EMS readiness: Seconds count when lives are on the line

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BASTROP, Texas (KXAN) – When you call for an ambulance, you expect prompt, professional service. A four-month KXAN investigation looked into how a Central Texas emergency medical services provider runs its business in a sprawling county where every minute counts when lives are on the line.

KXAN discovered a company dealing with challenges in service, equipment and resources.

After Neil and Mahala Hethorn called for an ambulance last March 5, the response was far from what they expected when a Guardian EMS paramedic arrived.

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“I’m doubled over, screaming, crying — and he wouldn’t do anything to help me and it was horrible,” Mahala Hethorn told KXAN.

Mahala had woken up in agony with a tear in an ulcer that would take emergency surgery to repair.

“(The paramedic) wouldn’t touch her,” Neil Hethorn said. “He cared more for those black gloves we was wearing and arranging them on his hand, than getting her to the gurney. That’s their job to put the patient on the gurney.”

Once Mahala was on the gurney, Neil Hethorn wrote in his complaint the paramedics bumped it down each step of the front stairs, prompting screams of pain from his wife. Theirs is one of dozens of complaints made to Bastrop County about Guardian EMS uncovered by KXAN.

The company’s written response to the Hethorn’s complaint came from Guardian’s then Operations Manager Mike Taylor. He said “corrective action” had been taken with the ambulance crew who came to their home and he would “contact Neil Hethorn directly.”

“That’s news to me,” Hethorn told KXAN after we showed him a copy of the email this summer.

In another 2009 complaint obtained through open records requests, an elderly woman wrote she was unable to spend a final hour with her dying husband because the Guardian paramedics had driven him to another Austin-area hospital than the one she requested.

And still another complaint from a Bastrop County Sheriff’s deputy at a vehicle crash scene, referred to a dirty, blood-stained backboard on a Guardian ambulance.

State inspections

In late October, a Guardian ambulance failed a spot inspection from the Department of State Health Services.

At the time, the inspector determined some medicines were not at required amounts, and the ambulance’s windshield was cracked in multiple places.

Guardian bosses later wrote to the State to complain and told KXAN the paramedics had mistakenly given an internal, pre-shift check-off sheet to the inspector, not the required one.

But that wasn’t the first time. Two other failed state inspections in January 2013 show the inspector found an ambulance’s rear tail light was broken and the air conditioning didn’t work.

And in both of the January inspections, again Bastrop ambulances were missing the required amount of medicines onboard. Other medicine vials were found to be expired and not on national medicine shortage lists. Being on such a list would allow their use under certain conditions. Guardian submitted letters from medical directors who testified as long as an expired medicine in the vial appeared clear it could be used.

On the day KXAN visited in November, Guardian EMS had recently received shipments of injectable medicines like atropine sulfate. Atropine dilates the pupils, increases heart rate, and reduces salivation and other secretions.

Also in the company’s stockroom, a new computer inventory program ensures there are enough medicines on shelves to make it to ambulances. Paramedics have to sign out each item and scan a tracking barcode. As well, the online system can be used to track and order equipment like new tires and other mechanical parts for ambulances.

But the problems don’t end there.

Dispatch difficulties

Dawn Adams manages the Bastrop county emergency communications center where 911 calls come in. EMS calls are then redirected to Guardian.

“It’s the expectation of the public that when they call 911 they should get instructions on what do to until help arrives,” said Adams.

Adams said her staff have to stay on the phone because Guardian’s dispatchers often don’t, telling KXAN she considers them a weak leak. And finding call locations has been an issue, too.

One county email KXAN discovered from January alleges: “Guardian screwed up a stroke call royally tonight… They used their GPS instead of map book again and took the very extended route… they are still lost.”

“One of the reasons we stay on the line is because we can plot the address with some very sophisticated 911 call maps,” Adams said. “Guardian doesn’t have any of those tools.”

Guardian’s Operations chief, Ross Bradley strongly refuted the dispatch difficulty, adding his dispatchers are nationally certified.

“(Those allegations) make it sound like its an occurrence that happens all the time. It does not happen every time.” he told KXAN. “Those are isolated incidents… and in those isolated instances, we have addressed that.”

Professionalism

Adams’ concerns extend to the professionalism of some Guardian staff. KXAN obtained audio copies of numerous 911 calls Adams complained of and sent to county officials to show they were substandard. Among them:  a call on Jan. 20 she described as “a fiasco” in an email to county managers.

Just before 4 p.m. that day, a mother with a sick 5-year-old called Guardian’s Ambulance Operations Center (AOC) for help. Here’s the transcript (and note the audio clip available with this story as related content has been condensed into one audio file to show continuity and reduce gaps in time.)
Jan 20th, 2013, 3:55 p.m.

AOC:  EMS, what’s the address of  your emergency?

Caller:  Yes ma’am. I’m here at the Valero in Elgin and I’m wondering if I can get an ambulance to take my son to Dell Children’s Hospital. He’s feelingreally weak, throwing up, having fever and he’s not doing good.

As the anxious mother waited, the paramedic in the field radioed Guardian’s Ambulance Operations Center or AOC, to say that call was outside the company’s coverage area.

4:02 p.m. 

Truck Number 8104:  8104 to AOC:

AOC:  8104 Go ahead.

8104:   Yes sir, that Valero with the KFC is going to be within Travis County. It’s about half a mile into their territory. If you’ll send it to them and have them respond. And remind them although it is Elgin City, it is Travis County. Please.

Then another voice countered that, starting a time-wasting back and forth.

Truck Number 2133:  8104, it’s inside city limits of Elgin it’s under y’all’s jurisdiction.

8104:  That’s a negative, sir. We’ve been out there and figured out the county line is about half a mile east of that location. That whole intersection and everything west of it is Travis County.

8104:  Hey, AOC we clear on all that?

AOC:  Yes. I’m trying to call Travis County now.

After Guardian’s Ross Bradley listened to a recording of the call with KXAN, he said he was unfamiliar with the incident. But he said the exchange did not reflect company policy.

“In the past, we have suspended and terminated employees for not wanting to complete the call. We do not stop until we know another provider is on scene,” he said.

A second issue for Bastrop’s Sheriff’s Office was how the Guardian dispatcher reacted to the suggestion from the Sheriff’s Office call taker he finally transfer the call to Austin-Travis County EMS. It was suggested in an email the Guardian dispatcher was not following emergency responder broadcast protocols where language is normally reduced to ’10’ codes and short, clear sentences. Here is the rest of the transcript:

4:03 p.m.

AOC: Bastrop SO go ahead.

Bastrop Sheriff’s Office: I’ve got that caller at the KFC on the phone, I can just transfer her to Travis County if that’s what you want me to do.

AOC: Outstanding! That’s what I’m talking about. Thank you, sir.

But six minutes later, 14 minutes after the original call –  Guardian got the call transferred back to them.

4:09 p.m.

AOC: AOC to 8120, I need you back en route. That call’s been transferred back to us. Caller stating she sees a sign Elgin High School address appears to be 18261 (U.S.) Highway 290. Need you back en route.

All this – while the anxious and frustrated mother waited, unsure who would arrive and when.

8120:  AOC, 8120 en route, advise the caller we got about a four-minute ETA (estimated time of arrival).

KXAN asked Bradley whether that dispatcher still works with Guardian EMS.  He responded that he didn’t think so.

Response times

KXAN looked into Guardian’s response times – a key part of the performance requirements in the contract with Bastrop County.

In urban areas such as Elgin, Bastrop, and Smithville, Guardian’s contract with the county requires an ambulance must make it to an emergency, life threatening call within 9 minutes 59 seconds after being dispatched – 90 percent of the time.

In outlying areas within the county, the goal is 19 minutes 59 seconds, per the contract. The contract allows for exceptions such as: a road blocked by a train; severe weather conditions like dense fog; or where the dispatch center receives erroneous information.

Countywide, records supplied to the County by Guardian EMS show the company is in compliance with the contract. In 2013 for example, monthly compliance rates through August ranged between 92 percent and 96 percent. However, those reports offer minimal detail about the few calls that didn’t make response times, and why the response goal was missed.

The contract also allows the county to fine Guardian $200 for each missed response time in any month where the 90% success rate is not achieved. County staff said no fines have been levied.

However, this year alone, KXAN found dozens of emergency response times in Bastrop’s urban areas as long as 33 minutes and as long as 54 minutes for non life threatening calls. In unincorporated areas, missed emergency response times were as long as 45 minutes and 59 minutes for non life threatening calls, records show.

Calls for outside aid

KXAN also discovered dozens of times where Guardian requested back up from other EMS agencies in neighboring counties.

Records show this year through September, Guardian called Travis and Caldwell counties for help 35 times. And in 2012, aid calls went out 69 times, 44 of those were made to Caldwell County to the south.

It became such a problem earlier this year, Glen Germer the EMS director at Lockhart/Caldwell EMS (Seton) sent a letter to Bastrop leaders. The copy KXAN obtained (and included in related content in the box above), reads in part:

“I am concerned the people of Bastrop County are at risk as the response time from Caldwell County may be around the 30 minute mark. Citizens expect and deserve a better response time.”

Bastrop County records do show call volumes and workload have jumped 20 percent in the past two years. Since then, Ross Bradley says Guardian has added another ambulance to the weekly rotation. Bradley pointed out the contract requires Guardian to provide 712 hours of ambulance service per week.

That’s divided among four to five crews. Bradley said he’s currently offering more than 800 hours to keep up with calls and to prevent paramedics having to work unwanted extra shifts.

Some of the pressure on Guardian crews has come from transports outside the county to full-service hospitals. It can take hours before a Bastrop ambulance crew can return to the county. Guardian is also permitted in its contract to perform non-emergency patient transports if other ambulances are available to rotate into a call area.

KXAN went to Bastrop County’s emergency operations chief, Mike Fisher, who said he couldn’t do much about the complaints other than direct them to Guardian EMS. Fisher conceded it’s better than having no ambulance service in Bastrop as more people move into local communities such as Cedar Creek.

The future

Guardian EMS is a 13-year old private company headquartered in Columbus, TX. Its website indicates it, or subsidiary companies have other EMS and patient transport services in more than two dozen other Texas counties or cities – including Travis and Williamson Counties in Central Texas.

In October, KXAN asked Bastrop’s Mike Fisher whether county taxpayers are getting the best level of service from Guardian EMS.

“That’s a difficult question. Are they a perfect service? The answer’s no — no question about that,” Fisher said. “Are they (taxpayers) getting quality service?” asked KXAN. “More often than not, of a high degree, yes they are.”

Each year, the county pays Guardian EMS $382,999.80 for the service. The original five-year contract (see related content in the box above) was signed in 2008 and includes three automatic, additional two-year extensions – the first of which kicked in in April of this year.  Unless the 2008 contract is reopened, that would leave Guardian EMS serving Bastrop County into 2019. County managers like Mike Fisher have already been planning ahead.

With complaints and rumors mounting at the end of 2012, Bastrop County leaders formed an EMS committee to research the county’s current and future needs. The committee was made up of the county judge, county commissioners, other county representatives, and representatives from area hospitals. It decided to hire a consultant, at cost to taxpayers of $14,000, to take an independent look into the issue.

In November, KXAN obtained an interim summary into the consultant’s report expected out before the end of the year. It mentions shortening response times which are called ‘adequate’ and references those monthly reports Guardian managers provide:

‘The current agreement for EMS services calls for periodic reporting of response times, number and location of calls, and other data to the County. These reports are largely self-generated by the provider (Guardian EMS) and must, for the most part, be taken at face value in the lack of a clear-cut method for validation.’ – Interim Summary Report into Bastrop County EMS Service

The interim summary also calls for a formal EMS Request for Proposals to be drafted for County Commissioners’ consideration that would put the county’s EMS contract up for bid from any EMS provider. In the current county contract with Guardian EMS, each party reserves the right to get out of the agreement with 120-days’ notice.

Guardian EMS COO Ross Bradley said he welcomes the report and any criticism. On the days in November KXAN visited, the Bastrop operation appeared to be in the midst of a re-organization or as Bradley called it, system improvements.

Even a couple paramedics on duty there on the day KXAN visited, admitted the operation is better now than it has been in terms of morale and efficiencies.

Some Guardian EMS paramedics and emergency medical technicians KXAN spoke to off camera indicated they live in the county, love their profession and simply want what’s best for their own families and neighbors. They said they hope Guardian EMS continues to staff, stock and maintain its operation appropriately and meet the company’s motto “Responding At the Speed of Life.”

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