Posted by Bernard O’Brien, July 27, 2009

Each day in the city there about 880 serious medical emergencies reported over the 911 system which are deemed by Emergency Medical Services dispatchers to require response by highly trained paramedics. On average 15 of these daily calls are instead responded to by emergency medical technicians (EMTs) with less training because paramedics are not available.

Even when paramedics are available to respond, they can’t always do it as quickly as city officials want. The city has a goal of paramedics arriving within 10 minutes of a call 90 percent of the time. They hit that mark about 700 times a day—but they’d have to do it an additional 80 times a day to reach the goal.

Although a proposal announced last January by Mayor Bloomberg would perhaps help remedy these public safety concerns by changing the manner in which many fire department ambulances are staffed, the city has not yet been granted the state regulatory approval needed to implement the proposal. The city unsuccessfully sought this same change in 2005.

The proposed restructuring would allow some city ambulances, as well as those operated by private ambulance services, to be staffed with teams composed of one paramedic and one EMT rather than the current practice of putting two paramedics in the same ambulance. This would allow more ambulances with at least one paramedic to arrive at more emergencies without hiring additional staff.

The planned change in ambulance staffing would also have implications for the city budget. Since an ambulance with a paramedic charges more, revenue would increase. The recently adopted budget for 2010 assumes that the planned change in ambulance staffing would have been underway on July 1 and estimates that the restructuring would raise $2.1 million a year. The increased revenue would allow for a commensurate reduction in the city subsidy for fire department ambulance operations.

Understanding the staffing change requires a bit of background on the two levels of ambulance service provided by the fire department as well as the important differences between paramedics and EMTs. There are two types of ambulances: Advanced Life Support and Basic Life Support. Advanced Life Support units, currently required to be staffed with two paramedics, are dispatched to the most serious medical emergencies, such as heart attacks, choking incidents, and third-degree burn cases. Basic Life Support units are staffed with two EMTs and are typically sent to less critical emergencies such as complaints of heat exhaustion or respiratory distress.

Paramedics are more highly trained than EMTs, with the former receiving some 1,500 hours of training as compared with 120 hours to 150 hours for technicians. Paramedics’ higher level of training allows them to perform advanced medical procedures, including intubation and the administration of drugs. The city charges more for advanced medical care, receiving higher reimbursements from Medicare and Medicaid as well as from patients’ private insurance plans.

There’s only one place in the state where Advanced Life Support ambulances are required to have two paramedics—New York City. Regulations governing ambulance staffing in New York State are issued by entities known as regional emergency medical services councils. The membership of each council consists of physician representatives from public and private hospitals as well as local emergency medical services providers. There’s a council with responsibility solely for New York City.

Under current staffing and deployment levels, there are times when ambulances with paramedics are unavailable or unable to reach an emergency in a timely manner. In fiscal year 2009, in about 2 percent of serious medical emergencies—or about 5,500 incidents—paramedics were not available and EMTs responded instead. Even when paramedics are available to respond, it wasn’t always as promptly as the city aims for. In fiscal year 2009, 80.4 percent of serious medical emergencies were responded to by paramedics in less than 10 minutes, falling short of the fire department’s own goal of 90 percent for this performance indicator. (Responder and response time data cover ambulances operated by the fire department and the private services.)

By teaming paramedics with emergency medical technicians, more ambulances would be staffed with at least one paramedic, increasing the likelihood that an ambulance with a paramedic shows up when needed and on time.

In refusing the city’s 2005 request, the local emergency services council asserted that the city had not submitted convincing evidence that Advanced Life Support units responding to 911 calls within the five boroughs could be safely staffed with fewer than two paramedics. The union representing paramedics agreed, saying that working individually would put too much pressure on paramedics and be a risk to patients. The city’s latest proposal to reverse the unique two-paramedic rule for ambulances operating in the five boroughs has yet to change the council’s mind.