Last of three parts
A crowd gathered around Joseph Reusch as the 79-year-old man lay dying on the cold pavement of Wolcott Square in the Hyde Park section of Boston last April.
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EMS OVERLAP CAN COST PRECIOUS TIME
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Boston has two departments performing emergency medical services: the Fire Department and the Boston Emergency Medical Services. Depending on the type of incident, the Fire Department is not always called. In the following calls, made to Boston EMS on Dec. 23, 1998, the Fire Department was not notified.
CEDAR STREET, MATTAPAN
Man with facial droop, indicating possible stroke
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2:32:59 p.m.
Call comes in from telephone.
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2:33:29
Boston EMS ambulance dispatched.
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2:49:15
EMS arrives on scene.
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Time elapsed:
16 minutes, 16 seconds
Nearest fire squad:
Engine 56, 1 minute away
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SEAVER STREET, DORCHESTER
Resident has a bleeding eye
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4:13:19 a.m.
Call comes in from police.
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4:15:04
Boston EMS ambulance dispatched.
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4:33:05
EMS arrives on scene.
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Time elapsed:
19 minutes, 46 seconds
Nearest fire squad:
Engine 24, 3 minutes away
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MORRISSEY BOULEVARD, DORCHESTER
Supermarket employee severs fingers in meat slicer
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12:46:52 p.m.
Call comes in from duty police officer.
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12:47:30
Boston EMS ambulance dispatched.
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12:57:08
EMS arrives on scene.
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Time elapsed:
10 minutes, 44 seconds
Nearest fire squad:
Engine 21, 2.5 minutes away
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WARDMAN STREET, JAMAICA PLAIN
15-year-old girl giving birth, in pain
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12:56:08 p.m.
Call comes in from telephone.
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12:57:39
Boston EMS ambulance dispatched.
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1:07:37
EMS arrives on scene.
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Time elapsed:
11 minutes, 29 seconds
Nearest fire squad:
Engine 42, 1 minute away
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NEPONSET AVENUE, DORCHESTER
Infant having a seizure, medication not helping
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5:36:40 p.m.
Call comes in from telephone.
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5:37:37
Boston EMS ambulance dispatched.
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5:45:12
EMS arrives on scene.
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Time elapsed:
8 minutes, 32 seconds
Nearest fire squad:
Engine 48, 3.5 minutes away
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NOTE: According to Boston EMS, some arrival times for ambulances may be earlier than logged, as EMTs sometimes delay calling in their arrival because of the nature of the emergency, among other reasons.
SOURCE: 911 logs
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As they waited and waited for help to arrive, many in the crowd became angry. Where was the ambulance? Where was the Fire Department?
Desperate to help Reusch, a Curry College student sprinted to a fire station on the other side of the intersection to summon help. The firefighters quickly drove to the scene.
When they arrived, the bystanders turned on the firefighters, demanding to know why it took them so long to get there. The man had lain on the ground for 10 minutes. The firehouse was only 100 yards away. Someone called 911. What happened?
Soon after, an ambulance arrived - some 15 minutes after the first call for medical help. Reusch was rushed to Faulkner Hospital in Jamaica Plain, but it was too late. He died at the hospital.
The people in Wolcott Square that night are still angry.
''I am 46 and smoke three packs a day,'' said Joe Lombardi, the owner of a Wolcott Square liquor store who was one of those frustrated onlookers the night Reusch died. ''I could drop any day. My concern is: What if it is me?''
The Hyde Park residents demanded to know why Reusch didn't get the help he needed. What they learned was disturbing: His case was not unique. Every day, across the city, emergency medical help is needlessly delayed because calls are handled by two different agencies. The Fire Department is often first to the scene, but the ambulance service is provided by a second city agency, Boston Emergency Medical Services.
It is an arrangement that has been abandoned by other cities. A recent survey of the 200 most populous cities indicates only 12 percent have a system akin to Boston's. And a Globe review of calls to 911 indicates the problem of emergency medical dispatch lingers, raising doubts about whether the current system, where two agencies essentially vie for the same turf, will ever succeed.
The strain between the agencies has grown over the past decade as the number of fires in the city has declined by more than half. While fires have dropped, the Fire Department has increased its response to medical calls to the point where they now comprise 40 percent of department activity.
To many observers, the hostilities between the EMS and Fire Department boil down to the issue of saving jobs, and a perception that each agency views the battle for medical calls as a fight for survival.
The key to medical response in the city depends on how an EMS dispatcher enters a call for help into the computer system. The coding of the type of injury automatically triggers a decision of whether or not the Fire Department, which has a separate dispatch system, will also be notified.
In the case of Reusch, the first call for an ambulance to Wolcott Square came at 6:55 p.m. The caller said someone was covered in blood, the result of a fight between college-age men in the square. One of the men smashed the window to Reusch's car, and it was soon after that the elderly man collapsed on the ground.
A second call for medical help, from the same address, was made at 7 p.m. The caller said the sitution was more urgent because a man was having a heart attack.
Even though the firehouse is only steps from the square, none of the codes entered for the incidents triggered an automatic response from the Fire Department. Finally, at 7:05, a dispatcher changed the code and the Fire Department was notified - some 10 minutes after the first call for assistance. At the same time, the college student ran inside the fire station seeking help.
If firefighters had arrived earlier, they might have made a difference. Every engine in the city is equipped with an automatic defibrilator and oxygen, vital tools that if administered quickly can stabilize a patient and save a life. Every firefighter is trained in basic life support, and one of every three is a trained emergency medical technician.
Concern about how the city's emergency crews respond, or don't respond, to medical emergencies is nothing new.
The Reusch case is similar to the death of Michael Passalacqua, who in 1995 suffered a fatal heart attack only steps from a firehouse in Charlestown. The Fire Department was not notified in that case. An ambulance didn't arrive until 19 minutes after the first 911 call.
In the past year, city officials have insisted that the situation has improved. A recent mayoral task force rejected the idea of merging the Fire Department and EMS, bucking the national trend to combine the two operations.
But a review of one day, last Dec. 23, found more than a dozen cases across Boston - including an elderly man suffering a stroke, a 15-year-old girl having a baby , and a supermarket employee who accidentally sliced off several fingers - where the Fire Department wasn't notified and the people needing help waited more than 10 minutes for an ambulance. The EMS said its average response time to incidents like these is 6 to 7 minutes.
Reusch's son, Joseph Jr., finds it hard to believe the city's response to medical emergencies is better today. A retired iron worker, the senior Reusch was a World War II veteran who won a Bronze Star Medal for helping to liberate Rome.
''He deserved more than dying on the street, waiting for help'' his son said. ''I don't understand why every other city in this country has ambulances in the firehouses and Boston doesn't.''
Tensions run high at accident scenes
In past years, there have been fistfights between firefighters and EMS personnel responding to the same call. Although both agencies say there have been no altercations recently, tension remains.
On Jan. 24, a dispute over medical care at an automobile accident escalated to the point where an EMS ambulance driver asked police to remove a firefighter from the scene. The firefighter, who is also an EMT and a registered nurse, said the ambulance driver became upset when the firefighter questioned the treatment of one of the accident victims.
''I noticed the patient clutching at his shoulder as the [ambulance driver] continued to move and push down slightly on the top of the patient's head,'' the firefighter reported. ''I ordered him to stop and he muttered for me not to interfere.... He then ordered me to back off and asked an officer at the scene to remove me.''
The firefighter said he interceded ''to stop what I feel was gross malpractice toward an occupant of the vehicle.''
Members of the EMS, meanwhile, accuse the Fire Department of being more concerned with preserving jobs made vulnerable by the decline in fires than providing the best possible medical care. In fact, on 9,016 of its 28,684 medical-related runs last year, the Fire Department provided little or no assistance, records indicate.
But because the Fire Department has five times the manpower of EMS and is more strategically located in stations throughout Boston, firefighters frequently arrive at a medical emergency well before an ambulance.
Concerned about the city's response to medical calls, Mayor Thomas M. Menino last year appointed a task force to look at the merit of merging the EMS with the Fire Department. In December, the task force report called for the agencies to remain separate, but urged improvements in communication between the organizations and strengthened management at EMS.
Dennis A. DiMarzio, the city's chief operating officer and a member of the task force, said the current system works and would not improve with a merger.
''Anyone [the task force] spoke to from outside Boston looked at our EMS as being an excellent service,'' he said. ''They were envious of the way we run it. We have a very good service. So why do anything of a dramatic nature when there is no need to?''
The paramedics and EMTs who work for the EMS enjoy national reputations for their skill and the high level of training they receive. The task force said it was concerned a merger would dilute those skills.
Some national experts, however, said the real issue is providing a seamless stream of care from the time someone calls 911 to their arrival at the hospital.
''The patient is the bottom line,'' said Gary Ludwig, chief paramedic for St. Louis, which merged its fire and EMS agencies two years ago. ''There is better integration between different components.''
Ludwig said mergers like the one in St. Louis also eliminate costly duplication, including separate dispatch systems and administrators who perform the same functions at two agencies.
In Boston, the EMS service has requested $4 million to build new bays for ambulances across the city, even though there are empty bays at 18 firehouses.
''If you look at systems that have done well through the years, they have been fire-based systems,'' said Dr. Paul Pepe, who directed emergency medical services in Seattle and Houston, and is past president of the National Association of EMS Physicians. Pepe said firefighters are the backbone of any EMS system because they almost always arrive first at the scene.
At its core, said Ludwig, the decision on whether to merge fire and EMS services generally comes down to turf and jobs. It is the reason there is often conflict between the two agencies, and a factor that provides an ever-present source for future disputes. ''Parties who don't want to give up their control of things is the leading cause for resisting mergers,'' said Ludwig. ''People don't want to lose their kingdoms.''
Smooth merger erases doubts in San Francisco
Two years ago San Francisco did what Boston has resisted: It merged the city's ambulance service into the Fire Department after a lengthy process.
At the lunch table inside San Francisco Fire Department Station 36 recently, paramedics John Marberry and Paul Jug deflected verbal barbs from firefighters while putting condiments on their sandwiches. The good-natured ribbing of the two ''medics'' is the best indication the men have been accepted into the firehouse culture.
Marberry and Jug said they worried how firefighters would treat them and how a merger would impact the quality of the service they provide. Now, they wonder why a merger didn't take place sooner. ''There is a much better working relationship,'' said Marberry. ''Things flow easier.''
Although they say response times are down and their workload is now more reasonable, one of the most significant improvements is harder to measure.
The paramedics said living with the firefighters and working with the same people on every shift improves their service to people in need of help.
''You get more of a feeling of how good each of the firefighters is at sensing a patient,'' said Marberry. If he knows he can trust the assessment of a firefighter, Marberry said he can transport a patient faster.
The paramedics also work together with firefighters to reduce nuisance calls.
Back at the firehouse, the paramedics discussed how they respond to calls and the treatment they provide. Such dialogue adds to the expertise of the firefighters, many of whom are EMT's, said Jug, a paramedic for 22 years. ''There are a lot of little niceties,'' he added.
Not every paramedic in San Francisco is as pleased with the merger as Jug and Marberry. About 8 percent of the paramedics opted not to live in the firehouses or become cross-trained in basic firefighting skills. And although response times are down, there are still incidents with unacceptable delays, officials said.
But Dr. S. Marshal Isaacs, medical director for the merged service, said there is no question the new system is an improvement. ''We believe in this system,'' he said. ''We thought our families, friends, and visitors would be best served by merged departments. Everybody benefits.''
Before the merger, Issacs worked for the city's public health agency, which operated San Francisco's ambulances. He said a key to the merger's success was the support of his former agency, something that has been a stumbling block to mergers in other cities.
For the Fire Department, combining the services made sense, said Richard Shortall, the EMS chief for the department. Fires in the city were down and firefighters were already responding to a large number of medical calls.
''We are a standing army,'' he said. ''It was a perfect fit.''
Neighbors bewildered by slow response time
Last Oct. 2, Christopher McGillicuddy went for a bike ride in his Dorchester neighborhood. The five-year-old wasn't wearing a helmet, and when he fell off his bike, he landed on his head.
A neighbor who witnessed the accident quickly called 911. It was the first of at least two calls.
Mary Ann Shea was pulling into her driveway when she heard her daughter say, ''Oh my God'' as the young boy fell off his bike. Shea, an anesthesia technician who works in an emergency room, immediately noticed the boy was bleeding from his head, mouth, and nose. She could feel a lump on his head growing as she cradled him in her arms. McGillicuddy slipped in and out of consciousness.
For 20 minutes, Shea said she waited for an ambulance. Finally, with the aid of a neighbor, the boy's father scooped the boy up and brought him to Carney Hospital.
When the ambulance finally arrived, Shea asked the paramedics what took them so long.
''They said, `We are really sorry,' but they had just received the call and had to come from West Roxbury,'' she said.
Logs indicate it took the ambulance 12 minutes to reach Brookvale Street, although neighbors said the delay was actually longer. What has Shea and her neighbors angry is that a fire station less than a mile away on Dorchester Avenue was never notified of the accident by EMS.
''I just couldn't understand why the Fire Department wasn't notified,'' said Shea. ''This poor kid. He was in and out of it the whole time.''
McGillicuddy's mother, Brenda, is more succinct: ''When a person calls 911, they should be here.''
After spending two days in the hospital, the boy was released and is completely healed today, his parents said.
The Fire Department wasn't notified of the bike accident because a dispatcher for EMS designated the incident with an ''injury 2'' code, a lower priority that doesn't trigger a Fire Department response.
Because the two agencies have separate dispatch centers, the key to whether or not the Fire Department is notified rests in how an incident is coded.
In the case of Joseph Reusch, the incident was coded as ''REQE,'' which means another agency, in this case the Police Department, requested the assistance of EMS. REQE is another code that does not require notification of the Fire Department. In total, the Fire Department is notifed on a third of the 83 codes used by EMS.
In a memo prepared for the Globe, the EMS said it simply isn't necessary to send firefighters to many medical calls.
''There is no medical justification to divert the valuable resources of [the Fire Department] for treatment of cuts, bruises, and similiar minor injuries,'' EMS said.
Nonetheless, John Auerbach, the executive director of the Boston Public Health Commission, which oversees the EMS operation, said he expects the mayor's task force, which is still active, to review the issue of coding and the possibility of combining the dispatch operations.
''We need to always be open for improvement,'' he said.
DiMarzio, however, strongly rejected any suggestion that there is a systemic problem with the way the city is responding to medical calls.
''We would say very strongly the dispatch system and its protocol is excellent,'' he said. ''It is really important not to give people in the city [an impression] that their medical care is less than the best. Did we blow any last year? Of course. But to characterize [the EMS service] as anything less than excellent is wrong.''
DiMarzio witnessed firsthand how a call was blown last Oct. 25 when he was in the stands watching a Pop Warner football game in Hyde Park.
Toward the end of the game, 9-year-old quarterback Steven Bonarrigo was tackled and didn't get up. Bonarrigo complained of a neck injury and numbness in his hands.
An EMT hired by the league called an ambulance at 10:20 a.m. According to 911 records, an ambulance wasn't dispatched until 10:25 and didn't arrive until 10:44.
Once again, the Fire Department wasn't notified of the incident. A parent flagged down a Fire Department car at 10:29, and an engine company arrived at the scene four minutes later.
DiMarzio said not notifying the Fire Department was insignificant since an EMT was at the field. He said the EMS service made a mistake by not calling for a private ambulance at a time when all the city ambulances were tied up on other calls.
But Bonarrigio's grandmother, Maureen Chludzinski, disagrees. ''Thank God the Fire Department came,'' she said. ''It took the heat off a little bit.''
Bonarrigio was taken to Children's Hospital and his injury proved not to be serious. His mother, Melanie, remains dismayed by the experience.
''It's a disgrace this goes on in Boston,'' she said. ''I am thinking on the field, `What is wrong here? I can't believe this is happening.'''
End of series
This story ran on page A01 of the Boston Globe on 02/09/99.
© Copyright 1999 Globe Newspaper Company.
