Pandemic stresses city’s ambulance system
Delivery of emergency care suffered before 2020
Even before the COVID-19 pandemic, the city of Memphis frequently ran out of ambulances.
“The Memphis Fire Department staffs 34 ambulances that are often all in use,” consultants with IBM wrote in a 2016 report. “Running out of resources routinely delays care and risks lives.”
Four years later, the number of ambulances citywide has increased only slightly, and the surge of hundreds of new COVID-19 patients into Memphis hospitals is placing more pressure on the area’s ambulance system.
“You know, with our COVID numbers increased, you’ve taken a system which was already stressed. And now all of a sudden added a very significant burden onto it,” said Dr. Peter E. Fischer, interim chief of trauma at Regional One Hospital.
Hospitals are now so full that patients sometimes wait in the emergency room for days for a bed to open up, medical staffers and patient family members said in recent interviews.
Lack of space and staff mean that when ambulance crews bring patients to the hospitals, the hospital staffers can’t accept them immediately unless they’re very sick. The crews often wait for patients to be admitted — in some recent cases, the waits have extended to six hours, seven hours or even more than eight hours.
Every hour that an ambulance crew spends at a hospital waiting for a bed is an hour they’re not on the street answering calls. And if you’re having a heart attack somewhere in the city, that can affect you, Fischer said.
“And that ambulance is tied up offloading a patient somewhere else, our
“You know, with our COVID numbers increased, you’ve taken a system which was already stressed. And now all of a sudden added a very significant burden onto it.”
Dr. Peter E. Fischer interim chief of trauma,
Regional One Hospital
hospital or any other hospital, and may not be able to respond to your heart attack as quickly as they would like,” he said.
Fire officials say they have developed techniques to work around temporary ambulance shortages.
If the fire department can’t get an ambulance to the scene of a medical emergency, it will send a fire truck staffed with paramedics. They can treat a patient on the scene, although the truck is not equipped to take the person to the hospital.
The city has long cooperated with private ambulance companies to transport patients under certain circumstances. The city recently signed an updated memorandum of agreement with a private ambulance company, Lifecare Ambulance Service, fire officials said.
Despite these workarounds, the current ambulance problems are severe enough to attract attention from top public health officials in Memphis.
Alisa Haushalter, the director of the Shelby County Health Department, raised the problem with Shelby County commissioners on Dec. 16. “Our system is strained and it’s not limited to the hospitals themselves, it’s also the ambulance services ... If the emergency room is full, the ambulance can’t offload that patient and run for another patient.”
She said the situation reflects broader pressure on health care workers. “We have to bring the COVID numbers down so the systems aren’t as overwhelmed.”
The new COVID-19 vaccines offer hope that the world will defeat the pandemic sometime in the near future.
But even if the pandemic ended tomorrow, Memphis would still face deep problems in its delivery of ambulance and emergency care. Those problems include the area’s poverty, abuse of the ambulance system for non-emergency care, the difficulties of servicing a huge geographic area, and the tricky details of handing off patients from ambulance crews to hospital staff.
The ongoing efforts to fix the issues could save lives.
Many jurisdictions in the United States and abroad have seen similar problems. Investigative news reports have documented pre-pandemic problems in ambulance service in settings ranging from rural Missouri to metro Atlanta. The problem of patients calling ambulances for non-emergency care has been documented as far away as the United Kingdom and Japan.
Just as in Memphis, the pandemic has made longstanding ambulance problems worse across the country. The American Ambulance Association recently asked the Department of Health and Human Services for emergency funding to keep ambulances running, The Washington Post reported. “The 911 emergency medical system throughout the United States is at a breaking point,” Aarron Reinert, the association’s president, wrote to federal health officials. The government approved about $1.5 billion in funding.
Ambulance crews sometimes wait more than 8 hours to drop off a patient
Dr. Joe Holley is an emergency physician who serves as medical director for several agencies in the Memphis area, including the Memphis Fire Department, the Shelby County Fire Department and others.
Holley said the current issues aren’t limited to a particular hospital, nor are they limited to the city of Memphis. “I know every EMS system in this region is experiencing significant increases in offload time in every hospital in the region. Because they’re full.”
He said an ambulance crew that’s dropping off a patient should be able to give a report to the hospital, transfer documentation, clean up the vehicle and leave within half an hour. “Our system is built on a 30-ish minute turnaround time. We’re currently seeing multiple hours.”
Those long delays don’t happen every time — in July through November of this year, 81 percent of ambulances managed to drop off their patients and leave within an hour, according to data recently presented to the Memphis and Shelby County COVID-19 Joint Task Force.
However, the proportion of very slow ambulance turnaround times has increased dramatically in recent weeks. In October of this year, for instance, the data showed 75 dropoffs that lasted four or more hours.
In November, that number more than doubled to 158.
And some of those waits were extremely long. In 12 cases, ambulance crews had to wait with a patient for more than eight hours.
The situation adds to the fatigue and frustration for ambulance crews, Holley said. “It makes things much worse for the guys in the truck.”
Many health care workers in hospitals and on ambulances have contracted COVID-19 or have been exposed to people who have it. That means other workers have to pick up the slack, Holley said — and they have to do so while facing heavier demand for medical services.
Fischer, the trauma doctor from Regional One, likewise spoke about the human toll.
“I think what you got to realize is that these are men and women that are being pushed to the absolute brink,” he said.
Regional One also operates a top-tier trauma center. A wave of record-breaking gun violence is sending more gunshot victims to the hospital, which Fischer said also adds to stress on the health care system and the people who run it.
Yet they’re still serving the public every day, he said.
That’s a point echoed by Gina Sweat, director of the Memphis Fire Department. She said most firefighters and paramedics work 24-hour shifts, staying busy most of that time and having to take COVID-19 precautions even during down time at the fire station.
When people call 911, emergency workers still show up. “And I just can’t tell you how proud I am of them,” she said.
Stressed voices on the radio, crowds of parked ambulances
Some of the stress facing emergency workers was evident in the voices that crackled over the fire department radio about 5:30 p.m. on Thursday, Dec. 10. Paramedics were talking to a patient.
“Inform her that every hospital’s going to be a four to six hour wait,” one emergency worker said to another. “Just keep her informed of that.”
A few minutes later, one emergency worker asked another which hospital they would transport a patient to.
“We’re going to have to call around. Everything seems to be backed up.”
A day earlier, on the evening of Wednesday, Dec. 9, a group of parked ambulances blocked the circular drive outside Methodist Germantown Hospital.
At one point there were 10 ambulances in the drive and nearby: five from the Memphis Fire Department, one from Germantown Fire Department, four from other agencies. Their engines rumbled loudly, idling.
Longstanding issues complicate ambulance response
The same paramedics who respond to cardiac arrests and gunshot wounds are also called to respond to minor problems such as toothaches and headaches. In a high-poverty city, some people use the ambulance system as primary care, people who work in the system say.
This problem has been documented for years — among the solutions in place today is the Radar program. It involves putting a doctor, nurse practitioner or physician’s assistant in a minivan and having them respond to less severe problems. A similar program was first piloted in 2017 and 2018. and Sweat said it was revived in March.
Today, the fire department staffs two Radar minivan units — and occasionally a third — operating 12 hours a day, said Deputy Chief Angie Shelton-sullivan, who oversees emergency medical services.
Sweat said the Radar units have already diverted hundreds of patients away from emergency rooms and into other types of medical care. “So I think right now with the way our ERS are being overcrowded, I think that’s phenomenal.”
Sweat said she’d like to have three of the Radar units running 24 hours a day.
A similar program called CARE responds to mental health emergencies, such as suicide attempts. The team includes a specially trained paramedic, a police officer and a mental health professional with Alliance Healthcare Services.
A big city, with a small number of ambulances
Another factor contributing to the city’s clogged ambulance system is the city’s large size — around 317 square miles — and the small number of ambulances to cover it all.
In recent years, the fire department has managed to bump up the number of ambulances on the street.
There are now 32 full time, 24-hour ambulances, fire officials said.
Another three ambulances operate 12 hours a day — those are staffed by
employees who work purely as medical personnel — they’re not cross-trained to put out fires.
There are also two “overtime ambulances.”
That’s a total of 37 ambulances, and with one dedicated to the airport, that means there are 36 available at peak times.
Would more ambulances help Memphis?
The IBM consultants noted in their 2016 report that adding ambulances costs money and doesn’t fix other issues that slow down service.
“Each additional staffed ambulance costs about a half million dollars per year to operate, and every trip to the hospital costs a little more than $1,000, including amortization of capital costs,” the consultants wrote.
The experience of Houston also suggests more ambulances wouldn’t necessarily lead to better service. Houston is one of the largest cities in the United States by geography at 637 square miles.
This summer, the fire chief said the system has 104 ambulances, giving it a ratio of about six square miles per ambulance, more favorable than Memphis — but it was still struggling with the problem of hospital handoff times.
Handoff to the hospital
Memphis’ hospital handoff times were also documented in the 2016 IBM report. The consultants recommended procedures to make it easier for paramedics to hand off the patient to the hospitals.
Holley, the medical director, explains that there’s no rule that says paramedics can’t leave a patient. But the emergency medical community has determined that if the hospital staff is overwhelmed and the patient is too sick to be simply left in the waiting room, sticking with the patient is “just the right thing to do,” Holley said.
Dr. Ben Bowman, the medical director of the emergency department at Methodist Germantown hospital, said there are, in fact, occasions when the paramedics can drop off a patient and leave quickly.
For instance, if the patient is critically ill, they’ll be taken into the hospital right away. Or if the patient is doing well, they can take a seat in the emergency room and wait.
It’s the patients in the middle that have to wait the longest, he said: those who are neither too sick nor too well.
And in many cases, ambulance crews end up waiting with them. With COVID-19 patients filling rooms and filling emergency room areas, the paramedics have to wait longer, Bowman said.
How to help in the meantime
Various groups of public health officials and emergency medicine experts are discussing the ambulance crunch.
In the meantime, Sweat, the Memphis Fire director, urges the public to reserve 911 for true emergencies.
Dr. Fischer, the Regional One physician, urges people to avoid behaviors that can land them in the hospital, like not wearing a seatbelt or driving drunk.
And Dr. Bowman from Methodist Le Bonheur Germantown Hospital urges people to take the basic steps that prevent the spread of COVID-19: continuing social distancing, wearing a mask and limiting gatherings. And he also welcomed news of vaccines.
“Because I really believe the vaccines will be a big step in the right direction to helping us slow the spread and get better control of the virus.”
Reporters Katherine Burgess and Samuel Hardiman contributed to this story. Producer Ray Padilla created graphics.
Investigative reporter Daniel Connolly plans follow-up stories on this issue and would like to hear about your ambulance experience, whether you’re a paramedic, another health care worker, a patient or a caregiver. You reach Daniel at 901-529-5296, daniel.connolly@ commercialappeal.com or on Twitter at @danielconnolly.