REGIONAL— North Country residents expect that when an accident happens or an illness strikes, they can rely on emergency services, like a local ambulance, to provide life-saving assistance.

But making sure there’s someone trained and available to respond when that 911 call goes out, has become a bigger challenge for many communities, according to emergency medical officials interviewed by the Timberjay.

“Volunteerism is dead,” is how one local ambulance director sized up the situation. With young people and parents increasingly forced to work longer hours to makes ends meet, and with a greater focus on family life, fewer potential recruits are available to staff volunteer emergency services, like fire and ambulance. And that puts more pressure on those who do respond when the call goes out.

For some services, switching from a traditional volunteer system to paid staffing is one solution to the problem, and most area services are proceeding with caution as they design new approaches to fit their needs. The Cook, Ely, and Hoyt Lakes ambulance services have all expanded their paid staffing in the past year in various ways, typically through adopting on-call systems that provide more compensation for their local volunteers, in order to improve response time for emergencies. Some are looking at upgrading their services to advanced life support, which requires the use of paramedics. That switch can improve patient care and provide higher levels of reimbursement for the services that make the switch.

The city of Tower’s ambulance service is taking a somewhat different approach in its plan to shift to a paid on-call service five days a week sometime this spring, and the plan, as currently envisioned, will mean a significant increase in the personnel costs for the city’s ambulance service, of anywhere from $165,000- $200,000 depending on a number of factors.

While smaller services, like Cook’s ambulance, pay relatively modest stipends for volunteers on-call ($3-$4 per hour depending on training in the case of Cook), the Tower City Council has already approved hourly pay ranging from $9 per hour for emergency medical responders (who have limited training) to $13 per hour for emergency medical technicians. And unlike most other departments, which maintain worker shifts ranging from four-to-twelve hours in length, Tower’s ambulance service is proposing to operate two 60-hour shifts, providing coverage by a two-person team from Monday through Friday. That’s likely to prevent local volunteers from serving in those roles. Indeed, the city had to delay implementation of its plan last year after none of the service’s current workforce expressed interest in the lengthy shifts. While some out-of-town residents expressed interest in the positions, according to Ambulance Director Steve Altenburg, none of them could meet the minimum response time of five minutes.

The city council, in response, recently approved a request by Altenburg to rent a house in town to provide quarters for the prospective new out-of-town hires, at an additional cost of $8,000-$10,000.

For Tower’s ambulance service, the change will potentially triple its current payroll, from about $86,000 last year, to more than $250,000. Last May, when Altenburg first presented his plan to the city council, he argued that inter-hospital patient transfers would pay the cost of the expanded payroll and other expenses. The ambulance service’s 2017 annual report notes that the service received 229 requests for transfers from one hospital to another and was able to accept 72, or just over 30 percent.

The increase in transfers between hospitals is significant and a widespread issue. EMS and hospital officials in the region all agree that demand for patient transfers—typically from primary care facilities like Ely-Bloomenson and the Cook Hospital to regional care centers in Duluth or elsewhere— has risen significantly in recent years. The availability of new ambulances to handle that demand has not grown as quickly, and that’s led to increasing wait times for patients needing transfer. Nicole Chiabotti, with the Cook Hospital, recently broke the numbers down from this past July 1-Nov. 22. “We had 99 patients who needed transfer from our emergency room during that time, and 33 percent were delayed because we couldn’t find an ambulance right away.”

Some of the delay could be a result of a new policy from St. Louis County dispatch, which now allows hospitals just one dispatched request for service, which goes to the hospital’s primary provider. According to Chiabotti, county officials made the change after calls for transfers (which are not considered emergencies in most cases) increasingly overloaded the county communications.

If county dispatchers don’t get a response from the local ambulance, hospital staff has to get on the phone to find an ambulance from somewhere else. “We go by distance,” said Chiabotti, first we call Orr, then we call Tower.”

Despite the higher demand for transfers, area ambulance directors all urged caution in assuming that a shift to a paid on-call system will significantly increase the number of transfers that an ambulance service can accept. They note that the first responsibility of any ambulance service is to provide emergency response within their coverage area.

While the Ely Ambulance maintains paid on-call staff 24 hours a day, seven days a week, Director Geoff Galaski estimates that his service accommodated only about 40 percent of the 144 transfer requests they received this year. “The biggest thing is timing,” he said. “If we get called for a psych transport at 1 a.m., it’s hard to find staff to fill in.”

“That’s the major piece of it,” said Bob Norlen, field services supervisor for the state of Minnesota’s Northeast EMS region. “You can do the transfer, but you always have to have a crew available to respond to an emergency. It would be tough to explain if someone died of a cardiac arrest while you were on a transfer.”

That’s one reason why the Cook City Council had, for years, prohibited transfers by the Cook Ambulance Service. They’ve only recently allowed the ambulance service to accept transfers, but only when they can confirm a back-up team is in place in the event of emergency.

Yet Tower’s plan would require its on-call personnel to accept virtually every transfer request to sustain the additional payroll and related costs from the proposed shift to paid on-call. City Clerk-Treasurer Linda Keith told the Tower City Council in December that the ambulance service nets about $1,000 on an average transfer, which means the service would need to take on an additional 170 transfers, (or about 100 percent of requests) to have any hope of covering its added costs. But the current plan only calls for paid staffing Monday through Friday, so the plan would only have the potential to increase transfer acceptance during those five days. Even if the ambulance service were able to accept 80 percent of the transfer requests (and no ambulance directed contacted for this story believed that was possible) during those days, and maintain its current acceptance level on the weekends, it would only increase the number of accepted transfers by 78. That would cover less than half of the payroll-related costs from the proposed paid on-call system.

Making the wrong decision can be costly for ambulance services, which is why most have exercised caution in moving forward with changes. Hoyt Lakes, for example, initially asked the state’s EMS regulatory board to do a study of their service and offer recommendations. When that study suggested a move toward a paid on-call system, the service hired a consultant to further develop the business model. “Only after that was the new system put in place,” said Hoyt Lake Ambulance director Jim Theodore.

The level of due diligence in the case of Tower is unclear. The city council approved the plan last May after a 15-minute presentation from Altenburg, a presentation that did not include all of the costs related to the program, such as payroll taxes and other fringe benefits, possible overtime costs, and the cost of rental and maintenance of living quarters for the staff.

Altenburg recently told the city council that the new system would likely provide some savings on existing payroll, since the new on-call staff could perform some functions currently done by existing staff, although he provided no specific numbers.

The ambulance department does potentially have room to absorb some additional costs even without corresponding income. The department showed $342,000 in revenue last year, with only $203,000 in expenditures. But the department’s city-approved budget for 2018 shows estimated expenditures of $331,000, (with projected revenue of $331,000) without including the cost of hiring on-call staffing or potential new revenue from additional transfers.

As it stands, the Tower Ambulance service has been effective for years in meeting the emergency needs of residents in its primary service territory, having been forced to request mutual aid only a handful of times in the past year. And it’s been able to take on at least as many transfers as most services with paid on-call staff, although it’s done so by overextending some of its volunteers. At least three members of the ambulance staff, including Altenburg, responded to more than 100 ambulance calls during 2017.