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Emergency response level changes under consideration

Costs and staffing issues are gnawing into care standards

By Jay Gamel

The rapidly rising costs of everything — from housing to houseplants — is not news to anyone on the planet. The price of providing emergency treatment is sensitive to rising costs, supply chain problems, and paying for the highly trained men and women who are first to come to your aid and make instant decisions on what to do before you get to a hospital. So says American Medical Response (AMR), the private company providing local ambulance services to Sebastopol, Rohnert Park, Cotati, and surrounding unincorporated areas, including Kenwood, since 1991.

Prior to renewing its exclusive noncompetition agreement with Sonoma County (which expired on June 30), AMR insisted it needs to implement a system of tiered responses, sending emergency medical technicians (EMTs) in place of higher-trained paramedics if dispatchers fielding 911 calls make that decision based on the information they have. Why send a surgeon when a trained nurse will do? The cost reductions can be substantial.

Paramedics provide advanced life support (ALS) and EMTs provide basic life support (BLS). Paramedics receive an additional 1,2001,500 hours of medical training. They can perform a much wider range of medical services on the spot and in the emergency vehicle on the way to the hospital. Paramedics are paid more and need to have more medical equipment available.

The need to keep costs down is problematical for all providers, government or private. People gripe about increasing taxes to pay for increased fire salaries and costs; they are equally unhappy being billed for the high cost of private ambulance service. With the July 1 increase, which no one disputed was necessary, AMR now charges $2,707 a call, $530 more than last year. While some or all of these costs may be offset by federal and/or state subsidies, no one disputes the need to fund the services offered. Rates vary from $2,274 (Sonoma Valley Fire District) to over $5,100 (LIFEwest Ambulance Service) for ambulance services in the county.

Up to now, ALS has been required to have a paramedic on board every ambulance it fields.

“Everyone calling 911 gets advanced life support service from the ambulance provider, but not the fire service,” Kenwood Fire Chief Daren Bellach said. “So it works.” All Kenwood Fire Department personnel can provide basic life support, as all firefighters in California are trained EMTs — a basic condition of employment.

South of Kenwood, the situation is different.

“All engine companies since 2017 are advanced life support, with paramedics on board, every day,” Sonoma Valley Fire District (SVFD) Chief Steve Akre said. “And we will stay that way one hundred percent. We are hiring nothing but paramedics.” The SVFD provides ambulance services from Dunbar Elementary School south to the Cherry Tree stand on Highway 121 between Schellville and Sears Point Raceway, including for the city of Sonoma, and has its own exclusive operating area.

“We do not do tiered response,” Akre said, and the SVFD has no plans to do so anytime soon.

Most fire districts acknowledge that tiered responses will become necessary and implemented, but they weren’t ready to do it on AMR’s accelerated schedule.

The decision to use a tiered response system is essentially the domain of the county’s regional medical director for the Coastal Valleys Emergency Medical Services (EMS) Agency, Dr. Mark Luoto, M.D.

However, the decision to award a contract for exclusive services is the responsibility of the county’s Board of Supervisors, as was made crystal clear by Second District Supervisor David Rabbitt on May 24, when the AMR contract was considered at the supervisors’ regular weekly meeting.

The idea of tiered response has been studied by a variety of interested groups, including local fire districts, fire chiefs, fire personnel, medical emergency personnel, and more, for the past several years, holding weekly meetings in some cases.

At the May 24 meeting, Tina Rivera, director of the county’s Department of Health Services, strongly advocated adopting AMR’s request to begin implementing tiered responses as of July 1, taking small steps at first, but with no specific guidelines in place.

Rivera acknowledged AMR’s difficulties getting equipment and hiring paramedics and said adopting tiered responses would be in the “interest of the system,” is based on evidence and best practices, is medically sound, is legally appropriate, and is financially responsible.

And while almost all the fire chiefs and uniformed emergency responders at the meeting agreed that tiered responses may become the standard of care for the county, all were equally adamant that the subject calls for much more deliberation and focused attention. Four supervisors agreed with them, with Third District Supervisor Chris Coursey disagreeing.

For now, paramedics will be on board all AMR ambulances, but the issue will continue to be discussed and studied and will surely return for consideration before the end of 2023.