The child in the grips of a severe seizure had to get to a trauma center right away. But as the minutes ticked by, a transport was nowhere in sight.
With every passing moment, Shanna and Terry Tolbert watched as their 2-year-old turned a deeper shade of blue. The child wasn’t getting enough oxygen, and the seconds seemed like hours for the young Dunwoody couple.
More than 20 minutes later, an ambulance pulled into the drive. But the Tolberts were gone. They were racing to the hospital, holding fast to their daughter half-strapped into her car seat.
“We had waited long enough,’’ Shanna Tolbert said. “If we let her continue to seize, we risk our daughter having brain damage or death.”
The public measures the adequacy of its emergency response services by the ticking of the clock. Do response times matter and when do they matter most? It is an issue now up for debate across DeKalb County, where examples of delays, like in the Tolberts’ case, have eroded public trust.
DeKalb County officials have committed more resources to try to reduce response times of its private ambulance company and improve services. Now, the county is taking the unprecedented step of conferring with cities as it prepares to re-bid the ambulance contract. But the county may have a tough time trying to persuade the public that it has addressed the problems. Data over the last year shows response times in virtually every city in DeKalb exceeded the county's nine-minute goal, in some cases by several minutes.
The county has been advised by one of its consultants that response times aren’t critical in most cases.
Yet, in a matter of minutes, a stabbing victim can bleed to death. A cardiac patient will die if life support is not performed. Even a slow response on a call that is not a life threat can chip away at public confidence, experts say.
“There is an expectation that if you dial 911, somebody will be there pretty dog-gone rapidly,’’ said Kyle Thornton, president of the National Association of State EMS Officials. “There has to be a way to recognize that and respect that.”
‘Inexcusable’
A meeting to draw input from cities — set for Thursday — comes just before the state is to decide whether to allow Dunwoody to operate its own service or keep DeKalb in control in all its cities.
The county has already promised additional sites to Brookhaven, which has built good will with the town’s city manager.
“I’m quite certain that the new terms and business model will assist in addressing any performance issues throughout the county,’’ City Manager Christian Sigman said.
The ambulance company, American Medical Response, says the delays are largely the result of long wait times at hospitals, where ambulances are held up for patients to be placed in beds, and it has been working closely with the county to improve response times.
But officials in Dunwoody are skeptical that the county will devote enough resources to manage needs over the long-term, after years of unanswered pleas to DeKalb for better service from American Medical Response, which has had the contract since 2013.
Mary Jo Thrasher, a Dunwoody resident whose husband died of a cardiac arrest last year, said DeKalb needs to be accountable to citizens if it is chosen by the state to continue as the sole ambulance provider for its 13 cities.
“People’s lives depend on the decisions they are making,’’ Thrasher said.
She said the incident that involved her husband is now mostly a blur. But police and fire arrived five minutes after she dialed 911 when her husband stopped breathing. The ambulance that carried the vital advanced life support equipment, however, did not show for 40 minutes. Sixty-seven-year-old Craig Thrasher was immediately pronounced dead at the hospital, she said. Documents obtained by The Atlanta Journal-Constitution showed he was the second cardiac victim in Dunwoody in less than a year to have experienced ambulance response times of more than 30 minutes.
“Whether the ambulance would have gotten there sooner, I don’t know if it would have made a difference,’’ Thrasher said. “But I still think it was inexcusable for them to take so long to get here.”
Others are concerned about the well-being of the county’s most vulnerable citizens, whose lives depend on an immediate transport.
Ireland Tolbert, who is now 3 ½, was born with a medical condition that triggers life-threatening epileptic seizures. The seizures are sporadic and do not subside until she is treated at a trauma center, her mother said.
The May 2017 incident was not the Tolbert family’s first cry for help. Six months before, it took an ambulance 28 minutes to respond. A report of the incident showed that the first ambulance that answered the call drove in the wrong direction and another had to be called.
Shanna Tolbert said the chances that her daughter will have more seizures is likely. Then what happens?
“No parent should find themselves having to make that decision, ‘Do I keep waiting on an ambulance or do I take my child?’” she said. “It’s like what is the least evil here because they are both terrible options.”
No standard
National bodies of EMS officials can’t agree on a standard response time to measure an appropriate response. That’s how delicate of an issue it is, Thornton said.
“No one has the political will to say that,’’ he said.
Right now, the industry operates on a general goal of about eight minutes. The threshold is based on research published in the Journal of American Medical Association in 1979 showing that response to out-of-hospital sudden cardiac arrest was distinctly improved if basic life support arrived within four minutes of EMS activation and advanced life support or defibrillation arrived within eight minutes.
But the job falls to local governments to develop a contractual obligation that establishes the standard and holds providers accountable. In DeKalb, there has been widespread debate recently on social media and community newspapers about whether the roughly nine minute standard is fast enough.
After a consultant hired by the county made comments that some residents believed were dismissive of the importance of EMS response to emergencies, some citizens were outraged.
“That’s absolutely ridiculous,’’ Shanna Tolbert said. “People die in an ambulance often. Even five extra minutes matter. Heck yeah, response times do matter.”
The consultant, Scott A. Clough, principal of AP Triton, a California consulting firm that crafts public safety solutions, addressed the issue last month in a room packed with residents and EMS officials.
“If we look at evidence-based research … the evidence is very compelling that response times have no impact on patient outcome and long-term rehabilitee system, with the exception of STEMIs (cardiac arrest), strokes and a very small amount of trauma patients,” said Clough, a retired fire captain, battalion chief and paramedic.
Triton’s website describes Clough as recognized for his “run it like a business” strategy to providing EMS services. Clough did not respond to an email and a voice message left at AP Triton offices or to a request for comment through DeKalb County.
DeKalb Fire Chief Darnell Fullum later clarified in a letter to a community newspaper that response times are critical, but some cases require faster response than others and the county’s plan is to improve services by strengthening triage.
Assessing urgency is important, Thornton said.
EMS typically handles dozens of calls per day, going from one to the next, barely stopping to take breaks, as needs outpace resources, he said. Because there are too many calls to handle, ambulances can be delayed.
So, EMS is taught to prioritize calls that pose a life threat. Of those that are, 8 to 12% require immediate intervention, Thornton said. The problem that arises: No one knows if something is a life threat unless there is a medic on the scene to evaluate the patient.
“Our job is to differentiate patients who have life threats from those who don’t,” said Thornton, who is the EMS bureau chief of the New Mexico Department of Public Health. “If we cannot find that life threat in a reasonable amount of time, then we are way behind the clock and that jeopardizes the patient even further.”
Take the case of a Dunwoody woman who was found unresponsive on the pavement. The woman apparently had lost her balance and fell while walking her three dogs, said Anne Hicks, a neighbor who found her.
Was it possible that she had just suffered a knot in her head? If so, the response time probably would not have been so critical. A medic on the scene would have been able to quickly evaluate the patient and identify whether rapid transport to a trauma center was needed. There are also nuances that the medic would be able to identify. Did the patient suffer a loss of consciousness? Changes in the level of response? An increase in the heart rate? Abnormal blood pressure? None of these assessments can be made if the medic is not there.
Hicks said it was scorching hot that day in June as neighbors, Dunwoody police and fire waited 30 minutes for the ambulance. She said she tried to keep the woman comfortable with cool packs as they waited.
“Those 30 minutes felt like hours,’’ Hicks said.
At the hospital, the woman went into coma and died days later of a severe head injury.
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Your right to know
As the state Department of Public Health considers whether DeKalb County will keep control of ambulance service in all its cities, it asked DeKalb to provide a variety of data, including average response times.
The AJC requested that data from the county itself and from DPH. DeKalb provided it electronically in under an hour at no cost under Georgia’s open records law.
It took the state several days to respond. A lawyer with the agency sent the AJC an estimate of $960.72 to provide the records.
Meredith Grant, associate general counsel, privacy officer for the Georgia DPH wrote: “After giving you credit for the first quarter hour at no cost, we estimate it will take us an additional 24 hours to fulfill the request. The hourly salary of the lowest paid full-time employee qualified to fulfill the request is $40.04 per hour. Therefore, we estimate it will cost $960.72 to provide the records you have requested (24 hours x $40.04/hour = $960.72)
“This is simply an estimate; the final charges may be more or less than the estimate. We further estimate the requested records will be ready for production in two weeks.”
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By the numbers
105,000 — the number of calls received by public safety dispatchers in DeKalb County last year.
52,000 — the calls that were for emergencies.
Nearly 15 minutes — Dunwoody reported ambulance response times for 90% of calls in 2017
10 minutes, 52 seconds — The city’s 90% average for a total of 4,264 incidents in a recent 12-month period.
13 minutes, 22 seconds — Stonecrest’s 90% average response time for a total of 7,443 incidents.
12 minutes, 18 seconds — Doraville’s 90% average response times for 1,505 incidents.
11 minutes, 17 seconds — Chamblee’s 90% average response time for 2,975 incidents.
16 minutes, 2 seconds — Decatur’s 90% average response time for 227 incidents.
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