City’s Approach to Medical Emergencies is Being Reshaped By COVID-19

Heart attacks in New York City are different amid the COVID-19 crisis.

If you called 911 in February to report that someone had gone into cardiac arrest, four emergency vehicles were likely to race to help. There’d be an FDNY engine carrying an officer, a driver and three firefighters certified in CFR-D, an advanced level of training in first aid and cardiopulmonary resuscitation. Two ambulances would show up: a “basic life support” or BLS rig staffed by two emergency medical technicians (EMTs), and an ALS or “advanced life support” ambulance carrying two paramedics with more advanced training. Finally, an officer from the FDNY’s emergency medical service would pull up to oversee the response. The firefighters and the EMTs might rotate performing CPR as paramedics conducted other procedures. If efforts to revive the victim on the scene did not work, one of the ambulances would transport the victim to the hospital for last ditch, advanced medical treatment.

With the city’s emergency medical service facing the greatest strains in its history, FDNY has altered key elements of its response to emergencies. Some of the changes affect the approach to heart attacks.

If you called in a cardiac arrest today, no BLS ambulance would arrive. And if a victim did not respond to resuscitation efforts within 20 minutes, they would be pronounced dead on the scene.

These reflect changes big and small that are percolating through the EMS system as it grapples with COVID-19.

A cascade of changes

Medical emergencies in New York City are categorized into one of eight segments, and fire engines have for decades responded to segments 1 through 3. As the coronavirus crisis set in, however, FDNY ordered fire companies to no longer respond to most segment 2 (difficulty breathing or unconscious person) or any segment 3 (major injury) emergencies—a move to reduce potential exposure to the virus and preserve the supply of personal protective equipment, according to the the department.

FDNY engine companies still go to all segment 1 events, which include cardiac arrests and choking. But because engine companies aren’t responding to most segment 2 or any segment 3 events, BLS ambulances are focusing on those emergencies and not going to segment 1 calls. That means fewer people with well-honed CPR skills at a heart attack scene.

Other changes are subtler and affect non-emergency calls. Two veteran FDNY paramedics tell City Limits they are, for the first time in their careers, counseling some of the people they treat to stay home rather than go to the hospital. That’s because many of the calls that have helped set records for 911 responses over the past three weeks are people who are not very ill, just worried. “I tell them, ‘The last place you want to be right now is a hospital,’” one medic says. “The city hospitals aren’t capable of handling it. Stay the f–k home.”

Meanwhile, the FDNY has deployed five “rapid response cars” in the Bronx staffed by firefighters to drive to 911 calls for segment 2 and 3 emergencies and assess the scene. That’s been done before, during winter storms, but this deployment could be far longer.

FDNY ambulances have now been equipped with the Lucas device, an automated system for chest compressions during CPR. That device had previously been issued to ambulance crews, then taken away but, “We were recently given them back due to current pandemic issues,” says Richard Guzman, who has been an FDNY paramedic since 2010 and worked in private ambulance services for eight years before that.

Other changes could be coming. Last week the Regional Emergency Medical Advisory Committee (REMSCO), which sets care guidelines for emergency medical response in the city, said that the city could spread its resources thinner: Staffing ALS ambulances with one paramedic and one EMT, as opposed to two medics, and BLS rigs with one EMT and a firefighter driver, as opposed to two EMTs.

FDNY has yet to make that staffing shift, which would depart from years of practice in New York City, but is the custom in some other localities. New York City paramedics say having two highly-skilled responders on the same rig is a far better approach, because they can consult one another on the best approach to complex, life-threatening situations.

‘A fractured system’

The COVID-19 crisis is by far the harshest test the city’s emergency medical system has ever faced. The medical service is a footnote in most histories of the September 11 terrorist attacks, although 10 emergency medical workers—two of them FDNY paramedics—perished at Ground Zero, and many others have been since sickened by their work there.

EMS in New York City is “a fractured system,” according to George Contreras, a 30-year veteran of EMS who teaches at John Jay College and the New York Medical College Center for Disaster Medicine. The 911 system includes both the city’s ambulances and those operated by hospitals, or by private companies contracted by the hospitals. City ambulances shoulder the bulk of the load—about 65 percent of calls in a given year—and pick up slack when the private firms bow out, as in 2018, when New York Community Hospital withdrew from the 911 system.

The city’s ambulances were operated by Health + Hospitals until 1996, when Mayor Giuliani merged EMS with FDNY. The move was cast as a bid for greater efficiency and better response times, but it also created a new purpose for engine companies during an era of far fewer fires. In 2018, FDNY fire companies responded to 41,000 fires and 300,000 medical emergencies.

A 2013 report by the Independent Budget Office found the city’s merged medical service was displaying better performance by many measures. More recently, however, IBO has documented increased overtime in FDNY’s ambulance corps. That could reflect a failure of EMS staffing to keep up with city population growth. City budget documents indicate that the number of FDNY EMTs has increased over the past decade—from 2,000 in fiscal year 2011 to 2,600 in the current year—while the number of paramedics has remained more or less flat: There were 769 in 2011 and 787 this year.

Others see flaws not in the city’s staffing, but in its approach. “Many of the incidents to which the EMS responds are not medical emergencies, but rather avoidable or unnecessary requests for assistance that could be handled better in ways other than sending an ambulance,” a 2018 report by the Citizen’s Budget Commission, a fiscal watchdog, contended. “The use of fire engines in addition to ambulances as a response to medical incidents is wasteful; the heavily staffed fire engines are far more expensive than ambulances as a response, and in many of the incidents to which they respond, fire engine personnel are not able to deal effectively with the medical condition.”

But sources say that math doesn’t reflect medical reality. On segment 2 and 3 calls, the FDNY crew is waived off if an ambulance gets there first, or leaves once an ambulance arrives, so there is limited overlap. And they say that on segment 1 calls—where a person teeters on the border between life and death—having extra hands is handy, especially during the physically exhausting performance of CPR.

Complaints of second-class status

While firefighters work closely with city EMTs and paramedics at emergency scenes, there are stark demographic differences between the two sides of the FDNY: fire companies are still overwhelmingly White, while a significant share of EMS is Black or Latino. Cultural differences are also there: Some veteran medics feel EMS is thought of as merely a waiting room for aspiring firefighters, because EMS members can get into the Fire Academy by taking a “promotional” exam—nomenclature that EMS lifers find offensive, because it implies that work in a fire company is superior to that of an ambulance crew.

The COVID-19 crisis is sharpening long-standing complaints by the EMS union about the pay differential between the two sides. Firefighters make between $44,000 and $85,000, maxing out well above FDNY paramedics, who earn $48,000 to $66,000 a year. EMTs’ salary range is $35,000 to $53,000.

“The fact that the mayor believes that $16 per hour is a living wage in this city for FDNY EMS workers, but insufficient for his own staff or others, is highly disturbing,” Oren Barzilay, the head of the FDNY EMS union, Local 2507, said in a statement last week. “The fact that he is willing to risk the lives of the FDNY’s dedicated EMS workforce for only $16 per hour is shameful.”

Asked about those concerns, Mayor de Blasio deflected. “We’re going to work with that union going forward,” he said Friday. “Those are long-term issues that can’t be decided in the middle of the crisis.”

The longest call

Contreras was active in the emergency medical service for the deadly 1993 attack on the World Trade Center, and the catastrophic assault in 2001. “What makes it even worse this time is that it is not a short-lived incident. This incident is lasting for weeks and probably months to come,” he said. “I never expected that I would see NYC EMS in this state of distress. Even during September 11, it was not this bad.”

FDNY EMS personnel, who typically do 12-hour tours, are now regularly working 16-hour shifts. Personal protective equipment is in short supply. Because they are involved in specialized rescue work, FDNY “haztac” ambulances are equipped with breathing apparatus for paramedics to use, but crews have been told not to employ them in COVID-19 responses according to Guzman. The pace of calls is non-stop, medics say—although the coronavirus-related cases fall into two distinct categories, according to Guzman. “There is a great increase in those less ill that are simply seeking answers to questions they have about the COVID-19 virus,” he said. “Those that are truly sick are critical and the numbers have been increasing by the hour.”

Contreras says the phenomenon of mildly ill people calling ambulances is not new. “Even under normal circumstances, people call 911 for many non-emergency calls,” he says. Those callers could go to the hospital on their own, but, “Many people still think that they will get seen faster even if they arrive via ambulance which is certainly not the case.”

It certainly isn’t the case now. Paramedics say they have never seen such long triage times for their patients at hospitals—time when the sick person remains strapped to the ambulance stretcher and the EMS crew remains with them, unable to answer other calls.

“The system is beyond taxed,” the other medic says. “This is 9/11 but on a different scale. A global scale.”

The loss of the BLS ambulance at segment 1 scene has been significant, Guzman said, especially since it takes so long to don PPE before beginning a job: “The time to get hands on to perform CPR has increased drastically.” What’s more, according to Contreras, a firefighter now drives the ambulance to the hospital, because both paramedics need to be in back working on the patient. When EMTs were at segment 1 scenes, one of them would do the driving. Now that a firefighter takes the wheel, it can put his or her engine out of service for a period.

No comfort

In its guidance on what to do with heart attack victims, REMSCO last week said, “victims of cardiac arrest, who do not respond to CPR and other standard treatments according to existing treatment guidelines, will be pronounced on the scene.”

“Due to the tremendous volume of patients in our Emergency Departments, patients who are pronounced on the scene will not be transported to an emergency department,” the guidance read. “Emergency Departments are severely overcrowded and transporting patients pronounced on the scene only increases ED workload and potentially exposes ED staff and patients to COVID19.” Ambulance crews are instructed to leave the NYPD in charge of the body or call the medical examiner’s office.

Contreras says the move is hard to stomach, but makes sense. “What we are currently seeing is principles of disaster medicine at work where we have to make very difficult decisions because of the austere environments,” he says.

For Guzman, the impact of social-distancing makes that harrowing moment, when CPR stops and hope ends, even harder.

“It’s hard to just pronounce a person and leave them there with family grieving. And now with the CoVid-19 issues, we can’t even console the families like we used to,” he said. “It’s becoming even more sad on a daily basis.”