Just before Mother’s Day, Apfollo Harvey Sr. watched his mother struggle to breathe while waiting 40 minutes for an ambulance to arrive. He could not feel her pulse as the 73-year-old diabetic lay still.
“I was so scared,” he said. “I thought the worst.”
Harvey’s long wait for an ambulance is not unusual in situations where the lives of south Fulton County residents can be at risk. By two different measures, ambulance service is falling short, an Atlanta Journal-Constitution investigation found.
From Sept. 1, 2018 to Jan. 10, there were more than 830 occurrences in which no ambulance was available in the 200 square-mile territory, according to county data. That’s what EMS officials call “level zero.” Sometimes, ambulances became available in only seconds or minutes. Other times, no matter how serious the injuries, a transport wasn’t available for up to an hour.
With so many level zero instances, average response times were also affected. With emergency calls, it's considered vital to arrive within nine minutes to save the most vulnerable patients. But south Fulton residents can't count on ambulances arriving that fast, county officials say. Average response times in some cities of south Fulton this spring were as long as 20 minutes, according to dispatch records.
In either situation, callers all too often were told that help was on the way when none seemed to arrive.
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One Fairburn woman who had overdosed lay unconscious for 27 minutes while her family panicked. A 41-year-old man with Crohn’s disease — who could barely speak on the call but said he was having trouble breathing — waited 19 minutes. A 71-year-old woman vomiting blood waited 42 minutes.
And it took 16 minutes to get to the 48-year-old man who was shot in the leg on South Fulton Industrial Boulevard.
The pleas for help, documented in 9-1-1 tapes, are excruciating.
“I’m laying in the parking lot,” the shooting victim, barely able to speak, told a dispatcher. “It just happened … just send them please … just send them, OK.”
“We need an am-bu-lance,” another caller shouted at the top of his lungs. “C’mon, we need ambulance … where you when we need you!”
The problem isn't a new one. Fire chiefs and local leaders who represent the communities in south Fulton have long voiced complaints of the poor service. Last year, to address the concerns, Grady EMS was chosen to replace the region's private ambulance provider. Grady pledged several improvements, including that it would average a nine-minute response to the most critical calls.
County officials say it has yet to fulfill that promise since taking over service July 1. Grady is “not even close to the nine minutes,” said Joseph Barasoain, director of emergency services for Fulton County.
South Fulton fire chiefs and Fulton EMS officials say that Grady has not provided ambulances and other resources necessary to fulfill its promises. What’s more, they say, Grady isn’t being held accountable for lagging response times.
Barasoain says that when he raises an issue with Grady, “basically, they tell us they do the very best they can.”
“If we had the power, then we could say, ‘Grady, this is what you’re going to do,’ but we can’t tell Grady anything,” he said. Fulton doesn’t get to choose its ambulance provider; state law gives that power to the Georgia Regional EMS Council, which is under the Georgia Department of Health.
Grady, however, has said it is hitting its milestones in some of the cities in the south Fulton area. Where it falls short, it pins the problem largely on the vastness of the geography.
The south Fulton territory includes urban sections of Atlanta, then suddenly shifts to rural terrain in the cities of Palmetto and Chattahoochee Hills. Palmetto, at the southern tip, has 5,000 people across its nearly 12 miles. The city of Chattahoochee Hills is mostly rural across its 51-square miles.
That has made the effort in south Fulton a challenge, said John Hanson, vice president of administrative emergency medical services for Grady.
"If we had the power, then we could say, 'Grady, this is what you're going to do,' but we can't tell Grady anything." —Joseph Barasoain, director of emergency services for Fulton County
Grady also says that some problems are the result of its not having control of dispatch throughout the entire area. Fulton County runs the dispatch from its headquarters in downtown Atlanta for most of the area, with Grady responsible for dispatch in College Park and East Point. Grady says if it gets full control, it will be able to more quickly move ambulances to locations where they are needed.
Fire chiefs have resisted that idea, however, because they believe it would remove a layer of oversight. By controlling dispatch, fire chiefs can track Grady’s responsiveness. When ambulances are slow to arrive, it can tie up first responders who try to fill the gap.
Meanwhile, other top Grady officials have painted a rosy picture to the EMS council.
In February correspondence to the state, Steve Moyers, vice president and dean of education for EMS at Grady Health System, said the provider was close to accomplishing its goals. In the correspondence, he wrote: “We continue to receive praise and accolades from our communities of interest.”
“Things seem to be going very well,’’ Moyers told the crowd. The fire chiefs in south Fulton, he said, were “quite pleased with what we’re doing.”
Lives at stake
It’s not clear if the tardiness of ambulances has cost a life. To determine that, experts contacted by the AJC said they would have to review every patient’s discharge records from hospitals.
But they told the AJC the data contained alarming trends. More than 160 callers canceled their 9-1-1 call for help, as some lost patience and said they got their own ride to the hospital.
At times, callers held on the line for several minutes while dispatchers gave them instructions before medics could be sent to help them.
Norman E. Hayes, who lives in the city of South Fulton, said several elderly neighbors have told him that, when the time comes, they fear that they will have to find their own way to the hospital or be left to die. One neighbor with chest pains dialed 9-1-1 – a week after New Year’s – and was put on hold for nearly 13 minutes, due to a situation in which no ambulance was available to respond a call, records showed. Ultimately, the neighbor cancelled the call and got a private ride to the hospital, records show.
“I know everyone is worried,’’ Hayes said.
Grady doesn’t track the level zero calls because the situation is “so dynamic,” said Bill Compton, senior vice president of Grady Emergency Medical Services. Grady ambulances are rolling through the south Fulton area throughout the day, so lag time on response is always changing.
What’s important, Grady says, to track response times to calls where lives are at stake.
“Everything during the day that has to do with the time between (when) a person called and the time the ambulance gets there, that end result is what we’re concerned about,’’ Compton said.
To try to meet timeliness goals, he said, Grady provides enough ambulances to meet what historic data shows is the likely call demand.
Experts said most ambulance providers do staff based on projected call volumes. But EMS officials say the two metrics — level zero calls and average response times — go hand in hand.
“As you can probably imagine, the more often you go to level zero, the worse your response times are going to be,’’ said Matt Zavadsky, chief strategic integration officer at MedStar Mobile Healthcare, which serves 435 square-miles of North Texas, including Fort Worth.
Mike Gnitecki, a paramedic from UT Health East Texas Emergency Medical Services, said the sheer lack of resources on so many level zero calls in south Fulton increases the chances of a loss of life or a worsening condition.
“Ultimately, if there are so many instances of level zero, that means there are not enough ambulances on the street,’’ Gnitecki said. “This is a serious issue and it deserves public scrutiny. Ultimately, it’s truly going to come down to how long are people having to wait for an ambulance when an emergency happens, and that’s going to be a very big thing.”
The bottom line on the availability of ambulances is money. Ambulance providers largely depend on reimbursement by insurers and government programs. But in economically disadvantaged areas, where some people don't have insurance and others depend on Medicaid, resources can be strained, limiting the number of ambulances and what services can be supported.
Subsidies run out
A decade ago, there wasn’t such an acute shortage of ambulances, Fulton County officials say.
Prior to 2009, Fulton County provided millions of dollars in subsidies to its ambulance providers for clear performance standards and response times. Among the standards, there were requirements for the number of ambulances and other resources dedicated to south Fulton.
When the subsidy money ran out in June 2008, as the great recession hit, the system began to break down, EMS officials say.
The halt in funding removed an important layer of oversight that county EMS officials could use to hold ambulance providers accountable to the promises they made as part of their contractual agreements.
“Without that, providers really can’t be forced or coerced into adhering to whatever measure you want to use to meet standards,’’ said Henry Argo, fire chief for the city of Palmetto.
American Medical Response, which was the ambulance provider for south Fulton before Grady was chosen, repeatedly said that it would need a subsidy to provide more resources and reach the goal of nine-minute response times.
AMR was averaging wait times of more than 20 minutes across the territory, according to data compiled by Charles Perdomo, who before taking on the role of the Fulton County’s EMS manager in July 2017 was an Oregon fire chief and a lieutenant with the Miami-Dade Fire Rescue.
"At some point, somebody has to say we've got to do something about it. You can only stand back and not do anything about a problem for so long before now you become negligent." —Charles Perdomo, Fulton County's EMS manager
Concerned about the waits, he reached out for help to the regional EMS director, EJ Dailey. She told him that she had heard about complaints but there was no documentation on the response times, he recalled. “Without documentation, we can’t investigate,” he said he was told.
Perdomo said he felt compelled to compile the data himself.
The AJC obtained the data through a request under the Georgia Open Records Act.
“At some point, somebody has to say we’ve got to do something about it,’’ Perdomo said. “You can only stand back and not do anything about a problem for so long before now you become negligent.”
Dailey did not respond to a request for comment. An official at the Georgia Department of Public Health confirmed that concerns of slow response times had been discussed at a November 2017 meeting of the regional EMS Council.
Terence Ramotar, regional director of AMR, said he put together a proposal that would have shaved times to 12 minutes on life-threatening calls. But he said he told DPH and the region’s EMS Council that anything better than that in the vast area would require the county to provide some funding.
“We were well aware that a nine-minute response time could not be achieved without other means of support,” he said.
Instead, after Fulton County shared data it compiled about service problems in south Fulton, the EMS Council decided to consider proposals from other ambulance providers. Only AMR and Grady submitted proposals.
Grady said it could meet the nine-minute goal without subsidies.
Hanson, vice president of administrative emergency medical service for Grady, said it pledged that because nine minutes is the industry standard on calls that require immediate medical attention.
“That was the appropriate response time, comparable to what we do in Atlanta,” he said.
Perdomo said he stopped compiling the data on response times and level zeroes in January. He said it was seen by EMS officials as contentious and no longer needed to investigate complaints.
At its May 9 meeting, members of the EMS council said it would continue to monitor Grady’s performance in south Fulton.
Grady is expected to meet with county EMS officials in June to provide updates.
Average response times vary
Fulton County EMS is responsible for the dispatch of emergency medical calls for most of south Fulton County. After a call is received, the information is shared with Grady EMS, which provides ambulance services. (For the cities of College Park and East Point, which also lie in south Fulton County, Grady is responsible for dispatching the calls and providing ambulance services.)
Here is a breakdown of ambulance response times for March 2019 for each of the six communities that receive dispatch services from Fulton County EMS. The information is retrieved from the computer-aided dispatch of Fulton County EMS.
The Fulton Industrial Boulevard area
The area: The 7.5 square miles has a population of only 450, but it is considered among the largest industrial and business complexes in the Atlanta region. It had 2,172 calls in 2017.
Time from call received to on-scene: 18:14 minutes
City of South Fulton
The area: 106 square miles with a population of 96,000. It had about 12,509 calls a year.
Time from call received to on scene: 15:34
Chattahoochee Hills
The area: 51 square miles with a population of 2,690. It had 302 calls.
Time from call received to on scene: 20:29 minutes
Fairburn
The area: about 17 square miles with a population of about 13,967. It had 2,173 calls.
Time from call received to on scene: 15:28
Palmetto
The area: 11.6 square miles with a population of 4,421. It had 930 calls.
From from call received to on scene: 13:15
Union City
The area: 19.3 square miles with a population of 20,805. It had 4,783 calls.
Time from call received to on scene: 14:01
(Source: Fulton County EMS)
While first responders, such as police and fire crews, may quickly respond to some emergency calls, they may not have paramedics or the equipment needed to save lives. That’s why it can be crucial for an ambulance to be on the scene within a few minutes.
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