ATLANTA -- At Fulton County's busiest ambulance dispatch center, it was shaping up to be a quiet night.
Thousands of basketball fans were watching the Southeastern Conference men's tournament in the Georgia Dome. Dentists from all over the country were milling about the Georgia World Congress Center. And in Cabbagetown and East Atlanta, people were enjoying a Friday evening out or relaxing at home in front of the TV.
Then a tornado hit.
Over the next few hours, through streets littered with debris, Grady Health System's Emergency Medical Service answered 158 calls and delivered 82 people to hospitals around town.
From Buckhead to Bankhead, from Alpharetta to Palmetto, when someone in Fulton County calls 911 with a medical emergency, an ambulance usually arrives within eight minutes.
But that could change this summer. The Fulton County Commission voted to eliminate $10 million in supplemental funding to the two ambulance companies Grady and Rural/Metro that provide the county's emergency service. For the 14 municipalities, that means coming up with the money by July 1, or having their residents wait longer for fewer ambulances.
In a recent letter, Pamela Stephenson, CEO of Grady, which furnishes ambulances to the central part of the county, asked the commission to reconsider its vote and appoint a panel of residents and medical experts to look at the EMS issue.
Without public funds, she wrote, Grady would have to cut the number of ambulances and attendants on duty, which would mean response times "greater than thirty (30) minutes for all life threatening emergencies."
"Nobody wants to see services reduced," said Reg James of Rural/Metro. But with no subsidies, he said, his company could not offer the same level of response.
Even short delays cost lives, said Dr. Katherine Heilpern, head of emergency medicine at Emory University School of Medicine, which provides a large percentage of Grady's physicians.
"Time is heart. Time is brain," said Heilpern. "That translates into lives lost."
"People will die," said Dr. Eric Ossmann, EMS medical director at Grady. "It's just that simple."
Yet five months after the County Commission approved the cuts, and three months before they go into effect, no resolution is in sight for much of the county, including Atlanta. The cities are still in the midst of negotiation with the ambulance providers, and the Fulton County Commission has yet to decide whether to continue providing funding for ambulances responding to unincorporated areas.
A matter of minutes
In their vote, Fulton commissioners relied on a document prepared by Alfred "Rocky" Moore, director of the county's Emergency Services Department. It recommended that the commission eliminate public funding and settle for a countywide standard response of up to 12 minutes in 90 percent of emergency calls.
But with fewer vehicles to handle what is expected to be the same, if not an increasing, demand, calls would back up and response times would grow "far beyond just 12 minutes," said Dr. Patrick O'Neal, director of the Office of Preparedness in Georgia's Department of Human Resources.
Should the county be hit with a major disaster, O'Neal said, "the ability to respond will obviously be compromised."
An increase in ambulance response time also could back up fire and police departments because their responders can't leave the scene of an emergency until an ambulance arrives, said Ossmann of Grady. "The County Commission really did not look critically at this issue," he said.
Last year, 18,000 roughly one in five of Grady's 95,000 ambulance calls were to critical situations, hospital records show.
Georgia has no mandatory standard for EMS response time because of differences in traffic, population density and distances from hospitals across the state, according to O'Neal.
Under a statewide EMS plan, regional councils determine who provides emergency ambulance service in each area. But the contracts themselves are between the ambulance providers and local governments. Grady has the contract for central Fulton; Rural/Metro covers north and south Fulton.
The ambulance services get most of their revenue by billing patients or their insurers for calls. But, because some patients are indigent or uninsured, some bills go unpaid. Since 1999, Fulton County has subsidized the ambulance services to ensure that enough vehicles and workers are available to respond to emergencies in eight minutes or less. That time is in line with recommendations from the American Heart Association and the American Stroke Association.
With the county's revenues falling, largely because of the incorporation of new cities, the commission decided in November to cut funding.
The result will be $6.8 million less for Grady, or about a third of the annual budget. For Rural/Metro the tally would be $630,000 less in north Fulton and $2.4 million less in south Fulton, said Moore.
"It was strictly a matter of finance," said Commissioner Emma Darnell of Atlanta, who voted for the cut. "We had to let a lot of things go."
Although some commissioners advocated giving the towns more time to take over the responsibility, Commissioner Bill Edwards argued that the new cities should be ready. "If you're going to . . . be a city, be a city," he said. "Grow up. Take control of your finances, and do what you've got to do."
Six north Fulton towns are negotiating together with Rural/Metro and are close to an agreement, said Johns Creek Mayor Mike Bodker. He said he favors the cities' assuming control of EMS, but would have liked more notice.
Each south Fulton city is working independently, said James of Rural/Metro.
Some of the smaller municipalities already had set their budgets for the year when the decision came down.
"The time line is pretty short," James said, "and we have a significant amount of work to do."
Another budget blow
The emergency medical service cuts are hitting Atlanta when the city faces its own projected shortfalls of about $65 million for the budget cycle ending June 30, and $120 million for 2009. Officials cite the increased costs of pensions, health care and fuel, decreasing revenues, and budgeting errors. Mayor Shirley Franklin said a property tax increase might be needed.
As for EMS, "we are still exploring the situation," said Greg Giornelli, Atlanta's chief operating officer, in a statement.
One possibility for Atlanta would be to have the city's fire department take over ambulance service. Already firefighters are first responders to 911 calls, usually beating the ambulance there by at least a couple of minutes.
"If you've got a guy who's a fireman and an EMS, he can do both jobs," said Chief Mike Beckman of the Atlanta Fire Department's EMS service.
There's one problem. The fire department has no ambulances.
Grady has about 26 in the field at peak times, stationed throughout the city. Grady officials estimate start-up cost for an ambulance system based in the fire department would be about $20 million.
The fire department has to be prepared to step in, Beckman said, even if that means using Grady ambulances.
"It's a logistical nightmare, that's what it is," said Beckman. But, he added, "If they threw the keys in the parking lot July 1, we'd pick them up and make it work. ... We would do what we have to do."
'We're the lifeline'
On a recent weekday morning at Grady, EMS communications manager Tim McMahan's three computer screens were glowing with colors red for life-threatening situations, yellow for other emergencies and green for nonemergency calls.
"We're the lifeline for people," McMahan said.
At a glance, he could tell whether an ambulance was en route, on the scene, or taking a patient to a hospital.
He could see immediately which of more than a dozen hospitals served by Grady ambulances were diverting patients to other facilities.
Ambulances that morning went to a gated community, an elementary school and a high-rise for the elderly. They took patients to Grady, Crawford Long and Piedmont.
Paramedics dealt with a pedestrian hit by a car, a pregnant woman having trouble breathing, a man who had been stabbed and someone threatening suicide.
They also responded to separate calls about two different people with chest pains at the same location. Ambulances arrived on the scene at 9:36 and 11:16 ---five minutes after being dispatched in both instances. The location? The Fulton County Government Building.
TWO AMBULANCE FIRMS AT ISSUE
Emergency service in Fulton County, 2007
Calls 33,674 95,000
Transports 29,366 67,000
Public funds $3 million $6.8 million