It’s an alarming statistic.
In some Monadnock Region communities, up to 35 percent of emergency medical calls went unanswered by first responders last year.
And that's just based on data the hospital keeps, according to James C. Suozzi, associate medical director and EMS director at Cheshire Medical Center/Dartmouth-Hitchcock Keene.
"Unanswered" doesn't mean someone suffering a medical emergency is left to die, but rather that the agency serving that community can’t respond. As a result, an ambulance from another provider must be sent to answer the call.
Communities that use Cheshire Medical Center as their primary hospital include Acworth, Alstead, Chesterfield, Fitzwilliam, Gilsum, Harrisville, Keene, Langdon, Marlborough, Marlow, Nelson, Richmond, Roxbury, Sullivan, Surry, Swanzey, Troy, Walpole, Westmoreland and Winchester.
They all have fire and rescue departments with some members trained to handle medical emergencies. But only seven also have their own ambulance services, mostly made up of paid on-call or volunteer staffs and each running one or two ambulances.
The remaining 13 towns rely on ambulance services outside their communities, primarily the Keene Fire Department and Keene-based R.J. DiLuzio Ambulance Service.
The former, a city department, runs three ambulances to cover Keene, Chesterfield, Nelson, Roxbury, Sullivan, Surry and Westmoreland.
The latter, a private business, runs six ambulances covering primarily Gilsum, Harrisville, Marlborough, Richmond and Swanzey. It also provides backup to Alstead, Fitzwilliam, Marlow, Stoddard, Troy, Walpole and Winchester.
Suozzi said he can't confirm whether the statistic he cited, which is only for communities that use the hospital, is a true reflection of unanswered calls in those communities because the data are based only on medical records.
"I suspect it's up to 35 percent, but it might be worse or it might be better," he said.
But it does indicate there's a problem, he said. And that's why he and other EMS officials are trying to collect more accurate data from the regional emergency dispatching system to determine just how strained it is.
Emergency dispatch call logs from the past few months provide some hints.
On Jan. 10 at 9:10 a.m., the Swanzey Fire Department and DiLuzio Ambulance were sent to Holbrook Avenue for a person with abdominal pain.
DiLuzio didn't have an ambulance to respond, and Winchester Ambulance was called to cover the call. Winchester was then taken off the call, and a DiLuzio Ambulance ended up arriving 30 minutes after the initial dispatch.
Swanzey Fire Chief Norman W. Skantze said he timed the response.
Two hours later at 11:10 a.m., Swanzey Fire and DiLuzio were called to Carolyn Lane for a psychological call. Both agencies were able to respond; the patient wasn't taken to the hospital.
Then at 11:30 a.m., Swanzey and DiLuzio were among the agencies sent to Nelson to help a person with a shoulder injury at Woodward Pond.
Two minutes later, Swanzey and DiLuzio were dispatched to Monadnock Highway for a medical call. Swanzey sent two medical responders, DiLuzio sent two personnel in a medic vehicle, and Keene had to respond as a backup agency to provide the ambulance, Skantze said.
For several towns in the Monadnock Region and southeastern Vermont, it's no secret that getting together a crew to go to fire and emergency medical calls can be challenging. But in recent years, it's been getting even more difficult, according to area fire and EMS officials.
They're especially concerned about getting people out to emergency medical calls, and say the problem's reaching a breaking point. Some services are struggling to stay afloat with fewer volunteers and funding constraints. Meanwhile, those that can make the calls are being stretched thin.
Waiting for an emergency medical responder or ambulance to come from another part of the county puts a patient — especially one who is seriously ill — at greater risk, according to Suozzi.
“A good example is that with somebody who is in respiratory arrest or cardiac arrest, seconds matter,” Suozzi said. “The chance of survival from cardiac arrest decreases by 10 percent for every minute without CPR.”
If the problem is not fixed, area officials say, people could have to wait longer for help to arrive — if it arrives at all.
“It’s not a good situation,” said Keene Fire Chief Mark F. Howard, whose department is one of the largest EMS providers in the Monadnock Region. “If this trend continues for the next three to five years, we could be in trouble."
In the past three to five years, emergency medical response agencies across the region have likely had to examine how to provide those services with the knowledge that some fellow agencies might not provide them in the future, according to Howard. For those that remain, he said, it is — and will be — tough, as they stretch staff and resources to fill the gaps.
“We can’t continue to lose more agencies or absorb more calls,” he said. “It’s not sustainable, and it puts communities at risk.”
The situation has led Howard and other city officials to evaluate the effects on Keene of providing backup ambulance services to non-contracted communities, if the primary ambulance service can't respond to the call.
The review includes considering whether Keene's ambulances should stop going to calls in communities that don't contract with the city, according to Howard.
Each town Keene contracts with pays an annual standby fee to the city to help cover the costs of staffing and equipment. The amount is calculated from the previous year's revenue shortfall for ambulance billing.
In fiscal year 2016, which ran from July 1, 2015, to June 30, 2016, Keene Fire sent an ambulance 28 times to calls in non-contract towns, with the most trips being 12 times to Swanzey, seven times to Winchester and five times to Marlborough, Howard said.
Keene Fire used to be called once, maybe twice a year to a non-contract town to answer an ambulance call, he said. But the frequency has grown. And he fears it will continue to do so as other ambulance services struggle to respond to calls, or just close.
"I don't think anybody is saying they're not going to respond. We are in the service of helping people," Howard said.
But as the fire chief and head of Keene's ambulance, he said, it's his job to run a fiscally responsible department.
"I want to make sure our service is sustainable, if this number of mutual aid calls doubles or triples in the next few years," he said.
'Playing Russian roulette'
Area ambulance services, whether private or public, aren't members of Southwestern N.H. District Fire Mutual Aid, and therefore don't have agreements in place through the agency to help one another, according to Mutual Aid Chief Philip J. Tirrell.
That means if an ambulance service is called to respond to a town as a backup agency, it can decline to go if it doesn't have a contract with that community.
When the agency formed in 1958, it was to dispatch fire departments, Tirrell said.
However, he said, soon after its dispatch center opened in 1962, Fire Mutual Aid began dispatching for ambulance services as a service to those member communities that used them.
"We've just assumed the responsibility as a cost of doing business," he said.
Whether those ambulance services should become members themselves and subsequently pay an annual fee to Mutual Aid has been an ongoing discussion of the agency's board of directors, according to Tirrell.
Some of that discussion has been fueled by how the agency should handle its dispatch operations in the future, assuming the demand for emergency medical services will grow, he said. Another part of the discussion has been how Mutual Aid should handle dispatching for a new private ambulance service if another one sets up shop in the region.
In the meantime, Tirrell said, if the area has a mass casualty incident or some other event requiring a large emergency response, there aren't enough ambulances and personnel to handle it.
"Really, with EMS in the region, the ambulance services are playing Russian roulette," he said. "And the person who really suffers is the person needing help who has to wait for a mutual aid service to get there."
One problem is that smaller emergency medical services agencies just can’t get enough volunteers. And those volunteers who can respond are doing so often and getting burned out, fire and EMS chiefs say.
Ambulance services nationwide that depend on volunteers and fundraising for revenue have found it difficult to maintain their operations, let alone advance them, according to a 2004 report by the National Rural Health Association.
As public and professional expectations of emergency medical services increase — and training and licensing becoming more complex — it's become challenging to keep running an agency with volunteers, the report says.
"Services have turned ... to paying stipends and/or employing part-time and full-time staff at those times when it is most difficult to attract volunteers, and/or provide EMT-Intermediate and Paramedic levels of care when they are not available on a volunteer basis," according to the report.
But making this change puts greater pressure on volunteer agencies to start following business practices like billing, reimbursement and requesting government subsidization to support their operations, the report notes.
In New Hampshire, there are three levels of licensing for emergency medical technicians. The first allows a technician to use basic skills to care for a patient.
An advanced EMT has more skills to keep patients' airways open, control bleeding and provide medications, including giving shots and starting intravenous fluids.
Someone who is a paramedic has a greater range of skills and training to care for patients, including providing medication for pain management.
Getting licensed at any of the levels is a huge time commitment.
An EMT Basic certification requires 150 to 190 hours of coursework, while an advanced license requires another 150 to 250 hours, according to the N.H. Bureau of Emergency Medical Services. People going for their paramedic licenses are required to do 1,200 hours of coursework, according to the New England EMS Institute.
For all that training, EMTs received a median pay of $15.38 an hour or $31,980 a year in 2015, according to the U.S. Bureau of Labor Statistics.
The low pay and high intensity of the work makes it difficult not only to attract qualified people, but also to retain them, according to Drew P. Hazelton, chief of Brattleboro-based Rescue Inc.
Often people will work as emergency medical technicians or paramedics for a few years before going on to better-compensated jobs in the medical profession, he said.
As demands for emergency medical services increase, so does the need for first responders from local communities to be available to tend to patients before ambulance personnel arrive, Hazelton said. But many first responders are either volunteers or on-call employees and aren’t often available because of their day jobs.
Another problem Rescue Inc. and other ambulance services face is being adequately compensated for the care they provide.
Rescue Inc. is a nonprofit organization that covers 15 communities in southern Vermont and southwestern New Hampshire, including Hinsdale and the village of West Chesterfield. It was founded in 1966, has stations in Brattleboro and Townshend, Vt., a staff of 56 paid full-time and part-time employees and volunteers, and seven ambulances.
Its call volume runs from 5,800 to 6,000 annually, Hazelton said.
Approximately 80 percent of the organization’s funding comes from billing, grants, donations and fundraising efforts, while the remaining 20 percent comes from local tax appropriations, he said.
Other ambulance services, including Peterborough, DiLuzio and Keene, also rely on contributions from the towns they cover to stay in the black, as Medicare, Medicaid and private health insurance reimbursements fall short.
When it comes to Medicare and Medicaid, there are six categories under which Peterborough Ambulance can be reimbursed for treating and transporting a patient, Peterborough Deputy Fire Chief Joshua H. Patrick said. They range from basic life support to specialty advanced life support.
Regardless of what it costs to treat a patient, the care must fit into one of those categories for reimbursement. And, more often than not, this money ends up being significantly less than the cost, according to Patrick, who is also clinical manager for the department.
Another quirk of the billing system is that, while the federal Patient Protection and Affordable Care Act mandated everyone have health insurance coverage, it didn’t make ambulance rides to emergency departments an item that would be covered by insurance with a patient co-pay, he said.
Now, that expense is part of a patient's health insurance deductible on most plans, he said.
As a result, patients now must pay, out of pocket, costs that can hit nearly $1,000, he said.
Before the Affordable Care Act went into effect, 7.6 percent of what Peterborough Ambulance billed in 2008 and 2009 went uncollected, he said, based on data from the service's billing company. Over the past 12 months, uncollected debt has jumped to 12.8 percent, he said.
The 2011 National EMS Assessment, prepared by the Federal Interagency Committee on Emergency Medical Services, notes that the majority of ambulance services in one-third of states across the country rely on volunteers to respond to emergency medical calls.
While "volunteer" typically means the person isn’t paid, there's no formal definition, the report notes. Many emergency medical service agencies are considered volunteer if some of their staff is paid, or if they don’t bill for services.
Of the 37 Monadnock Region fire and rescue departments and ambulance agencies licensed by the state in The Sentinel’s coverage area, state records show that 27, or about 73 percent, are classified as volunteer.
Only 14 of the 37 agencies are licensed to transport patients, which means they have EMTs and ambulances. Agencies that are licensed as non-transport agencies can provide emergency medical care, but don't have a way to get patients to a hospital.
Other challenges emergency medical response agencies face here and nationwide have been fueled by increasing costs; an aging population and the opioid crisis, according to fire and medical officials.
Out of 3,430 calls from July 1, 2015, to June 30, 2016, Keene emergency medical personnel treated 500 patients in the 51 to 60 age group, according to Howard. That was followed by 480 people in the 81 to 90 age group, he said.
However, the age group that grew the most from fiscal year 2015 to 2016 were patients ages 21 to 30, according to Howard.
"I believe that is partially due to the opiate problem," he said. "When we’re responding to (opioid) overdoses, that’s often the age group we’re seeing."
Picking up the slack
In the past 10 years, the region has lost Lefevre Ambulance Service of Bellows Falls and Marl-Harris First Aid and Emergency Squad Inc., which served Marlborough and Harrisville.
As a result, agencies that can consistently staff ambulances end up picking up the slack, straining their operations and leaving their own coverage areas vulnerable, according to local fire chiefs and Suozzi.
Those agencies — like the Keene Fire Department and DiLuzio Ambulance Service — are limited in their ability to absorb additional calls because of finances and staffing levels, Howard said.
“Right now, with the agencies we have left to pick up the pieces, I don’t feel like there are enough,” Suozzi said.
He and Mark E. Houghton, assistant chief of Walpole Fire and EMS, are working with the vendor of dispatching software used by Southwestern N.H. District Fire Mutual Aid to see if there's a way to track medical calls. If so, they're hoping to break down the information to determine how long it takes first responders and ambulance personnel to get to a call, and where the responders are coming from, according to Suozzi.
“We’ve seen anecdotally that it’s getting worse,” Suozzi said. “I think the system is severely strained, and it’s serious."
But he and other officials need the hard numbers and statistics to know the severity of the problem, so they can fix it, he said.
As for whether the problem has affected patient survival rates or outcomes, Suozzi said he doesn't know. But many patients who have had to wait for emergency responders to be called a second time, or for help to come from an agency outside their city or town, have been very sick. And that has him worried.
It also has other fire and EMS officials concerned, including Hazelton, who believes emergency medical services in whole are reaching a breaking point in the region.
“Our EMS system is on the verge of collapse from a funding and a structural perspective,” he said.