as critics presume. If hes right, Jui may be
saving more lives each year than just about any other doctor in town.
Cost savings debated
Lt. Mike Wight, a firefighter and paramedic with Portland Fire & Rescue, says it takes a lot of teamwork to effectively resuscitate someone during a medical trauma.
Two people cant do that, Wight says. Four people have a very hard time doing it.
Critics who think its overdoing it to send six people to assist someone with a possible heart attack should see what a hospital is like when that same patient is brought in, Wight says. They likely have a dozen or more people sprinting to that room.
Portland Fire Chief Erin Janssens says shes very supportive of the idea of using two-person crews on so-called rapid response vehicles on some calls instead of four-person fire engine crews. But she isnt sure it can be done in a cost-effective way.
When you have a critical call, you need a team of six people there, Janssens says.
Dr. Gary Oxman, the recently retired Multnomah County health officer, says Tualatin Valley Fire & Rescue has shown that the two-person rapid response vehicles or RRVs can be used in a way that is clinically effective, meaning that it doesnt compromise health outcomes. However, he doesnt think thats where big cost savings will be achieved.
Tualatin Valley Fire & Rescue only uses the RRVs for 8 percent of all its dispatch calls, notes City Commissioner Steve Novick.
And Novick notes that 85 percent of the Fire Bureaus budget is spent on personnel, which is why he suggested reducing the number of fire crews on nighttime shifts at select fire stations where the call volume is low.
The city of Portland commissioned a study by TriData, an Arlington, Va., consulting firm, on how to effectively deploy RRVs, and its December 2011 report concluded that Portland Fire & Rescue is unique in that it does respond to every medical call with a fire vehicle, and the call volume could be reduced significantly if it did not.
Jui takes issue with that report, saying some West Coast cities are comparable to Multnomah Countys system. And fire engines and ambulances dont jointly respond to every call, he says; sometimes either one or the other responds.
According to Multnomah County emergency medical services, AMR ambulances were dispatched 74,249 times in 2012. The Fire Bureau did not send any vehicles on 9,123 of those calls, and sent a two-person rapid-response or rescue vehicle on 1,844 other calls.
Randy Lauer, general manager for AMR in Oregon, agrees that a four-person fire engine and two-person ambulance dont need to respond to so many of the 9-1-1 calls.
On the aggregate, you probably could reduce the Fire Bureaus responses by half, probably pretty easily, Lauer says. But the savings is in the wear and tear of the vehicles, so the savings is going to be marginal.
TriDatas report notes that the Fire Bureaus fire engines get 4 to 5 miles per gallon of gas, while an SUV serving as an RRV might get more like 25 miles per gallon. Over the course of a year, using an RRV instead of a fire engine might save $29,200 a year, TriData concluded, plus savings on vehicle maintenance and replacement schedules. In addition, TriData found, the Fire Bureaus mission is being compromised by responding to an ever growing number of non-emergency medical calls.
The public might see a fire engine with four firefighters race to a scene where its not ultimately needed and see that as a waste of money or a sign of inefficiency, Novick says. However, it might be more inefficient, he says, to pay those same firefighters to sit in the station waiting until the next fire.
Ultimately, the Fire Bureau responds to medical emergencies to meet the standards set by Jui, says City Commissioner Amanda Fritz.
Changing 9-1-1 screening?
TriData concluded that changes in the medical response system should start in the way emergency calls are dispatched at the city Bureau of Emergency Communications 9-1-1 center. Police calls are prioritized at the dispatch center, so those with greater public safety concerns are handled sooner than others, TriData noted. Currently, medical calls are not prioritized and the call is handled in the order which it is received.
Jui disputes that, saying there is a tiered response to calls at the 9-1-1 center. The question is how well were doing it, he says.
Novick, who learned Monday that hell oversee the Bureau of Emergency Communications, would like to explore ways to have a more fine-grained screening of calls at the 9-1-1 center, to reduce the number of unneeded emergency responses and emergency hospital visits.
Dr. Justin Denny, Multnomah County health officer, says one study showed that 15 percent of the people taken by ambulance to hospital emergency rooms would be better served by their primary care doctors. That study is at least a decade old, he says, so the number may be higher, given the increasing number of uninsured people who use the 9-1-1 system and hospital emergency rooms for their primary medical care. A pilot study by Kaiser is showing that closer to half its patients would do better to get treated at the companys clinics and hospitals instead of emergency rooms, Denny says.
Multnomah County is taking a look at incorporating social workers into the 9-1-1 system, Denny says, as a way of addressing those people who are overusing the system unnecessarily. Novick has talked to Kaiser about having a role in the system, so it can divert its patients who call 9-1-1 to Kaiser facilities, when appropriate.
Fritz says the 9-1-1 system can do more to screen calls, with the proper medical guidance from Jui and others.
However, that would require more staff at the 9-1-1 dispatch center, Fritz says. In the 2013-14 city budget set for final approval later this month, we just cut four call-taker positions, she notes.
Experts say there will always be a delicate balancing act between saving lives in emergency situations and saving money. To save the most lives from heart attacks, it would require ambulances to arrive in less than four minutes, and few cities will pay for that type of concentration of ambulances.
Lauer, of AMR, has a cheaper idea: train as many citizens as possible in cardiopulmonary resuscitation, or CPR. Thats what really makes a difference in the community, he says, because four minutes is not very much time.Add a comment