Sunday, May 11, 2003

[IMAGE] 'Running hot': With lights and siren on, firefighters Walter Cruse (left) and Mike Carey take Ambulance 12, the city's busiest, along Hopple Street on a 2 a.m. run late in a 24-hour shift.
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'You call, we haul'

They respond to life-or-death calls - and plenty of minor maladies, too. In Cincinnati, everyone who wants an ambulance ride gets one.

Story by Jane Prendergast / Photos by Glenn Hartong
The Cincinnati Enquirer

Cincinnati firefighters take hundreds of people to the hospital each week for emergencies - and for ailments including hiccups, toothaches and menstrual cramps.

It's the result of a "you call, we haul" policy that says anyone who wants an ambulance ride to the hospital gets one.

The policy is supposed to ensure quick crisis care for everyone who needs it. But instead, it costs the city millions and could threaten rapid response to life-or-death needs, the Enquirer has found.

[IMAGE] Firefighter Mike Carey checks a woman's hand after an accident on Interstate 75
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The policy is also getting harder to maintain. As city residents grow older and poorer, they're using ambulances more - testing the Cincinnati Fire Department's limits. People without cars or taxi fare, or who lack health insurance, know they can see a doctor fast by dialing the most well-known phone number in the land: 911.

Last year, just a little more than 10 percent of all Fire Department runs were to fight fires. More than 60 percent were for medical emergencies. And of those, the firefighters union president estimates that one of every three was for a minor malady.

"We're becoming the provider of first choice for some people," Fire Chief Robert Wright says. "They don't see the harm in what they're doing. And some people are lonely."

Emergency dispatchers prioritize runs, juggling six ambulances and five paramedic units as they move all over the city. But runs have increased dramatically, even as the city's population and the number of firefighters have fallen. Some ambulance crews stay busy their entire 24-hour shifts.

Emergency medical technicians took a Price Hill baby to Cincinnati Children's Hospital Medical Center in March because she was blowing bubbles. "Babies do that," firefighter Doug Stern reassured the mother. She wanted the baby examined by a doctor anyway.

[IMAGE] Walter Cruse and Mike Carey load a woman into Ambulance 12 along Westwood Avenue. She'll be talking by the time to arrives at Good Sam.
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City leaders - hesitant to relax "you call, we haul" for fear they'll be sued - are left with few options. They could be more aggressive in collecting unpaid ambulance fees, which last year topped $4.5 million of $7.9 million billed through mid-November. Or they could split firefighters' shifts to relieve the stress on emergency responders.

But even those changes wouldn't reduce non-emergency runs, Wright says. Many people believe their problems are emergencies. And telling a patient otherwise would be bad customer service and unacceptable, the chief says.

Sometimes, the customers are like an 84-year-old Westwood woman who has lived alone since her husband died eight months ago. They'd been married 63 years.

One night in March, she slid out of bed, was unable to pull herself up and spent the night on the floor. In the morning, her daughter found her and called 911. The daughter was afraid to move her mother and worried there might be something seriously wrong.

There wasn't. Still, the mother thanked the emergency medical technicians repeatedly for helping her during an exceedingly bumpy ride down Queen City Avenue to Christ Hospital in an ambulance.

She didn't complain, saying, "I might need them again."

Paper cuts? Diaper rash?

Cincinnati's six ambulances made 28,563 runs last year, an average of 78 a day. The number of emergency medical runs by all Fire Department personnel and equipment - including fire trucks and rescue squads - was nearly double that.

No one keeps track of how many runs were for non-life-threatening problems. Wright says that's too subjective.

But Joe Diebold, president of Local 48 of the International Association of Firefighters union, estimates that one of every three calls is unnecessary. He personally has been called to a home because a child wouldn't sleep.

Dozens of firefighters recount more examples: Paper cuts. Crying babies. Women in labor who need rides to the hospital. Firefighters in Camp Washington recently responded to a report of a 1-year-old bleeding baby. The baby had diaper rash.

"This kind of thing happens every day," Diebold says.

City Manager Valerie Lemmie rode with an ambulance crew last fall, and not one of the more than a dozen people transported required hospitalization.

"What's striking here is the number of calls they get from people who don't need emergency care," Lemmie says. She proposes a public awareness campaign about when - and when not - to call 911.

Cincinnati responded last year to the financial side of the problem by increasing the charge for ambulance rides. Basic ambulance runs jumped $72, to $252. The fee for more sophisticated paramedic runs increased by $8, to $433. The city also added a $5-per-mile fee.

The city bills patients' insurance carriers, if they have them, and Medicare or Medicaid. But depending upon the patient's ailment, the insurer doesn't always pay the entire bill.

Those without insurance are billed directly, but aren't forced to pay.

Many don't.

Change in mission

Over the past three decades, the Fire Department's mission has turned from predominantly fighting fires to mostly providing emergency medical care.

It's a trend across the country as fire prevention technology improves, lessening fire calls, and societal factors such as poverty and a lack of access to health care worsen.

At the same time, the Fire Department has lost personnel. Some 978 firefighters worked for Cincinnati when Wright came on the job in 1973. That number is now about 800. There will be no recruit class this year; the chief cut it again to try to keep his staffing at levels budgeted by the city.

All 800 firefighters are emergency medical technicians, trained in basic emergency medicine. In addition, 155 are paramedics, a number that's grown from two in 1976.

Paramedics have hundreds of hours of extra training that allows them to perform more advanced procedures, including administering drugs and inserting breathing tubes.

Fire chiefs everywhere debate how to balance the increasing workload with budgetary concerns, says Jack Krakeel, Emergency Medical Services director for the International Association of Fire Chiefs and chief of public services in Fayetteville, Ga.

"It is one of the top issues we face today," Krakeel says. "We are always trying to come up with new ideas, but it can be very difficult. It's a daunting task, both from an operations perspective and a public-policy perspective."

Dr. Gregory Fermann, director of clinical operations at University Hospital, says many people dial 911 because they think arriving at the emergency room in an ambulance will get them seen faster. It does, but only briefly - until hospital personnel realize the problem isn't an emergency.

University Hospital is going to start sending ambulance patients more quickly to the lobby to wait after physicians determine they don't need immediate care, he says. That, he hopes, will send a message to patients.

"I think everyone's feeling the pressure," Fermann says.

'An emergency to them'

Cincinnati fire officials say their "you call, we haul" policy doesn't hinder ambulances' ability to get where they're needed most. Dispatchers do their best to prioritize, Wright says. And Mark Gissiner, former director of the Office of Municipal Investigation, says he can't remember any complaints about timing leading to poor care.

But firefighters say the possibility exists every day that all ambulances will be busy when someone needs life-or-death care.

"It is unquestionable that the workload created by EMS abusers has and will continue to have very serious consequences for citizens with dire medical emergencies," Diebold says. "Every day, there's ambulances out of service, and emergency calls still come in."

Krakeel agrees: "That's just common sense."

Other area departments have policies similar to Cincinnati's. Covington Chief Joe Heringhaus says his department, because of fear of lawsuits, also will take to the hospital almost anyone who wants to go.

And Lacey Calloway, a former district chief in Cincinnati who now works as an assistant chief in Dayton, says the policy is similar there, too.

"The thing that you have to remember is, if it's a splinter in your son's finger, you may think that's an emergency," Calloway says. "It's always an emergency to them."

Some firefighters are more aggressive than others in trying to persuade some patients not to go to the hospital by ambulance. They'll ask if a neighbor can drive them or if a relative can be called.

Some fire departments also are more willing to risk liability and let firefighters make on-scene decisions about whether someone needs to go to the hospital.

In Dallas, where the population of more than 1 million is triple the city of Cincinnati's, the nearly 2,000 firefighters made almost 147,000 emergency medical runs last year. But they transported just 60,594 of those to the hospital - or fewer than half the calls.

"A toothache?" says Dallas Lt. Joel Lavender. "No, you don't go."

Other kinds of calls mandate transportation to a hospital - a break in a major bone, chest pain, an elderly person alone with the "weak and dizzies."

In Phoenix, calls for minor medical help are sometimes answered by teams of emergency medical technicians and social workers who ride around the city in minivans. The program saves money, Phoenix Chief Alex Brunacini says, and directs resources more appropriately. The department made more than 104,000 emergency medical runs last year, and transported people in roughly half.

In San Francisco, rescue personnel give taxi vouchers to patients they think do not need immediate transportation. Houston sends emergency medical supervisors to scenes to determine whether the caller needs to go to the hospital.

Many cities have systems in which people who need help with non-emergencies can dial 211 or 311, Krakeel says.

Some cities also are starting to charge fees for runs in which personnel respond but don't transport anyone. Wright says he's considering doing that, too.

Sometimes, reward is a pie

There are still many people, firefighters say, who don't take advantage of the system. At the firehouse in Sayler Park, people needing help sometimes drive the patient to the firehouse or call the station's non-emergency phone to avoid calling 911.

"They say things like, 'We're sorry to bother you, but Grandma's having chest pain,' " firefighter Tim Smith says. "We get a lot of thank-you cards. And we do have ladies who make us pies."

Lt. Al Pining recently started his 42nd year with the Cincinnati Fire Department. He has watched as the work became less about fighting fires and more about emergency medical service, a change that's difficult for old-timers to embrace. He's made plenty of runs that might be considered unnecessary and says it's easy to become frustrated.

At the same time, though, he says it's very difficult to walk out of a house - particularly where the patient is elderly - when the patient has decided not to go to the hospital this time.

"You kind of cringe when you walk out of there," Pining says. "You just hope you don't have to go back. Because if you do, it's going to be something serious."


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