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Critical Care For Ambulances?

The Anderson Valley Ambulance Service is a local, non-profit service staffed by volunteer EMTs, providing medical transport to Valley residents for the past 50 years or so. Initially, transport was by a Pontiac station wagon, organized to take injured millworkers over the hill to Ukiah. Now, the modern ambulance and Basic Life Support (BLS) service is supported by subscription, donations, fund-raisers, and billed patient insurance, and run by local people. Generally it is well regarded and does a very good job in a difficult service area extending over 250 square miles of hilly back-country.

Last week rumors of change, potential take-over by anonymous powers in Ukiah, or even worse, by the mysterious Local Area Emergency Management Agency (LEMSA) out of Sonoma County, spread throughout the County’s medical service community.

Anderson Valley’s first responders plus a vocal group of concerned residents filled the Senior Center last Monday night to hear consultant Rick Keller and county administrative analyst David Grim explain just why the County wants to set up an exclusive operating area for local ambulances.

In 2011, Keller’s emergency services consulting firm, Fitch & Associates, completed a comprehensive and quite critical assessment of Mendocino County’s pre-hospital emergency services. The report recommended some 42 changes in all phases of pre-hospital emergency care, only one of which is medical transport.

Now, however, financial pressures threaten ambulance service in Fort Bragg, and Laytonville, and the entrance on the scene of corporate outsider VeriHealth competes for the patient transport dollar and threatens the viability of existing Ukiah Valley services. A change in ambulance operation has been bumped to the top of the list “to address the needed improvements.” The county executive office contracted again with Fitch for a feasibility study of exclusive operating areas for Mendocino’s twelve different ground and air ambulances, the thought being that with limited patients there is only so much money, and a stable ambulance service has to have some idea of probable revenue in order to plan its operations and remain in business.

At Monday’s meeting Keller and Grim faced an initially suspicious “hands off our ambulance” home team by stressing that no decisions on ambulance service have been made; they are conducting a feasibility study which will include financial and service implications; their analysis and recommendations will be public; and will go to the Board of Supervisors in mid- May. Fifth District Supervisor Dan Hamburg emphasized that there must be enough time for adequate public discussion between the report and any Board action.

Keller pointed out that their assignment was to report on feasibility of an exclusive operating area. If they find it possible, and that it will result in improved service countywide, they will recommend approval. If asked, they will help prepare a request for a proposal for the change. If they feel the exclusive operating area will not work, they will prepare “Option II” to assess other long-term strategies to improve the existing system.

Ambulance volunteer David Severn asked, “Is there a need for improvement?” The quick answer from both Grim and Keller was “Yes!” Calling the present system “critical, unsustainable, fragile,” both emphasized that all avenues for improvement would have to work county-wide. County Fair Board member Morgan Baynham called for an EIR prior to dismantling Anderson Valley’s Ambulance Service. AVAS manager Art Hatcher wanted to know who would design a request for a proposal for whichever options are chosen. Supervisor Hamburg said the Supes were responsible and would either have the proposal designed in-house, by the consultant, or delegate it to the Local Emergency Management Service Agency (the Sonoma County entity which from which the County buys emergency management service direction to the tune of $99,000 per year, a contract inexplicably extended just last month by the Supes for three more years, before doing this “ambulance feasibility study”.)

The geography and demography of Mendocino make a one-size-fits-all solution unlikely. An exclusive operating area could be arranged for existing individual ambulance companies; for all basic life support companies; or for just advanced life support companies; or even for the whole county except Anderson Valley.

Ambulance EMT Martha Hyde wanted to know if the Supes could actually make a decision which would end Anderson Valley Ambulance Service in its present form. The short answer from Fire Chief and ambulance volunteer Colin Wilson was “Yes.” “There is a bigger picture,” Wilson said. “While ambulance service works in Anderson Valley, it is a disaster in the north part of Mendocino and on the Coast, and Ukiah Ambulance is just sustaining, but not profitable. And even in Anderson Valley, it could be better. We could have a paramedic here all the time.”

Anderson Valley’s Basic Life Support (BLS) ambulance EMTs generally have around 150 hours training and do life-saving advanced first aid. Advanced Life Support (ALS) ambulances, described by the consultant as the gold standard of care, are staffed by paramedics who have around 1800 hours of training and can perform advanced techniques and administer advanced airway management, intravenous therapy, and specified drugs.

AVAS board member Phillip Thomas noted “ALS is not the gold standard if there is delayed response” (such as waiting for an additional hour for ALS transport from Ukiah). He added that the Board of Supervisors needs to consider that fiscal soundness for a service derives from community support, not run fees, and AVAS is community based with 500 family subscribers.

Although AVAS has paramedics on their roster, they are not allowed to practice to the full extent of their skills because the service cannot provide paramedic staffing 24-7 on all runs. This arbitrary standard is imposed by the LEMSA and has been galling AVAS medics for decades.

In closing, EMT Martha Hyde asked David Grim what is the best vehicle for responders to present their views to the Supes as they make their decision. Grim assured the group that all comments would be relayed as a part of the study. Hyde persisted “What specific augmentation does Anderson Valley need to present?”

Grimm’s summary take-away was, “There is a high incentive in the community [to provide good ambulance care], you are doing a good job and want to continue, you do not want to be controlled by an anonymous outside agency.”

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