Milwaukee County Plan For Paramedic Service Tailored to 19 Communities
FEATURES
Whether or not the work of Squad 51 on TV’s “Emergency” show is always true to life, it’s a fact that fire department emergency medical services are setting impressive records. In Seattle, 804 lives were saved in seven years of paramedic operation. More than half of them were long-term survivors.
However, questions are being raised about the ability of some urban tax bases to support these services.
Citing the high cost of communications and hospital equipment, the city manager of Scottsdale, Ariz., asked last November, “Who really gets the benefit of all this? Primarily heart attack victims, most of whom are elderly and who end up dying a month or a year later.”
Fire officials say that the reason Scottsdale residents pay about half the area’s average per capita cost for fire protection is that the community employs no paramedics.
Financial, political pitfalls
In writing legislation, planning for manpower and equipment needs, and tailoring programs to the community, it is helpful to be aware of the problems, as well as the benefits, of EMS programs. These problems are not only financial, but also political. The experience of Milwaukee County, Wis., shows that success requires much more than simply putting paramedics on the street.
This 239-square-mile region, divided into five civil defense or emergency preparedness zones, contains over a million persons in 19 municipalities. These range from semi-rural villages of under 1700 residents to the City of Milwaukee. Logical EMS response areas often cut across political boundaries. Emergency hospital locations don’t always fit the geographical population pattern.
Nevertheless, after five years of debate, the county government in April 1977 adopted a plan for county wide paramedic service to all five zones. There were to be 10 units: five in Milwaukee, one each for neighboring Zone C (which had begun using its own paramedic crews three years earlier), and one each serving Zones B, D, and E.
Personnel costs split
The county would pay all direct paramedic salaries, furnish the $600,000 hospital radio link, and maintain the vehicles. Each municipality choosing to join the program was to supply the vehicle and pay the men’s fringe benefits. In Milwaukee, fringe benefits total about 43 percent of the base pay. The total 1978 cost was estimated at $1 million to $1.2 million and the county’s share was about 75 percent. The fiveyear total cost estimate was $8.4 million.
At the time this plan was approved, all the suburbs except those in Zone C were using only their own fire department ambulances or rescue squads, mostly with state-certified EMT-1s. In Milwaukee, the city’s seven (now eight) fire department two-man lifesaving squads, also EMT-staffed, were used mostly to stabilize victims of heart attack, stroke, drowning, etc., pending removal to a hospital by police ambulance.
Police patrol officers handled all such emergency transport with a fleet of 22 panel-truck ambulances. Occasionally, in life-threatening situations or at fire scenes, the fire department squad would transport. Patients were generally taken to the hospital of their choice. Police officers were trained in first aid, but nothing more. For 1977, the police department reported about 50,000 ambulance calls.
Two problems faced
As that year drew to a close, Milwaukee faced two EMS problems. The first was whether to participate in the countywide paramedic program and if so, on what terms. Some city officials, including the mayor, felt that Milwaukee residents would have to pay far more tax money into the system than the benefits would justify.
Admittedly, each resident would help support the program through county taxes whether the city joined or not. So over t he mayor’s veto, the city council on July 26, 2977, accepted a five-year county contract. Negotiations were handled by Fire Chief William Stamm, the city health commissioner and the city attorney.
Fire fighter EMTs began paramedic training within two weeks. The course was expedited by rotating experienced Zone C paramedics in to assist hospital personnel. On November 7, 1977, the first Milwaukee paramedic unit went in service as MED-3 (Medical Emergency Department). Existing Zone C units were titled MED-1 and MED-2.
Location dispute
The location of MED-3 turned out to be anot her political issue. The first site chosen, downtown fire headquarters, was abandoned because inner city councilmen reportedly saw it as serving primarily an out-of-city shopper/office worker population, present only during the day. The location finally selected overcame that objection, besides being closer to the paramedic base, County General Hospital in Zone C. The location also favored neither the north nor south sides of the city—factions not always in accord.
When a second unit, MED-4 was ready last February 27, it took the same quarters, and MED-3 shifted to the south side. The third unit, due in June, will be on the north side.
Lengthy negotiations dealt with the serving of certain city corridors, or fringe areas, best served by the existing Zone C crews. Both West Allis and Wauwatosa were unhappy about increases in their response areas and tax bills even though the county agreed to reimburse both cities for some of their 1977 and 1978 costs.
In West Allis, county payments to support operation of the 11 paramedics in that city (making three to four runs daily) were expected to total $200,000 in 1979 and in 1980. But in the latter year, with a higher countywide program budget, West Allis taxpayers would be contributing $250,000 annually to the program—a net loss for the community. Although West Allis has now OK’d a tentative contract with the county, negotiations are continuing.
Positions added
For 1978, Milwaukee’s mayor added 58 fire fighter positions to his budget to fill vacancies created by the eventual assignment of that many men to paramedic crews. Milwaukee paramedics are not expected to remain in fire fighting, although in West Allis that was originally planned.
What is the ultimate cost to the taxpayer? The average Milwaukee homeowner will probably pay $8 to $10 annually for paramedic service. Vehicle cost is about $43,000, including $14,000 in equipment. Some federal grant help is expected, at least for two of the units serving low-income areas. The average paramedic salary is $16,300 plus $6300 in fringes.
The benefit? Contrary to the opinion expressed in Scottsdale, there’s much more to this than dealing with elderly cardiac patients. Zone C paramedics have handled at least 150 cases of diabetic insulin shock—a potentially fatal condition afflicting those of all ages. Countywide, local emergency medical specialists believe 144 lives can be saved yearly by the paramedic program.
In addition, paramedics are seen as playing a major community educational role. Last summer, four major medical groups announced plans for a CPR training program to reach 350,000 citizens. Several community organizations have already started work. Paramedics can train instructors and provide speakers for this program.
Communities disagree
Although Milwaukee’s problems in getting started with paramedics seem to be solved, the situation is not so clear in the smaller suburbs—particularly in the southern tier Zone D. All four communities in Zone D would have to join the county program to make it work for the entire zone. Two agreed to do so; the other two did not.
Each faced annual costs of $23,000 to $33,000 on tight budgets. One of these fire departments is presently all-volunteer. Others use many volunteers or call men. The lone paramedic crew for the zone would have to be full-time. So new manpower would be required, with full fringe benefits, which could exceed the entire present fire department salary budget. Administration could be cumbersome as it would be jointly handled by all four fire chiefs.
Furthermore, the single unit’s total response area would be nearly 60 square miles without any hospital facilities at all. Local ambulance or squad response would still be needed as the first-in unit.
According to the mayor of Franklin, “One unit is not enough . . . and two is too many.”
Alternative sought
The two Zone D communities that did wish to join the program have begun studying ways to go it alone, perhaps by linking up with the City of Milwaukee. Otherwise, despite the county tax burden on their residents, Zone D will remain outside.
In Zone E, the reaction was similar.
Said the mayor of St. Francis, “If we go with the zone setup, it’s just not feasible. We’re too spread out.”
Echoed the mayor of nearby Oak Creek, “It’s not possible, given the population structure.”
His community has 15,500 residents in 28 1/2 square miles.
The seven somewhat more compact North Shore suburbs nf Zone A were able to take a more optimistic view. After some months of discussion, they agreed on locating one paramedic unit in Glendale. Four communities had signed the county contract by April 7. This crew could be trained and in service by the end of this year.
The second EMS problem the City of Milwaukee faced at the same time was the shifting of all emergency ambulance service from the police to the fire department. State law required that by 1978 only certified EMTs or paramedics could operate such ambulances. Police officers had no such training. Furthermore, no police ambulances were built or equipped to current standards. The city could not afford a new fleet, whereas money was available for the fire department’s small number of units.
So it was decided that as of last January 1, all ambulance calls would be routed to fire department dispatchers. Three extra men were hired for the alarm office to carry this extra load.
Photos by Tom Novara.
For nonemergency transportation, a private ambulance would be called, for which a patient fee of $75 was to be charged. Originally, the city council had planned a $75 fee for transportation by fire squad, too, but citizen protests killed that before it got past the talking stage.
Unfortunately, the city’s ambulance certification ordinance contained some aggravating loopholes. The fee was not fixed by law. It turned out that the $75 was only a base rate, with extras to cover costs of night service, oxygen, medications, and trips of unusual length. It was logical that private operators, enjoying no tax subsidy, had to recover their expenses. But the public was outraged by such charges after the “free” service by tax-supported police ambulances.
Also, private operators could drop out of the program without notice, and several threatened to do so if the city council tried to cut their fees. Councilmen in turn threatened to withdraw ambulance certification for companies not cooperating in fee structure adjustment only to find that the law had inadvertently omitted a certification procedure.
Four firms approved
The legal complications were quickly resolved. Four Firms were soon certified after vehicle inspection and approval by the fire department. Compromise fees eliminated some added charges.
But public discontent remained high. One firm proved unable to sustain a quick enough response time and had to be dropped. Vehicle shortages sometimes resulted in fire squads being tied up as much as an hour waiting for an ambulance.
Service has since improved markedly. For one thing, the private firms have worked out service areas to better plan their coverages. Ambulances now monitor the fire radio and roll on rescue calls as soon as they are broadcast. The ambulance then stops about a block from the scene to wait until the fire department unit requests their help. Stamm has agreed that this shortens response times and helps get fire units back in service quicker.
Under a new municipal ordinance, private ambulances must take emergency cases to the nearest full-service emergency hospital. The loss of patient choice remains a further cause for public dissatisfaction.
Dispatcher uses judgment
If the dispatcher judges from the call that the patient needs stabilization or resuscitation before being moved, a complete EMT/paramedic fire department response is usually made. As many as four vehicles will be sent:
- The nearest of the city’s 36 engine companies. Its crew, generally CPRtrained at least, can often start treatment before other units arrive.
- The nearest lifesaving squad.
- The closest paramedic unit.
- A private ambulance.
When to send which of these units is obviously a decision for highly trained dispatchers. Often the entire respons isn’t needed. The first-in crew then radios to call off one or more of the other units.
Nevertheless, there has been a big increase in the number of rescue runs for both squads and engines. The total for such responses in January 1977 was 764. In January 1978 it was 2055. Milwaukee’s city health commissioner estimated that 96 percent of all ambulance conveyances would be made by private firms. Figures from early 1978 show about a 90 percent ratio with 6 percent transports by lifesaving squad and percent by the one MED unit then operating, which answered 204 calls and made 50 transports in January.
Petition for old service
After six months of operation, the total EMS load on the Milwaukee Fire Department is being handled smoothly from a medical standpoint. However, south side residents have launched petition drive to restore the old ambulance setup. Some 20,000 signatures persuaded the council to start another study of the problem, including a look at fee subsidies for medicaid patients, but this could be so costly that the drive seems unlikely to succeed.
Milwaukee’s police chief has complained that the new service can hinder law enforcement. In what appears to have been an isolated case, it was discovered hours after an injured man was taken to a hospital by private ambulance that he was a beating victim. Police were then notified, but the trail was cold. Generally, the few injuries resulting from foul play are quickly recognized by ambulance crews or fire fighters, and police are called at once.
In retrospect, it appears that local officials outside the fire department did not do all their homework. Paramedics do save lives. In principle, the fire department is ideally situated to furnish all community EMS, but Milwaukee County’s experience shows that what works in one community may not work in another.
Long and careful interagency planning may have to precede successful change in this vital community service, especially in a time of growing taxpayer dissatisfaction with local government.