By Jessica Wickham, Tompkins Weekly
Editor's note: a previous version of this article cited the $560,000 budget as that of the Tompkins County Emergency Response Center. The budget is for the Groton Fire Department.
Dan Ferguson, a volunteer firefighter and emergency medical technician (EMT) for Lansing, grew up with a strong sense of community.
“I grew up in a large family, and it was kind of printed into us that we needed to give back to the community,” he said.
That drive eventually led Ferguson to join the Lansing Fire Department in the late ’90s and become a certified EMT. The experience has been a fulfilling one, but he’s been at it long enough to experience firsthand growing challenges for emergency medical services (EMS) in the county.
In recent years, county EMS have experienced a significant strain on services due to two large changes: an increase in demand for services and a decrease in volunteers to provide those services. Tackling the wide-ranging effects of these issues has proven difficult, and it’s a problem many departments are still dealing with, as sources can show.
The problem
“Volunteerism is going down,” said Tompkins County Department of Emergency Response Director Brian Robison. “If you call 911, there’s an expectation that someone’s going to show up relatively quickly, and if you have dwindling numbers, that’s tough.”
According to the department’s recent Comprehensive Analysis of Tompkins County Emergency Medical Services, EMS have experienced a 30% decline in certified EMTs between 2003 and 2017. Volunteer fire departments in the county experienced an overall loss of 45% of their certified EMTs between that same time frame, with 123 total in 2003 and just 68 in 2017.
In conjunction with that, demand for services has significantly increased. The analysis found that between 2006 and 2016, calls for EMS increased by 60%, from 10,786 to 16,060. In 2016, primary ambulance services were dispatched to nearly 10,000 incidents.
How did we get here?
For volunteer shortages, sources identified several reasons for the decline. First, an aging population in the county means that many EMS providers are aging out of the system.
“I’m knocking on the door at 50, and oftentimes, … a lot of the responders and a lot of the officers are definitely getting older, and that’s a concern,” Ferguson said.
Second, the training required to become an EMS provider has increased in recent years.
Geoff Dunn, community preparedness coordinator for the Tompkins County Center for Emergency Response, said that there are three main levels of EMS providers: certified first responders (CFRs), EMTs and paramedics.
Certification for CFRs, who provide basic life-saving care like CPR, can take 48 to 60 hours of training. EMTs, who provide life-saving measures along with services like extremity splinting or providing medication, require 150 to 200 hours of training. Paramedics, who do everything first responders and EMTs do plus services like chest tube placement or chest decompression, take 1,000 to 1,200 hours of training.
That amount of training can be difficult for many to fit into their already-busy schedules, several sources described. Robison said that can discourage people who want to help but don’t have the time.
“They want to volunteer, but they’re just getting pulled in so many different directions that it’s not physically possible to devote the amount of time it takes to even get trained, much less be on call to perform the duties,” Robison said.
That certification is to become an unpaid volunteer, which, for people who have to make a living, isn’t a viable option. George Tamborelle, Cayuga Heights fire chief and supervisor for Bangs Ambulance, which services a large portion of the county, explained it best.
“If I’m going to do an 18-month paramedic program, why don’t I just go and take a two-year physician assistant program or a two-year nursing program?” Tamborelle said. “Basically, you’re learning a lot of the same things for much more pay.”
A third problem leading to decreased volunteerism is a changing culture, said Lee Shurtleff, retired director of the Tompkins County Department of Emergency Response.
“The population of Tompkins County has become a bit transient,” Shurtleff said. “We don’t see in the smaller towns generation after generation of families remaining like they used to.”
Because people are leaving their home communities more and more, that means it’s hard to create an early interest in EMS.
As for the causes of increased demands for services, sources cited a few key changes. The comprehensive analysis cited previously identified several factors, including a steady county-wide population increase (15% over the past 30 years), a rapidly aging population and increased calls for falls, mental health incidents and substance abuse, categories that now comprise over a quarter of current EMS incidents.
The changing nature of calls means that situations have become more dangerous, requiring more EMS manpower to be sent out than in years past, Tamborelle said.
“Where you used to send one EMT out in the rescue truck, now, there’s a lot of situations where you really don’t want to do that,” he said. “You want two or three people on that scene.”
Robison said another issue he’s seen is that emergency rooms are becoming a person’s default medical center, and EMS providers, their default doctors.
“For many people, the emergency room has become your first resort whenever there’s an illness, and consequently, they’re calling for an ambulance for a transport to the emergency room,” he said.
Effects
A logical effect of decreasing volunteers and increasing demand for services would be an increase in response time, Robison said, but EMS providers throughout the county have taken to hiring paid personnel to ensure that doesn’t happen.
“As the ambulance services have seen a diminishing in volunteers, they’ve begun to hire paramedics to fill those places, so it’s created a cost, but they’re able to respond 24 hours a day,” Shurtleff said.
Paid paramedics help to sustain Groton, Trumansburg and Dryden community ambulance services. Bangs Ambulance, which services approximately 75% of the county, also pays its employees, and its services were cited by many sources as a way to fill in the volunteer gaps.
That added cost puts a strain on departments, though, sources said. For the Groton Fire Department, about $280,000 out of its $560,000 budget is strictly for paying paramedics. That cost is supported by contracts with village and town governments and funded totally by property tax dollars, which have increased to meet the demand.
And despite these efforts, response time can still be inconsistent. As the comprehensive analysis put it, “outside of Ithaca (which has a paid staff 24/7), response by the volunteer agencies is largely unpredictable and reveals a routine inability for many to respond to their calls for service.”
Ferguson said he’s seen the inconsistent response rate himself, with the largest deficit being in the middle of the day, when many volunteers are at work. Recently introduced automatic mutual aid means that departments can cover each other in the event of a shortage, and paid services can also make up for the lack of volunteer availability, but especially in places like Lansing, mutual aid and paid services are coming from farther away.
“If you dial 911 … and you need EMS assistance, you’ve automatically got an advanced life support ambulance coming to you,” Ferguson said. “What you may not have is a local first responder that gets there. ... Depending on the amount of volume of activity that’s going on in the county and the distance you’re at, it may be a while before you see somebody.”
Solutions and strategies
Increasing the volunteer EMS base requires strategies from multiple angles, sources agreed. First, community outreach can go a long way to create early interest in EMS and bring in younger generations.
Robison said that most county departments are engaged in school outreach. Ferguson, a teacher at Lansing High School, has frequently participated in these efforts by telling his students about his volunteer work.
Using current and emerging technologies can help create community interest in EMS as well, Shurtleff said.
Dunn said that he and others believe there are people eager to volunteer out in the county, but as previously discussed, training for the position can be demanding on the individual. This is why he and others see a need for increased accessibility to training programs.
One way to do that is to expand CFR trainings to targeted rural areas as opposed to the current model of one centralized course at Tompkins Cortland Community College.
“Move it out of the TC3 setting and make it mobile and teach a class in Newfield one semester and teach a class in Lansing one semester,” Tamborelle said. “If you take that out of a fixed site and make it something more mobile, then I think it becomes easier for people to take and continue to serve as EMTs.”
Tackling the increasing call volume largely involves preventing the issues from occurring in the first place and having additional resources to handle situations like those involving mental health.
Robison said the Emergency Response Center is working with the Tompkins County Office for the Aging and other agencies to prevent falls. Shurtleff said that educating the community on how to avoid emergencies can help decrease overall EMS call volumes.
“We’ve seen success with crime prevention programs, fire prevention programs,” he said. “The same concept can apply to the emergency medical services realm.”
Community paramedicine is another way to decrease EMS call volumes, Robison said. Community paramedics, currently used in places like New York City, provide personalized and coordinated care to patients in their home, working in a public health and primary care role to address the needs of residents in non-emergency situations. If applied to Tompkins County, Robison said, this system could help to decrease the use of EMS as a first resort.
A last-resort option if none of these strategies work would be to have a paid, county-wide service for emergency response, but as Shurtleff said, “we’re not there yet.”
“The public expects this service, and they’ve had it pretty good for a long, long time because basically, it’s been free,” Shurtleff said. “There may come a day where they’re going to have to pay for it. … That’s what we’re working ... to avoid.”
Recent measures
One way centers have compensated for the volunteer loss is by changing the dispatch side of EMS. In 2004, dispatch services throughout the county consolidated to the Tompkins County Emergency Response Center.
“As we consolidated, that drove our numbers up,” said Dispatch Center Supervisor Jan Knope. “We’re busier than normal, … but we’re doing more than we used to do, too.”
Robison said the county recently implemented Emergency Medical Dispatching protocols to enable call prioritization, enhance responder safety and provide pre-arrival instructions.
“That buys you time in the event that there would be a delayed response,” he said.
About five years ago, the center also decreased dispatch time by about 30 seconds by having two people on each call instead of one.
“The person answering the phone asks all the questions, and then, they get to a certain point, and then, the supervisor dispatches the call,” said Christina Dravis, communications center manager.
An attempt on the education side of things was TC3’s Certified First Responder Course, originally offered in the fall of 2019. Shurtleff said it was a way to increase community education basic emergency skills.
“If you can train cores of people that can respond immediately in the community to stabilize the situation while the advanced life support and ambulance are responding, it’s probably the most effective investment in training and volunteer recruitment that you can do,” he said.
The plan was to run the 24-student course twice a week from Aug. 22 until December. The $260 cost for each participant could be reimbursed by the state.
But, as Dunn said, only about five people signed up, which was not enough to run the course. This is why the Emergency Response Center is looking at shifting that training model in ways mentioned previously.
Another education effort was the Community Emergency Response Team (CERT) Basic Training Program in Dryden. In September, the town of Dryden became the first in the county to offer the CERT Basic Training Program, in which participants learn disaster preparedness, team organization, disaster psychology, medical operations, fire suppression and light search and rescue. Ten people graduated from the first CERT course in November.
Colleges can also provide volunteers, as seen in Cornell University’s Emergency Medical Service and the students that work in Cayuga Heights.
Cornell University Emergency Medical Service (CUEMS) is a student-operated, New York state certified, first response emergency medical services agency that serves the Ithaca Campus of Cornell University and surrounding University-owned properties and roadways, 24/7 during the school year, according to its website.
Cayuga Heights relies heavily on college students to fill its EMS ranks, especially at the fire station, where, because of the increasing need for EMT services in fire departments, they also receive experience as EMTs.
Another measure implemented in Cayuga Heights is its live-in bunker program, allowing seven firefighters, who are often students from local colleges, to live in a second-floor dormitory at the station rent free in exchange for duty shifts.
But having a large student membership creates its own set of problems, Tamborelle cautioned.
“Our problem is that we’re transient,” he said. “Every three or four years, we’re turning over the department, so we really push hard and make things available.”
On the ambulance side of things, Bangs Ambulance has tried to make training and service as accessible as possible, Tamborelle said, but being able to pay its personnel fairly is a difficult task.
“You’re fighting the insurance companies. You’re fighting Medicare and Medicaid for reimbursement,” he said. “There’s [also] that balance of how much can you pay somebody and continue to keep the business alive.”
In addition to these efforts, the county has invested $25 million in a shared interoperable voice radio communications system that improved coverage; expanded capacity and placed all responders on a common operating platform; established public programs for CPR, Public Access Defibrillators, Narcan and first aid; and secured and leveraged over $10 million in state and federal grants to equip the first response community and further the goal of communications and operations, according to the comprehensive analysis.
Conclusion
Overall, there will always be a need for emergency services, sources said, so it’s imperative to properly tackle needs like volunteer shortages and increased demand.
“We have to try to be proactive, try to be innovative in finding ways to get people into this field because it’s one of those things, you don’t need them until you need them,” Robison said.
For now, providers throughout the county are working on new ways to approach and solve this problem.
This was originally written in Tompkins weekly written Wednesday, December 11, 2019 1:00 am
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