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Ambulances: Durham County's emergency rooms on wheels

This is the third story in a five-part series examining emergency trauma care at Duke and in the local community.

"I need you to tell me everywhere you're hurting," says Mike Clumpner, a Durham County Emergency Medical Technician-Paramedic. It is just after noon on Saturday, April 11 and he is in the back of an ambulance ministering care to a 29-year-old assault victim.

The victim, who may need surgery on a broken nose and injured ankle, is being transferred to Durham Regional Hospital. Because police suspect the victim may have broken into his family's home that morning and stolen a number of items, a police cruiser follows the ambulance.

Inside the ambulance, the medics are going about their jobs, taking the man's vital signs and administering a dose of morphine. Less than 10 minutes later, the victim is delivered to waiting Emergency Department personnel at Durham Regional. After a quick debriefing and some required paperwork, the medics are back out the door, free to respond to the next radio call.

"[The assault] is a good example of something we see often," said Durham County EMT intermediate Derek Isenberg, a Trinity senior.

At its peak, between 9:30 and 10 p.m., the county ambulance system usually includes nine stations, 11 operating trucks, 22 staffers and one supervisor. The ambulances serve as the first response to an emergency 911 call.

The unoccupied ambulance nearest to an accident scene is directed to the call, said director of Emergency Medical Services Mike Smith.

Each ambulance is staffed by either two EMT paramedics or one paramedic and an EMT intermediate.

EMT basics are certified to splint broken arms and perform other non-invasive procedures, said Isenberg. EMT intermediates are allowed to give patients some medications and to start intravenous needles. With the highest level of certification, EMT paramedics are allowed to give patients a large range of drugs, including morphine and other controlled substances, to intubate patients that have stopped breathing and even to defibrillate in cases of cardiac arrest.

While in the ambulance, patients can receive a wide range of care. For example, with permission from the hospital, patients may be given morphine to ease their pain. Clumpner explained, however, that EMTs frequently have to deal with patients who, because of prolonged drug use, have a high tolerance for painkillers.

Not all ambulance calls end in a trip to the emergency room; of the 20,423 patients served by ambulances last year, only 13,969 required some form of transportation. In other cases, patients were treated on the spot or medics decided it would be safe for the patients to make their own way to the Emergency Department.

"An ambulance is for emergencies only," explained Matt Womble, Trinity '95, a Durham county paramedic. He added that unnecessarily transporting patients ties up ambulances that might be needed for other calls.

An ambulance ride anywhere within the county carries the hefty price tag of $360.

In an emergency, costs are initially ignored and the patient is transported to the nearest appropriate Emergency Department. If the patient has medical insurance, their plans usually cover the bill, Smith said. For the uninsured, the $360 falls directly on patients' shoulders.

Emergency Medical Services even has its own collection agency, but does not always enforce fees. "A lot of time they decide it's not even worth trying [to collect]," Isenberg said, "because there's no money to collect anyway."

EMTs said they occasionally encounter patients who insist on transportation to a medical facility. In cases where such care is unnecessary, paramedics are required to explain that patients' insurance will probably not cover the tab.

Contrary to popular belief, ambulances do not always use their sirens and lights. Just over half of all responses are code threes, in which lights are used and drivers do not follow traffic laws, Smith said. In fact, the medics stressed that code three procedures are followed only when time is of the absolute essence-in cases of potential heart attacks, drug overdoses, shootings and other serious traumas.

"It puts the public in danger every time we run light and sirens," explained Isenberg. "It puts us in danger and the patient in danger." He added that the response time difference between code three and code two is only about two minutes.

In typical trauma cases such as assaults, bullet wounds and knifings, the police arrive on the scene first and secure the premises. Still, Smith said, assaults on medics are "not infrequent." He recalled a recent case in which the neighbors of a patient were shooting at officers and medics whenever they turned on their flashlights.

Smith added that his office has followed up on some of these incidents, leading to a few arrests. "Anytime you go into a situation like that, " Smith said, "tempers are hot and emotions run hot-emotions take over the brain." But not for the medics, who constantly strive to remain cool under pressure.

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