A big difference between emergency medical services in the District and in the Maryland and Virginia suburbs is that suburban services rely heavily on volunteers, while DC hasn’t had volunteers for more than a century.
The combination of volunteers and career people has served Maryland and Virginia well, according to EMS experts in both states. “Our volunteers are trained just like our career people, and all are required to be qualified in fire suppression and EMS,” says Ned Sherburne, himself a volunteer and chief of the Bethesda–Chevy Chase Fire and Rescue Service.
DC’s Fire and Emergency Medical Services agency is funded by tax dollars; emergency services in the suburbs are funded by both tax money and donations. B-CC Fire and Rescue is almost completely supported by private donations and endowments.
EMTs in all the suburban jurisdictions are also trained in fire suppression, and there appears to be little of the friction between fire and emergency medical personnel so evident in DC.
“Some firefighters don’t like to do EMS, mainly because of all the paperwork, and some EMTs don’t like to do fires,” says Sherburne, “but the majority of our people like to do both.”
Volunteers work a certain number of hours each week and are given lots of responsibility. At both the B-CC and Glen Echo departments in Maryland, all-volunteer forces cover nights and weekends. Fire/EMS forces in St. Mary’s and Calvert counties are all-volunteer.
EMS departments in most outlying Virginia suburbs have more volunteer than career people. The closer you get to DC, the higher the percentage of career EMS officers, says Melinda Duncan of the Northern Virginia EMS Council. There are 1,400 volunteer and 500 career fire-and-rescue-service providers in Loudoun County; Prince William has about 1,300 volunteers and 500 career officers. Fairfax County has a career EMS staff of 1,400 and 250 volunteers. Arlington and Alexandria have relatively fewer volunteers.
Salaries and benefits for career EMTs in Maryland and Northern Virginia are generally better than they are for civilian EMTs in DC, and training-and-certification programs are more rigorous. The entry-level salary for civilian EMTs in the District is $41,218; for firefighter EMTs it’s $44,301. In Montgomery County, the beginning EMT salary is $43,278; firefighter EMTs in Arlington County start at $44,636, in Fairfax County at $48,278.
In Maryland, both volunteer and career EMTs must meet statewide training-and-certification standards. Maryland also has statewide standards for emergency medical protocols, which means patients with similar medical conditions will be treated the same way whether they’re in Baltimore or Bethesda. The state regularly updates its medical protocols.
Maryland’s integrated statewide EMS system—singled out for excellence in a 2007 Institute of Medicine study—is administered by the Baltimore-based Maryland Institute for Emergency Medical Services Systems (MIEMSS). Established in 1972 as a statewide trauma system that designated certain hospitals as trauma centers, MIEMSS is an independent agency governed by an 11-member board; it’s funded through a surcharge on vehicle registration. MIEMSS divides the state into five regions; Region V comprises Montgomery, Prince George’s, Calvert, Charles, and St. Mary’s counties.
A statewide communications system is headquartered at the Emergency Medical Resource Center (EMRC) in Baltimore. When a Beltway accident recently injured nine people, Sherburne says, he was put in contact through EMRC with three hospitals—Holy Cross, Suburban, and Shady Grove—to coordinate which patients should be taken where.
Virginia doesn’t have a statewide EMS system like Maryland’s, but Northern Virginia EMS departments are medically driven and regularly update their medical protocols. EMS departments in both states provide EMTs with all the drugs needed for emergency care, including Valium and morphine, neither of which District EMTs have.
Like Maryland, Virginia has a training-and-certification program for EMTs, and emergency services maintain ongoing dialogue with medical facilities.
Jurisdictions in Northern Virginia have similar EMS protocols. According to Melinda Duncan, Northern Virginia EMS agencies take a regional approach: “Everybody has everybody else’s information, so if the closest unit to an emergency is in another county, that unit goes across the county line because it is the closest.”
The Fairfax County Fire and Rescue Department’s Task Force I, established in 1986, is an internationally recognized disaster-response team that includes 200 specially trained career and volunteer firefighters and EMTs with expertise in the rescue of victims from collapsed structures. Besides responding to local emergencies, Task Force I has traveled to help out after disasters such as earthquakes in Turkey and Pakistan.
Northern Virginia’s 2.2 million people are served by about 5,000 EMTs operating out of more than 80 EMS or EMS/fire stations. In 2007, Northern Virginia EMS departments responded to more than 230,000 emergency calls, Duncan says.
Maryland’s Region V has a little more than 2 million residents served by 6,400-plus EMS providers, more than half of them volunteers. They operate out of 121 EMS and EMS/fire stations—Prince George’s County has the most, with 45—and in 2007 responded to 260,856 EMS calls and made 123,937 transports.
In 2007, the District’s EMS responded to 121,415 medical calls that resulted in 76,841 transports; DC has a daytime population of more than 1 million people.
Both Maryland and Virginia are developing specialty medical centers for stroke and heart problems similar to those they now have for trauma. Maryland has designated 29 primary stroke centers, among them Suburban, Holy Cross, Shady Grove, Montgomery General, and Prince George’s Medical Center.
Both Maryland and Northern Virginia allow patients to choose the hospital they want to go to in nonemergency cases; in emergencies, patients are taken to the nearest available emergency department or specialty center. “Right now about 85 percent of patients are taken by EMS to the nearest hospital,” says MIEMSS executive director Dr. Robert Bass, “and 15 percent go to a specialty center.”
One problem Maryland and Virginia share is increasing difficulty in recruiting volunteers. “We’re struggling to keep a volunteer force just like everyone else,” says Northern Virginia’s Duncan. “The economy is keeping some people away.”
Sherburne says B-CC Fire and Rescue recruits “all the time—you can never stop recruiting money or people.” It brings in six to ten volunteers a month and keeps two or three for a year or more.
Recruitment is most critical in the all-volunteer forces in Prince William and Loudoun counties in Virginia and St. Mary’s and Calvert counties in Maryland. A disadvantage of volunteer forces is that they have fewer paramedics—the most highly trained EMTs—because of the amount of time and training required to become one.
The possibility of fewer volunteers and the prospect of replacing them with career EMTs have given added urgency to the issue of billing patients for EMS transports. The District now bills $408 for a basic-life-support transport and $508 for advanced; it took in about $12.3 million in transport fees in 2008.
Arlington and Alexandria both bill $400 to $675, depending the type of emergency. Fairfax also collects EMS-transport fees. Private insurers and Medicare reimburse varying amounts for EMS transports.
Duncan says some volunteer EMS agencies in Northern Virginia do not bill, in part out of fear that doing so will reduce donations. As of now, neither Loudoun nor Prince William county—both volunteer agencies—charges for EMS transports.
Maryland counties’ billing policies vary. Montgomery County EMS chief Michael McAdams favors billing, noting that aging fire/EMS stations are in need of repair and that many ambulances need replacing; transport fees would net about $12 million the first year.
County fire and EMS volunteers generally oppose charging. A proposal to begin charging was tabled recently by the Montgomery County Council. Prince George’s bills for EMS transports, as do Charles and Frederick.
Like the District, most jurisdictions in Maryland and Virginia employ “soft billing.” Bills are sent electronically to a health insurer, but if they’re not paid, no one is dunned. Says Maryland Region V administrator Marie Warner-Crosson: “We don’t want anyone to be denied medical care because of money.”