Ambulance responses in our region raise alarms: Part I in a series
By Miriam Raftery
March 22, 2015 (San Diego’s East County) – What if you had a medical emergency and the nearest ambulance had to come from Imperial County or other distant places up to an hour away? That’s the very real prospect facing rural East County residents under a stealth change in ambulance service approved by a county bureaucrat with no public notice, no hearing, and no vote by the Supervisors.
While some aspects of coverage stand to improve under the contract, adding more in-district ambulances and newer equipment, there are some major concerns raised by local safety advocates with regard to mutual aid and staffing.
Unless public pressure can improve this deal, effective April 1st Mercy Medical Transportation, Inc. will replace American Medical Response (AMR) as the ambulance provider in an inland San Diego region known as Zone 2 Rural and Otay Mesa Service Area. That extends from Jamul to Jacumba, south to Otay at the border including the prison, and communities just north of I-8 such as Descanso and Pine Valley., as well as Mount Laguna at the farthest point north. View contract.
(The contract does not include other mountain areas such as Ramona or Julian; Lakeside, incorporated cities and some tribal areas in East County are also excluded.)
In the 2012-2013 fiscal year, the area to be served had 3,016 ambulance calls and 2,624 ambulance transports.
County rules allow this life-or-death decision to be made without input of Supervisors or the public. The $2,340,000 three-year contract is signed by John Pellegrino, director of the County’s Department of purchasing and Contracting. Rural planners were not consulted, and it is unclear whether the County consulted anyone with medical expertise beyond companies bidding on the contract.
Sources interviewed by ECM have stated that both Mercy and AMR are reputable companies that generally do the best they can with the resources provided. That’s not the problem.
Based in Escondido, Mercy has been around since December 1993. Since 2002, its been providing services for San Diego County and the Valley Center Fire Protection for rural areas in North County. Its president is also president of McCormick Ambulance in Los Angeles County, responding to about 9,000 911 calls a month. Mercy has shown a philanthropic side, provided ambulance services free in New Orleans during Hurricane Katrina, serving as the 911 ambulance service in the disaster area, according to Mercy’s president.
“We are proud to bring all brand new, state-of-the-art ambulances and equipment to the Zone 2 rural area,” says Richard Roesch, president of Mercy. Mercy plans to add an additional ALS (advanced life service) ambulance to the fleet, which will be posted in Alpine during the day and available to cover uncovered areas during daytime only. So if two units in Alpine are available, one would “move up” to cover a call in Jamul or Campo. Roesch says this would be better coverage than now. He adds, “Our people are our biggest asset. In addition to being EMTs or paramedics, they are also trained Firefighters 1s.”
The contract requires just four ambulances for the entire district. But Mercy's Allyse Roesch told ECM on March 23, "As we took a tour of the service area and did more research, we found that the area would be best served with the addition of those 2 units (in Alpine and Otay Mesa). Our goal is for best patient care and 100% response time compliance, not just adequate service." These two units are permanent, she says, but adds, "If we find that the locations of those 2 units needs to be changed to allow for maximum coverage we will. Also, these 2 additional units will be staffed by Mercy personnel.
Mercy's plan would station two 24/7 ALS ambulances in Alpine, double the number there now. Another 24/7 ALS ambulance would be stationed at the Cal-Fire County Fire Station in Bouelvard once the new station is built; meanwhile the unit will be stationed in Lake Morena to serve the farthest east areas of the county currently served by a unit in Campo. In addition, ALS will have a 24/7 ALS ambulance at the Cal Fire San Diego Rural ALS station in Jamul, as well as two ALS ambulances 24/7 at the Cal Fire/County Fire station in Otay Mesa, which currently only has one ambulance.
The problem is inadequate budgeting by the County to adequately cover the vast East County area--a problem under both the new and old contract. Best case, there are not enough ambulances funded to cover the backcountry, putting lives are at stake, medical transport and firefighting professionals have told ECM.
The two critical areas of concern are mutual aid (which agency will respond if the nearest Mercy ambulance is already on a call) and staffing--(whether ambulances will have two paramedics, or one paramedic and am Emergency Medical Technician. The difference is crucial, since EMTs cannot defibrillate a heart patient, intubate a patient with breathing difficulties, or start an IV to administer intravenous medications or fluids.
Mutual Aid Concerns
Mercy promised the County it would secure seven mutual aid agreements. If only four to six are signed by April 1st, it would be required add one extra ambulance. If just one to three are signed, it would add two extra ambulances to the initial four in the contract. (These points may be irrelevant if Mercy abides by keeping two extra permanent ambulances here -- a decision that is not required in the contract.)
As of last Friday, only one such mutual agreement has been signed that can be documented through County public records and a request to Mercy – with Schaefer Ambulance Service Inc. in Imperial County. There is also nothing in the Schaefer contract requiring two paramedics, or even one, on the ambulances dispatched for mutual aid.
In an e-mail last week, Roesch told ECM, “We currently have secured mutual agreements, either oral or written, with the following agencies: Viejas Fire Department (FD), Sycuan FD, Julain Cuyamaca Fire Protection Ambulance Service, Mesa Grande, Schaefer (imperial County), Santee FD, Lakeside FD.”
But e-mails obtained by ECM through a public records search reveal Mercy has reached out to numerous other entities to request mutual aid, and some responded with encouraging e-mails, such as Viejas stating Mercy could reference Viejas in its proposal to the County.
But no mutual contracts had been signed as of March 16th, other than with Schaefer. ECM invited Mercy ‘s president to be interviewed on Monday, March 23rd and he initially agreed, but after we asked him to bring signed copies of mutual aid he cancelled and said he would not be available until after April 1st due to a busy schedule.
Roesch claims oral agreements have been used in the past. But shouldn’t something as crucial as back-up ambulance services through mutual aid with local agencies be confirmed with a written contract, has was done with Schaefer in Imperial Valley?
Mark Ostrander, former Cal-Fire Battalion Chief for rural East County, expressed shock to learn this. “Oh my gosh, so we’re talking 45-minutes plus,” said Ostrander, a resident of Jacumba Hot Springs.
Some of the other agencies proposed for mutual aid are also outside the service area, meaning ambulances would travel long distances , such as from Mesa Grande, Barona and Lakeside.
Others are within the service area including Alpine Fire District as well as tribal fire departments at Viejas and Sycuan. Viejas and Sycuan have both voiced support for mutual aid, though no signed contracts have been provided , and both are within the service area.
But tribal resources have already been tapped for mutual aid to the point that at least one tribal fire department has voiced concerns that such calls are becoming routine and that they were not being reimbursed for those costs, Mark Ostrander, former Cal Fire Battalion Chief, told ECM. Tribal departments also must cover casinos, raising questions over how available help would be if Mercy relies too heavily on tribal responders.
Under the old contract with AMR, mutual aid could come from additional sources within the service district such as El Cajon , La Mesa, Lemon Grove, Bonita and National City, not merely tribal sources. But those other agencies used in the past are not even on the list of seven mutual aid entities proposed by Mercy in its correspondence to the County. Some of these cities are serviced by AMR, which may not be eager to rush to the aid of its competitor.
That said, Mercy’s president told ECM he has reached out to El Cajon’s Fire Chief but “we have no agreements” and has also reached out to AMR, the provider for La Mesa. “Alpine does not have a transport ambulance, therefore we do not have a mutual aid agreement with them,” he said, adding that reliance on tribal units in Zone 2 “makes the most sense” to utilize for mutual aid—and for Mercy in turn to back tribal departments up if they are not available.
As for the Schaefer ambulance service out of El Centro, multiple sources told ECM that Schaefer often runs ambulances without two paramedics and that some personnel are not certified by San Diego County. Certification in our county is required to treat patients.
Staffing: Paramedics vs. EMTs
“The County held AMR to a higher standard of care, requiring dual paramedics on every vehicle,” an AMR medical provider who asked that his name not be published told ECM. “EMTs can only take vital signs and reports, nothing else.”
The contract requires dual paramedics on Mercy ambulances – but there’s an exception, if there are Advanced Life Support (ALS) first responders in the area Mercy is covering, then Mercy could respond with one EMT and one paramedic.
But only a handful of fire stations in this district have paramedics—and rural fire stations have had many “dark days” when they were closed due to lack of money and manpower – weeks at a time, in some cases, as ECM has previously reported here and here. Others have been short-staffed. At least one death occurred when two stations were closed simultaneously, resulted in a long response time. Reliance on fire station paramedics where resources are already strained raises the concern that a contract breach could occur if Mercy counts on a response from a station that’s not open or under-staffed.
East County Magazine has contacted Supervisor Dianne Jacob, who represents East County, regarding the concerns raised by our investigation, but we have not yet received a reply.
Response times: How many ambulances do we need?
The City of San Diego runs 28 ambulances within its city limits, not counting about 47 units available through firefighter paramedics and additional help through mutual aid. By contrast, the County plans to have Mercy operate just four ambulances for the vast area covered in this contract—again, from the Imperial County line to Jamul, from the Mexican border north to Descanso and Pine Valley.
Already response times are unacceptable slow by any impartial medical standard in the rural areas. In both the old AMR and the new Mercy contract, the county requires that medical calls be responded to in 30 minutes or less in rural areas, at least 90% of the time. In urban areas, the requirement is 10 minutes. There are also exceptions –if there’s a traffic jam, fire or severe weather, for instance, longer responses times don’t count toward that average. Rural East County gets snow and rural highways such as 94 are often blocked by accidents.
“We will exceed these requirements especially with adding a unit,” Roesch predicts, referencing the contractual response times. He adds that in its current service area, “we far exceed contractual response time standards. In fact, we self-impose more stringent response time criteria than required by contracts. Currently in Valley Center we rae at 99.95 compliance (our average response time is approximately 9 minutes) and in Mariposa County we are over 98% compliance ,” he says, adding that Mariposa only requires 90% compliance.
Mercy is also pursuing the idea of putting ambulances at a couple of fire stations and relying on firefighter paramedics to staff them. Roesch calls this “thinking out of the box”, noting these would be in addition to the four ambulances staffed by Mercy. This could be “better for the patient” he says, reducing patient’s time to get to a hospital.
But not everyone is so optimistic.
Donna Tisdale, chair of Boulevard’s Planning Group, is skeptical after having seen problems with fire station staffing in her area on a recurrent basis, despite upgrades promised by the County. Law enforcement response times are also much slower than elsewhere in her rural community, as ECM has reported. “The County is always exaggerating the level of services we will receive out here.”
“I’m very concerned,” an AMR employee who lives in the district told ECM, adding that response times are already too long due to the County not funding enough ambulances to serve such a big area. “I know for a fact that some of the paramedics will never ride motorcycles in this area because they don’t have the response time that they should have in rural East County. All of the 94 highway is a very dangerous road. The response times are huge.” If you have an accident with severe injuries, he adds, “You’re pretty much dead.”
His concerns are echoed by Ostrander, who says county ambulance services are “already lacking” along both the I-8 corridor and highway 94 in East County. He says there have already been deaths due to ambulances not arriving in time.
For heart attacks, anything over a few minutes means the patient likely will not survive, or will have brain damage if they do. For stroke, heart attack and serious traumas medics refer to a “golden hour” to get patients to a hospital within 60 minutes. That limit is already often exceeded in East County.
A mother who asked not to be named told ECM that back in 2010, “My son almost died. It took two hours to get an ambulance here when he was having a seizure.” Her neighbor’s son was bitten by a rattlesnake and survived thanks to air transport, but she worries about snakebites and the elderly in her community not getting to a hospital fast enough.
There also concerns over coverage of the Otay Mesa detention facilities, where the current prison population of 6,400 could rise to 8,300 during the contract term, according to figures in the County contract.
A 2013 board action that launched the competitive bid process was “routine” according to a spokesperson from Supervisor Dianne Jacob’s office, following “fixed rules about awarding contracts, partly to keep the process from being politicized.” In this case, the staff evaluated three factors equally as part of the Request for Proposal process: program requirements, expertise and price. Some implementation details such as placement of apparatus remain to be finalized.
That’s not acceptable to rural residents, who are upset that the County is talking about funding a new stadium for the Chargers and recently spent millions on a water park while short-shrifting ambulance service for rural areas.
“That frosts me big time,” Ostrander says. “We don’t have enough money to put in a good, decent fire department , we don’t have enough money for ambulance service, but we have enough money for the Chargers? That benefits only a few people—and none of the benefits will be out here.”
He adds, “This is just a blatant, callous disregard for the residents in the backcountry.”
Ostrander believes there are other places the County could cut its budgets in order to increase funding for ambulance services. The County has budgeted less than $800,000 a year for ambulance in the district in question, or about $200,000 per each of the four ambulances.
“We need at least three more,” says Ostrander. He wants to see an ambulance stationed at Campo, another in either Boulevard or Jacumba, and a third in either Potrero or Barrett Junction.
Lack of sunshine
Many rural readers are fuming over that process and argue that the public should have been allowed to provide public comment and input on something of such critical public safety importance.
“They were sticking this through because they don’t want to get this in the media,” Ostrander maintains, though the County contends the action was routine. “They’re blatantly trying to hide it. They don’t have open government.”
ECM asked Terry Francke, general counsel at Californians Aware which has previously sued the County for violating open government laws, if the secrecy here is a concern.
“ I’m not aware of any law that requires a formal public hearing based on these facts,” he told ECM.
But he concludes, “Of course that doesn’t mean that the supervisors can avoid hearing from the public about the situation. I’d expect that to happen, if not now, then when the first person dies because the supervisors saw to it that ambulance help was left too far away.”
Update March 23, 2016: An earlier version of this story indicated that Mercy would not have an ambulance stationed east of Alpine. Mercy has since informed us that it will station an ambulance in Lake Morena and later, Boulevard once the new station there is completed. We have updated the story to include this change of plans by Mercy. Find additional details here.