Underfunded and Understaffed: Our Local EMS System is in Crisis

This is the first part of a two-part exploration of the challenges facing local EMS systems. In part two, the Herald will explore potential ways that the systems can be improved and steps that have been proposed.

The roads in northeastern Dutchess County were covered in ice on Jan. 28. Police and Emergency Medical Services (EMS) were busy with accidents: five in Milan and just as many in Stanford. En route to a minor car crash on the southbound Taconic State Parkway, a local first responder spotted a vehicle that had slammed into a tree. “I pulled over because the situation looked serious, and it was,” he said.

By the time the first responder parked his privately owned vehicle, the victim, who suffered a broken arm and leg, had already called 911. “I couldn’t do anything for him,” said the first responder, who spoke to the Herald on the condition of anonymity. “He needed a spinal board and a Hare traction splint, both of which I didn’t have. What he really needed was an ambulance.” The first responder placed another 911 call; an emergency vehicle arrived 20 minutes later. “That took too long for an injury like this,” the first responder said. “It shouldn’t have happened.”

The caller on the Taconic was one of many experiencing longer response times for emergency services. Across the nation, 4.5 million people live in “EMS deserts,” where people live more than 25 minutes from an ambulance station. In New York, over 80% of counties are considered EMS deserts. The problem is greater in rural counties like Dutchess and Columbia, where ambulances must travel long distances and populations tend to be sicker, poorer and older, leading to escalating call volumes. This, and a decline in emergency services staffing and funding shortfalls, has created a crisis.

Each town in the Pine Plains Central School District has found a different way to manage its EMS. Stanford created a tax district and hired a professional ambulance service, Northern Dutchess Paramedics (NDP), in Rhinebeck. NDP and Copake Community Rescue render aid to Gallatin. Ancram is served by the Copake squad. Milan and Pine Plains, which rely entirely on volunteers, have a verbal agreement with NDP: Because local responders aren’t on call during the workday — 6 a.m. to 6 p.m. — NDP services the areas during those hours, and as backup overnight.

But there’s no easy or streamlined solution. “It took the EMS 60 years to get into this mess,” said Dana Smith, commissioner of the Dutchess County Department of Emergency Response. “And it’s going to take a while to fix it.”

How an emergency phone call plays out in Dutchess County

Since its inception, 53 years ago, to reduce death and disability from trauma, stroke and heart attack, EMS has been the backbone of prehospital care across the nation. It is a complex system of medical personnel, communication networks and high-tech vehicles, all set in motion by a 911 call. A mix of Emergency Medical Responders instructed in basic lifesaving skills, certified Emergency Medical Technicians (EMTs) and paramedics (EMTs with advanced training) administer urgent treatment at the scene and during ambulance transport to the hospital.

Dutchess County 911 calls are fielded by emergency response dispatchers in Poughkeepsie. Trained to quickly obtain critical information from a distraught victim, the call-taker designates a level of priority for each emergency: Level one is the most critical, given for something like a stroke; level four is the least urgent, for, say, someone who’s fallen and can’t get up.

Dispatchers then contact the appropriate responder — fire, police or EMS. Professional ambulance services like NDP attend medical emergencies solo or assist volunteer rescue squads like Milan’s and Pine Plains’. Career EMS is not dispatched for a level four emergency as long as local rescue is available. Once on the scene, the officer in charge radios 911, informing the dispatcher about ambulance presence and patient status. During transport, EMS personnel are in constant contact with the emergency room by text, using a special triage app. Once the patient is admitted to the ER, the ambulance returns to home base, where it is cleaned, restocked and readied for the next call.

Small towns plagued by inconsistent ambulance response times 

According to the National Fire Protection Association, the targeted response time for EMS, from the time of the call to arrival on the scene, is within nine minutes. An ambulance delay can lead to disaster. Heart attack victims, for example, can avoid catastrophic consequences — myocardial damage or death — if they get to the hospital during the “golden hour,” a 60-minute window for administering life-saving treatments. Ambulance off-load times in the Hudson Valley — the duration from dispatch to ER transfer — average 50 minutes, so any additional delay can be consequential.

Dutchess County’s December 2021 EMS operation review revealed inconsistent ambulance response times, with larger cities faring better than small towns. Milan’s rescue squad took more than 20 minutes to arrive at the scene 14% of the time, Stanford’s and Pine Plains’ ambulance took longer than 20 minutes 16% of the time, Gallatin’s 17% of the time.

Milan and Stanford couldn’t respond at all half of the time; and Pine Plains was unable to attend 26% of emergencies. In every case an ambulance eventually arrived, assisted by a nearby town. The study reported that nonresponse rates throughout the county have climbed in the past five years: Stanford and Pine Plains were among the exceptions, showing modest improvement.

Municipalities forced to cover costs and provide service

New York is one of 39 states in which EMS is not designated an essential service like law enforcement or fire response. With no guaranteed state funding, municipalities have to cobble together money from tax subsidies through general funds, the principle support for basic town services, or by using a property tax to create special districts to contract ambulance services. Each town must search for the most affordable ambulance provider — volunteer, private, town-owned or operated by the local fire department. Some contracts are formal, while others are verbal.

Columbia County pays NDP and Copake Community Rescue on an “as needed” basis to help underserved towns like Ancram and Gallatin. Town Supervisor John Reilly told the Herald that the county covers Gallatin’s costs with sales tax and other resources: A “chargeback agreement” subtracts town monies owed for ambulance services. Gallatin is also supported by five local squads, including Milan, Pine Plains and Taghkanic, paid through town and county taxes. 

According to former Ancram Town Supervisor Art Bassin, the town pays the Copake squad through the Columbia County tax levy. The estimated annual cost is added every October to the county property tax. The Pine Plains and Milan crews are paid for by the local fire department, donations and fundraisers. North East shares costs with Amenia and Dover.

“Three years ago, it became evident our volunteer rescue squad couldn’t do it anymore,” said Stanford Town Supervisor Wendy Burton. “The fire department contracted for ambulance service with Northern Dutchess Paramedics EMS. The annual cost was so phenomenal — $750,000 — it broke their budget. The fire department asked the town to take over and it broke our budget, too.”

Stanford created an ambulance district in 2023 funded by local taxpayers that serves all residents. “It helped, but this year the cost will be $850,000,” Burton said. “It’s just not sustainable and puts a terrible burden on the taxpayer.”

Mark Browne, president and chief operating officer for NDP, blames the patchwork system that’s developed over the years for high costs and poor coverage. “Every town is doing something different,” he said. “We are contracted with 60% of towns. With others, like Milan and Pine Plains, our agreement is a handshake; any payment comes from the patient’s insurance, and that’s usually poor.”

NDP is forced to make hard choices. “If two 911 calls come in at the same time, the higher priority call takes precedence,” Browne said. “And if we have a contractual obligation with a town, we have to consider that too.”

Medicaid covers only 65% of the cost of transport. Worse, if a trip to the hospital is not deemed necessary, or if it’s more appropriate for the patient to be taken to a mental health facility, such as Dutchess County’s Stabilization Center, in Poughkeepsie, the ambulance service gets no reimbursement at all.

Urban areas pay lower fees for similar services. Smith said that Poughkeepsie “has three ambulances, two convenient hospitals and a high volume of 911 calls [EMS providers get paid per call]. Their services cost them $150,000 less than Stanford’s.”

Local ambulance coverage is confusing, disorganized and shrinking

For some towns, service areas overlap; for others, EMS presence is inadequate and neighboring municipalities are frequently called for help. Dubbed mutual aid, the decades-old agreement allows cooperation between emergency responders across jurisdictions. Used in every district, mutual aid ensures that an ambulance will always arrive, although response time can be impacted.

Of the 950-plus ambulance services in New York state, more than 20 went out of business in 2022, citing lack of staff, rising operational costs and poor reimbursement.

Browne manages NDP’s 22 ambulances and three “first response” cars —vehicles that transport medical personnel and equipment to the scene — servicing half of Northern Dutchess County and corners of Columbia County and Litchfield County, Conn. With 140 professional staff, 60% EMTs and 40% paramedics, NDP responds to more than 60 calls a day. “Twenty years ago, NDP received 100 calls per year,” Browne said. “Now, it’s in the thousands.”

Unnecessary calls can drain resources and cause delays. “Society is relying too heavily on EMS for routine health care, but it doesn’t matter what the call is for,” Smith said. “If people call 911, we have to go.” All those with EMS have an unnecessary summons that sticks with them — for sunburned feet, for a tick bite, for a toothache.

There are currently three career ambulance companies active in Dutchess County: Empress, Ambulnz and NDP. “If neither the local squad nor a career ambulance is available — which happens more than 20% of the time — 911 contacts an alternative provider,” Smith said.

When NDP is dispatched as backup, it is often sent back by the Milan Rescue Squad if no help is needed. According to squad captain Peggy Coons, who also serves as secretary of Milan’s zoning and planning boards, this happens more than a third of the time, which frustrates Browne. “When we get a 911 call, we have to provide a full crew with an ambulance, and if Milan turns us back we don’t get paid anything,” he said. “It’s not a lot of calls, but it adds up.”

It’s a hard job and fewer people want to do it 

New York state EMS personnel has dropped from 120,000 to less than 80,000 in the past two decades, including a 30% drop in new EMTs since the COVID-19 pandemic. “We’re losing paramedics, too,” Smith said. “About 30 years ago, New York state schools graduated a total of 520 paramedics, but only 120 this last year. There haven’t been enough students, so two of the four teaching centers in our area have closed.”

“It’s a tough situation,” said Brian Walsh, Pine Plains’ town supervisor and chief of the volunteer fire department, which oversees the town’s local emergency response service. The Pine Plains Rescue Squad includes eight to 10 volunteer EMTs and answers to the Board of Fire Commissioners. “Volunteers put out a lot of time and effort; individuals don’t have time to volunteer anymore,” Walsh said. “I hope more people step up. It helps the community, keeps everybody safe and taxes down.”

While the majority of EMTs in urban areas receive wages, three-fourths of those in Northeastern Dutchess County are volunteers. “The job is both physically and emotionally strenuous and the pay, for non-volunteers, is low,” Coons said. “Ten years ago, we had twice as many volunteers. People can’t afford to do it anymore. Most work out of town, and when they’re home, they want to be with their families. Plus, training is a big commitment.”

Coons also said EMT certification requires a minimum six months of classes — usually nights and weekends — followed by a practical and national exam. It takes up to two years to become a paramedic. “We also have updated training throughout the year — Hazmat, CPR and trauma,” she added. “We drill twice a month and check our vehicles every Monday night.”

Smith was candid about the downsides of an EMS career. “You work a 12-hour shift four or five times a week. You can’t take a break or relax, you can’t eat. It wears you out,” he said. “Our people do this because they love the nature of the work. Those who are paid sure don’t do it for the money — the wages are on par with McDonald’s.” Career EMTs in New York state earn an average hourly wage of $20, and paramedics earn $24. McDonald’s pays $15 to $25 per hour.

Ed Cerul, chief of the Stanford Fire Company, echoed Smith’s concerns: “EMS as a livelihood is rough; it’s traumatic — you barely have time to process one case before you get called to another. You see people on their worst day. These are also reasons we’re dying for volunteers.”

An EMT for 34 years, Coons said most communities don’t understand what EMS personnel do: “They think we just hang out at the firehouse all day. We all have full time jobs.” Two crew members are on call every night, and it’s mandated that each ambulance has at least one EMT. “When you add up travel time, patient evaluation and treatment, waiting at the ER, cleanup and reloading, each call can take up to three hours,” Coons said. “So if we get four calls in a shift, you can count on 12 hours of work. Makes for a long night.”

Coons recalled a few times when she was the only responder available. “I had to drive the ambulance and attend the patient by myself,” she said.

Despite the challenges, Coons loves her work. She remembered being approached at the local Dunkin’ Donuts by a stranger. “He thanked me profusely and said, ‘You saved my life in a car accident; you stayed with me the whole time,’” Coons said. “We take care of so many people, I’m ashamed to say that I didn’t remember him, but his thanks stuck with me. Helping people is what it’s all about.”