We take ambulance service for granted in our area, but do we really know how it works? You may wonder what to expect when you call 911, how they decide if you need an ambulance and, if you do, how quickly they’ll be there and where they’ll take you.
On the evening of November 18, SEARCH hosted an Ambulance Services Forum on Zoom. Members of the public and government officials were invited to attend and submit questions. Heads of the service in each county - Clay Carroll in Yancey County and Bryant Reid in Mitchell County - gave an overview of services and addressed the submitted inquiries. Bruce Ikard, a well-known announcer on WKYK/WTOE radio, moderated the program. Conrad Leavitt provided the the recording site and support at Trillivision Studio in Burnsville.
Watch the video recording of the Ambulance Services Forum here:
SEARCH created a condensed transcript of the forum below:
Clay Carroll’s Summary of Heritage EMS:
24 hour, 7 day a week service. We have 4 EMS units, 3 staffed per day. 28 staff, 27 of which are paramedics. Around 4200 calls a year, about 2500-3000 of those are transports. About 60% to BRRH, 30% to Mission, the rest are VA, Johnson City, etc.
Bryant Reid’s Summary of Mitchell Medics:
One 12 hour truck that runs from 7am to 7pm and two 24 hour trucks. They all operate 7 days a week. About 2800 calls total for 2021. Approximately 65% of those calls are transports. 36 employees, 28 of which are paramedics, 2-3 are advanced EMTs. We take about 96 patients to BRRH per month, about 17 to Mission, and few to other locations like Johnson City.
Is staffing for your services in this area an issue, vs. a place like Charlotte?
CC: I don’t think so. Heritage is blessed with the longevity of its employees. And we have excellent colleges in the area like Mayland and A-B Tech that we recruit from. People are attracted to the services we provide.
BR: I feel an honor to work beside Clay. But so far, since I’ve moved here, the beautiful location and proximity to locations like Boone and Asheville seem to have helped with recruitment. We are actually recruiting top-notch people in an era when many have struggles with staffing. We’ve brought in over 100 years of combined experience. I think it’s due to what this area has to offer and what Mitchell Medics has the potential to be as a model rural EMS system.
How do you decide if you’re going to transport somebody by air or by ground?
CC: We have protocols and all of our people are trained to follow certain criteria to make that decision. For instance, if it’s a cardiac patient, we know how to interpret the EKG reading and base it on that. Our paramedics are really proficient in reading the information and telling which part of the heart is having an infarction. So they transmit that and make the call whether a heart patient will skip the ED and go straight to the cath lab.
Can a patient choose which hospital they go to?
BR: Ultimately, in some cases they can, within our system. A lot depends on the medical insurance each patient has and this will dictate what’s approved. Sometimes choosing a different hospital from the “closest appropriate facility” will result in insurance not covering the whole bill. It’s our part to inform the patient when a location might not be covered. We advocate for what’s best for the patient and follow protocols to address their medical needs and the severity of the needs. We ask, “What is the fastest way to get them safely to care?”
CC: It depends on whether the patient is stable or unstable. It’s different for Heritage because we don’t have a hospital. If stable, we will transport you where you want to go. If unstable, we have to consider what is safest for your condition.
How is working with RTS (who was invited to the forum) going?
CC: I used to be part of Mission. Great organization. If you’re a citizen of Yancey County and you’re at BRRH, we’ll transport you on to Asheville even though a lot of times that responsibility is for RTS. So we do work with them. We are obligated to cover our citizens.
BR: There is no contractual agreement set up between us and RTS. The hospital will communicate with them or us to dispatch appropriately to get the right transport unit available. Our primary duty and responsibility is to the citizens out in the community that do not have health care. I can’t send every one of my trucks an hour or two out of county and not have anyone left to cover the county if it’s not truly emergent.
Do your two services transport people for each other or do anything back and forth?
CC: We do.
BR: There are mutual aid agreements. In my short experience here Clay and his group have been great to work with. It’s a great team effort. Rural EMS is so much different from a lot of other EMS services because of its unique challenges. It’s a great working relationship.
CC: To give you a little history on that, when we have a mass casualty event we might have trucks from 2 or 3 other counties because we’re limited in resources. You can’t plan every staffing need in every event. Mutual aid happens throughout NC EMS services.
What does ambulance transport cost?
BR: A lot of the charges are based on the Center for Medicare and Medicaid Services. Medicare has their minimum cost charges. There’s also a mileage component, and charges based on what level of care the EMS service provides. A basic life support Medicare transport rate would be in the low to mid hundreds. Medicare rates go up as a patient requires more advanced life support from EMS such as IV or cardiac monitor 12 lead. Then Medicare rates go up a couple more hundred, and private insurance rates go up from there.
CC: He’s right. The Medicaid and Medicare rates have been established over the years, set by our county government.
BR: We can’t go in and add anything to the pre-set rates.
What do you do when you pick up somebody that has no form of insurance at all?
CC: In our system we have the responsibility to respond. The patient can do a write-in to the billing company when they get the bill. That’s handled by a third party, so we’re not personally involved in that.
BR: We’re the same way. We have a legal obligation to respond when someone calls 911 and needs an ambulance. We don’t ask you for insurance information on the scene. That’s secondary. We’re worried about the patient care you need right now. If billing issues come up on the back end we encourage you to contact billing and work with them. We can do flexible payment plans and we’ll work with the people.
How do you work with dispatchers?
CC: It’s one of our county departments. Dispatchers are trained and certified through the state of NC. They have to coordinate the calls that come through their center. They stay on the line with the patient until we arrive and sometimes give instructions.
BR: Stephanie Wiseman is our 911 Director and it’s a stand-alone agency. Dispatch and EMS are different, but Stephanie and her organization have been great to work with.
How much are rescue squads involved in this day and time in our area?
CC: We have a very active rescue squad here in Yancey County. They are all volunteers. The number one function is rescue, for example, at a motor vehicle accident if someone needs to be extracted, a river rescue, flooding events, or searches of individuals lost in mountain areas. They are certified by the state and trained at an intermediate or advanced level so that they can back us up in mass casualty situations. In certain situations they can get to a scene faster than we can because they are in more dispersed locations throughout the county.
BR: Rescue is primarily trained for rescue, like dispatch is trained for dispatch, fire is trained for fire, etc. The EMS system is all of these components put together.
What are your response times?
BR: It’s a unique challenge with rural EMS. Our average response time for emergency dispatches is 30 minutes, but it can be longer for our northernmost districts. That’s where mutual aid can come in to reduce times.
What is the protocol for responding to drug overdoses?
BR: It doesn't matter what we’re called out for. We’re going to treat every patient the best we can.
CC: It’s a medical call. Another part of our EMS system that I’ll brag about is our sheriff’s department. We’re grateful they and the fire departments help with calls. We trained our personnel to be able to handle some of the medication for overdoses.
Are overdoses automatically transported to a hospital? Is there any follow-up post-overdose?
BR: If the patient has the capacity to make decisions then we don’t automatically take them to a hospital unless they request it.
CC: Yancey County just hired a community paramedicine person to start in January to follow up with overdose patients.
What is the protocol for mass casualty situations?
BR: It’s the nature of the beast that we’re in - Emergency Medical Services. We’ve got our own work family inside our agencies and our systems that we work with. If there’s a need, people come rushing to it. We have a national standard called ICS - the Incident Command System approach. The first qualified person on the scene will take command and call the shots in order to prevent chaos. That person will take lead and start triaging patients, coordinate with the communications group, and get the right resources there. If the situation is big enough there may be multiple leaders who make a unified plan. There are training and classes for this, although it is rarely used. We can call in off-duty personnel and neighboring counties may come in to help.
CC: My people work 24-hour shifts, but paramedics will show up to a situation even if they’re not working that day because they know it’s bad and will assist.
Can someone call you and ask you to meet them somewhere if they live in a particularly remote location, in order to save time?
CC: It happens, but it’s important to know the patient can be taken care of at a basic level wherever they are. The dispatcher will let the EMS crew know that the patient has moved and will meet them at a set location. Sometimes an ambulance takes five minutes to arrive but it feels like thirty because of the mindset in some emergencies. It’s important for communication to be coordinated with the dispatcher.
BR: Certain patients should not be moved. Sometimes it’s not safe for a patient to drive or even be driven in a car.
If a patient is unable to speak due to a stroke or other condition, but is able to dial 911, would the dispatcher know where the patient is and would an EMS unit be dispatched to their location?
CC: We cover Mt. Mitchell and portions of the Blue Ridge Parkway and we have been able to locate people in these remote locations after they have pinged us.
Are EMS services set up in a sustainable way in this area?
BR: Mitchell Medics has no issues that I foresee with maintaining what we’ve got. I see us growing,progressing, and expanding our service.
CC: It is very much sustainable and that is one one my goals as I get to the age of retirement. My heart is in it and I’m proud of our staff and what we’ve invested in it. But I wouldn't retire until the organization is guaranteed to keep running in a sustainable way. I’ve got both older, experienced people and new, bright, young people with drive. It’s a mixture and if your heart’s there, it’s sustainable.
Are the county commissioners going to give you enough money over the next 5-7 years to sustain this?
CC: When we explained what we were doing and how we were doing, the county government bought in 110%. I’ve got a really good county manager that is listening and understanding and is getting the process down.
BR: A problem over the years is that EMS hasn’t communicated with the counties and representatives to let them know what we do, having events like this to educate people. From my experience Mitchell County asks on a regular basis what we need.
CC: All affiliations, religious or political, go out the window when you’re a patient. You get the same care.
Summary from Stephanie Wiseman:
In the 911 center we take calls and send help based on a series of questions. We have a set of protocols and we review those with our EMS partners and make sure that we have the right responses for them to go. The dispatchers are certified nationally and in the state. We do lots of training. We’re in the process of developing some out-of-the-box training with Bryant, and maybe giving each side of the house a view of what goes on. I’m looking forward to that.
We get all kinds of calls and sometimes we get information and we dispatch it and when the EMS guys get there they find out it’s something completely different. Sometimes a patient doesn’t really want to tell us what’s going on. They might not really open up until they see the doctor. We give instructions - we’re able to give CPR instructions and help deliver babies over the phone. We can help if someone is choking or with bleeding control. A lot of these things were not happening in dispatch years ago.