Lights in the Distance 

If Richmond represents the future of EMS, then its medics have never been more vital.

Ambulance service in Richmond used to be an inefficient web of municipal and volunteer squads. Poorly managed EMS organizations struggled with their operations, responding with vehicles that arrived late if they arrived at all.

To address the problem, City Council pushed the General Assembly to pass legislation authorizing the city to create an umbrella authority to provide emergency medical services and health care to city residents. The new model — the Richmond Ambulance Authority — emerged in 1991.

The city hired a private contractor to outfit and operate the system. And the ambulance authority hired as its executive director Jerry Overton, who had directed an EMS system in Kansas City, Mo. It also tapped Dr. Joseph P. Ornato, a cardiologist at VCU Medical Center, as its medical director. Fifteen years later, the two men remain at their posts. Emergency medical services, centralized within the quasi-governmental, $13 million agency, have gone from disarray to cohesion. Ambulances respond to 911 calls in 9 minutes or less 90 percent of the time.

The medic's job has shifted too. Men and women in the field are now called to administer lifesaving techniques that once fell exclusively to emergency room doctors. It's a unique role because medics go to the patient, Overton says. It's a pivotal role as well, he says, because the medic must "react and act," applying new tools and treatments in a setting that can be as depressing as it is exhilarating. This is especially true in Richmond, where high concentrations of poverty and crime translate into greater rates of sickness and violence that end up demanding a medic's attention.

"You have to be an adrenaline junkie to like a job like this in a city like this," Simms says. Two years ago, he moved his family from Bedford County to take a job in Richmond. He never thought he'd stay this long, he says. "A year here … is like two or three anywhere else," he surmises, of the nature and volume of trauma he sees.

Dr. Kevin Ward, director of research for the emergency department at VCU Medical Center, has worked at ERs in big cities, including New Orleans, Detroit and Pittsburgh. But he says Richmond's medics stand out.

"What they do is move the emergency department out" to the community, he says. "They're our eyes and ears. … They're sort of like the school teachers of medicine. Just as we undervalue teachers even though we value the work they do, the same can be said for Richmond's [medics]."

Herein a symbiotic relationship between VCU Medical Center and the ambulance authority has developed that positions Richmond as a front-runner in EMS.

VCU Medical Center, located in the heart of the city, is one of the leading trauma centers in the nation, conducting groundbreaking and controversial research on everything from cardiac arrest to blood substitutes. What it tests and on whom could end up saving the lives of soldiers on the battlefield or gunshot victims in Richmond's deadliest neighborhoods.

The Richmond Ambulance Authority is a critical part of the equation in cases where research is best applied immediately — before the patient enters the hospital setting. Ornato, known for his connections and ability to bring medical trials to VCU, and Overton have strengthened the relationship between the hospital and the authority.

"Our [EMS workers] are our most precious commodity. They're in the field, and there's a sense of autonomy for a lot of them," says Rohn Brown, technical assistance coordinator for the Virginia Department of Health's Office of Emergency Medical Services. The Richmond medics, he says, "have a really great reputation for doing progressive things."

"Joe and I have never subscribed to the status quo," Overton says, and that they don't sounds promising for the future of EMS. But whether their efforts succeed could very well depend on the medics — men and women who get paid an average of $25,000 a year to work 12-hour-plus shifts in a high-stress environment where people in trouble need a hand.

HEADING SOUTH OVER THE ROBERT E. LEE Bridge en route to the pregnant woman who's bleeding, Simms hits the truck's sirens and red and yellow lights. The speedometer hovers at 60 mph. Cars move to accommodate the vehicle, but a few must be urged. He taps his horn at the vehicle in front of him, and it shifts into the right-hand lane. "People still won't get out of your way," he complains.

There are 62.5 square miles and 197,000 potential patients to cover in city limits, Simms says. While he's the shift supervisor providing backup, according to protocol, the first responders posted at any one of the two dozen targeted locations throughout the city have just 539 seconds — less than nine minutes — to respond to life-threatening calls. If they're late, they're penalized.

Simms, 36, is one of 62 paramedics trained in advanced lifesaving with the ambulance authority, which is cited as one of the nation's leading innovators in EMS by the Los Angeles-based Reason Public Policy Institute, a nonpartisan think tank. In the last three years, either through partnerships with VCU or on its own, the authority has tested and implemented new methods in the treatment of cardiac arrest — such as use of defibrillators, the automated CPR device AutoPulse and administering the drug amiodarone — and has studied community patterns of pediatric trauma. In addition, it has adopted technology in its dispatch communications center that has been lauded worldwide and includes the use of a "black box" monitoring device for recording ambulance data much like that in airplanes.

Yet despite the advent of new approaches to EMS and the consequent increase in requirements and responsibility for the medic, the high-stress, low-pay nature of the job has remained the same. EMS workers are in demand. And forecasters say the need for them will grow sizably as the baby boomer generation ages.

The salary range for paramedics in Virginia is $21,000 to $35,000, with a median salary of $25,000 in 2005, cites Career Prospects Virginia, a nonprofit agency that studies workplace salaries and trends.

"The pay sucks," Simms quips, and it explains why turnover is high and why medics often move to other EMS agencies such as fire departments — where pay is nominally greater.

Paul "Paulie" Tibbert had to explain why he wasn't "getting on fire," he says, because he's a fourth-generation emergency services worker. He comes from a long line of firefighters. A Boston native whose accent isn't the least diminished from years spent in the South, Tibbert's fear of heights limited his local fire-department experience to that of a ground-based volunteer. EMS is more his style, says the goateed medic and shift supervisor. He wears thin-rimmed glasses and a tiny stud in his left ear that occasionally catches the light. He laments that firefighters get all the glory because they've been around since the beginning of civilized society, whereas a paramedic's history is relatively new. "It's still the red-headed stepchild," he says of the profession.

A self-professed type-A personality, Tibbert doesn't appear to let perceptions stop him. He takes charge. On a recent Friday night a little before 11, he arrives at the scene of a bungalow in the Carver neighborhood where a fellow medic, Dan Brown, along with an emergency medical technician and an EMS student, have responded to what's called a lift assist. A severely obese woman weighing about 450 pounds has fallen in a back bedroom and can't get up. None of the three other adults who also appear to live in the home can lift her.

The smell inside the home — of dogs and excrement — is overpowering. After several minutes of positioning themselves around the woman, the four EMS workers manage to hoist her into bed. She apologizes profusely, her husband watching solemnly from the doorway. Tibbert and Brown reassure the woman that it's OK.

Just as Tibbert is about to pull away, Brown approaches him. It seems the EMT, a young, small-framed woman, believes she's strained her back during the lift. After examining her, Tibbert agrees, and advises Brown to take her to the emergency room at Retreat Hospital.

"In urban areas, 911 is many people's primary care," he says of the poor neighborhoods EMS frequents. "The areas we go into are so nasty you think, How can people live like this? But they may think they're living better than their parents did."

When Tibbert is on duty as shift supervisor, if he's not assisting with calls, he's making rounds at emergency rooms. Tonight is no exception. He stops in at CJW Medical Center, Retreat Hospital and VCU Medical Center — where most of the ambulance authority's transports wind up — and he does this multiple times. ER docs and nurses know him well, he says.

Just before 2 a.m., a green four-door sedan with Arizona license plates takes a sharp turn on Walmsley Boulevard near Caldwell Road. It ends up airborne and then entangled in a thick hedge of bushes. The 911 call comes in as dire, requesting multiple response. Tibbert is on the scene in minutes. Already, fire, ambulance and police crews are there. The EMS workers will be less visible. "We're here for like 10 minutes," Tibbert says of the EMS workers' in-and-out job, compared with that of firefighters and police, who stay on the scene to gather information while reporters and camera crews arrive seeking headlines.

The car is off the ground, wedged in the thicket. It is utterly demolished. With the vehicles, lights and workers on the scene, the site looks like a movie set, albeit a somber and nearly silent one. Ten Richmond firefighters surround the vehicle with axes, and one holds the Jaws of Life. Meanwhile, a firefighter has hoisted himself into the back seat of the car, where the victims are.

It's not known yet whether a third person was driving the vehicle and either was thrown from the car or fled the scene. The focus now is on the two men inside. Within minutes, the car is severed in half, its windshield torn away. A denim jacket that must belong to one of the passengers lies on the hood. The car appears to have narrowly missed a gas pipeline and also a utility pole. Tibbert and a handful of medics flock around the car with two gurneys and equipment to stabilize the victims.

Brown takes pictures of the scene with his cell phone. After 45 minutes, the preliminary work of extracting the two known victims is done. They are pulled from the car — their necks and heads immobilized by padding — and they are placed on gurneys. They appear responsive, but mutter only a few words in Spanish. The medics place them each in an ambulance headed for VCU Medical Center.

Tibbert follows the twin ambulances to the hospital. At 3 a.m., 11 vehicles fill the ambulance lane out in front of the emergency room. Inside, people flood the ER. Four teenagers have just been brought in from an accident in Henrico County that occurred an hour earlier at the intersection of Gaskins and Quioccasin roads. Two of the teens, a male and female, will not survive.

Brown, a medic charged with helping one of the Walmsley victims, pulls aside the pink curtain that marks the ER's trauma/resuscitation room and walks in. The room is abuzz with dozens of doctors, nurses and residents. The two men from the Walmsley accident are on gurneys in what appear to be booths of treatment. One is combative and won't allow an IV line to be inserted. Brown approaches a middle-aged man who stands at the front of the room and appears to be the lead doctor. The medic holds a pair of sneakers he retrieved from the scene of the accident in one hand. In the other he holds his cell phone. He shows the doctor what the car looked like when EMS workers found it, in case seeing the images might help show how to treat the patient.



IN 2005, RICHMOND AMBULANCE AUTHORITY medics and EMTs responded to nearly 40,000 emergency calls citywide. Of those, 30,000 patients required a medic's attention and a ride to a hospital. The authority responded to 10,000 nonemergency calls either to assist in medical situations or to carry individuals nationwide to and from health care facilities such as veterans' hospitals. The authority makes money on these calls. Per capita, Overton says, Richmond is the busiest "high-performance" EMS system in the nation, with 1,450 emergency transports per 10,000 residents, compared with a city such as Fort Worth, Texas, with 720 emergency transports per 10,000 residents. On average, the authority's ambulances are called out 91 times a day.

Soon that could change. This month, the authority officially starts the Community Health Access Project, in which registered nurses field non-life-threatening 911 calls. It means that, for the first time, the authority won't necessarily dispatch one of its 29 vehicles for house calls. Instead, a nurse in the dispatch room will assess the patient's complaint and make other arrangements for less-immediate health care intervention.

The move is a diversionary one, aiming to free up medics and vehicles for the most urgent cases and save costs. An average trip to the ER in an RAA ambulance costs $350, paid in part by the patient's insurance and Medicare or Medicaid, as well as the city and the authority.

The project is being piloted in Richmond as well as in towns in England and Australia, Overton says. It's his pet project, the one he sees as having the best long-term outcome for patients and the authority alike.

Whereas Overton praises the nurse-intervention program, Ornato is quick to applaud the success of the AutoPulse. The device is a kind of board with a strap attached that detects a patient's chest size and administers automated CPR-like compressions that are stronger and more consistent than those administered through manual CPR. Humans giving CPR are able to generate only a low shock-level value of blood flow to the brain and heart. Studies found that the AutoPulse generates 277 percent more blood flow to the heart than that produced by manual CPR, Ornato says. The device that RAA tested more than three years ago is now FDA-approved, and some of its medics say their input was important in its approval.



WHILE IT'S A FULL MOON on a mild mid-February night — conditions ripe for trauma, Simms says — no critical cases surface. By the time he arrives at the residence of the pregnant woman with complaints of vaginal bleeding, the authority's EMS workers who were posted nearby are already on the scene. They tell Simms she appears to be suffering from Braxton-Hicks contractions, or false labor. She is taken to VCU Medical Center.

Simms' introduction to the world of EMS was literally trial by fire, he says. When he was 15, he accidentally set fire to a hayfield while lighting firecrackers. As a lesson, his stepfather talked to the county fire chief, who agreed to take Simms on as a volunteer. In time, his experience led him to a career in EMS because he was told that his outgoing personality and concern for others made him a natural. He ended up some years later meeting his wife, a medic at the time, in the back of a rescue squad, he muses.

His first three months in Richmond, Simms recalls, he administered more Narcan, an antidote to drug overdoses, and saw more gunshot victims than he did in the 15 years he was in Bedford. "Back home if you had a gunshot victim, it was because of a hunting accident," he says.

Coasting east along Semmes Avenue after 10 p.m., Simms says that the public-relations component of his role includes making rounds, being seen and getting to know Richmond police and firefighters. "One thing a paramedic is — and that's autonomous," he says. "Give me my truck, my tools and let me go to work." But sometimes, when the streets are empty and the city is calm as it appear now, the work must seem solitary and fleeting.

Inching over the horizon is work that Simms describes as the "expanded scope of paramedicine," whereby medics go into neighborhoods to promote public health by administering a range of services, anything from tetanus shots to school physicals and inoculations. While Overton stresses a desire not to repeat services provided by organizations such as Bon Secours' Care-A-Van, he says partnerships are in the works that will further highlight EMS in an array of community outreach projects.

Just before midnight, Simms gets two calls, one after the other, from his "mirror," Travis Puffenberger, the authority's lead dispatcher. The first is for a "man down" in Creighton Court, a public housing complex. The second is for an asthmatic elderly woman residing in a nursing home on Chamberlayne Avenue.

As backup to the primary ambulances, Simms goes where he's needed most. While the Creighton call appears more life-threatening, the medics responding have it under control, Simms learns, and the EMS team on-site at the nursing home have asked for assistance. The woman was having difficulty breathing, so the health care worker on staff had called 911 to take her to the hospital. Now the woman is refusing to go. Simms converses with the medic at the scene.

"Is she alert and oriented?" he asks. "Does she appear to be a threat to herself or others?" Over the phone, the medic answers yes to the first question, no to the second.

"We can't force her to go," Simms tells the medic. The medic explains that the health care worker is insisting that the woman go to the hospital. Simms heads to the nursing home to help settle the matter. En route, he reasons: "We can't force people to take care of themselves. If we could, we wouldn't have jobs."

The nursing home looks decrepit. Inside a handful of elderly people sit in chairs or wheelchairs at a cafeteria-style table. They are idle and unattended. The patient is a 77-year-old woman dressed in a sweat suit and dingy slippers. She sits upright on her cot in a small cinder-block room — there are two cots and a tiny TV. Her right ring finger is a nub.

The medic sees this and tries to spark conversation, a precursor to trust. He points to her hand and asks what happened. She replies that she lost it in a fight with a woman more than 50 years ago. She says the woman bit it off.

Simms speaks to the health care worker who had complained to him that the EMS workers had talked down to her and insulted her. He smoothes things over by explaining that his staff has to assume most people don't know EMS protocol, like she probably does. Next, he urges the patient to go to the hospital. Her breathing is audibly strained. An asthma inhaler rests on an end table beside a plastic sandwich bag filled with cookies. The woman pleads with Simms not to make her go. Repeatedly he tells her he can't force her, but that she should go.

Meanwhile, the health care worker has phoned the facilities manager, who arrives in about a half-hour. In a familial way, the manager fusses with the woman for getting her out of bed. She puts an arm around the patient's shoulder and leans in as if to whisper, though she speaks loudly. "If you don't go, I won't give you any more cigarettes," she warns.

Moments later, the woman allows the EMT and the medic to help her onto the gurney. Simms, who has hours to go before his shift ends and he goes home to make breakfast for his kids, appears satisfied yet accustomed to the irony. "Now you have an administrator giving an asthma patient cigarettes," he says, watching as the EMS workers usher the woman out the door. But the call was "legitimate," he says, and he's in no position to judge. S

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