Exploring EMS Option

(from Maine Townsman, November 2007)
By Lee Burnett

The emergency medical care provided at no charge to U.S. Supreme Court Chief Justice John Roberts last summer focused attention on a vanishing feature of small-town life in Maine.

A dwindling few Maine communities – one of them being St. George, where Roberts suffered a mild seizure while vacationing at his summer house  – still provide free ambulance service to any soul unfortunate enough to need it. The “special” treatment that Roberts got is the same treatment everyone gets.

“We treated him no differently than we treat anybody,” said Mike Smith, a contractor who is also the director of the all-volunteer St. George Volunteer Ambulance Associates. Smith said St. George is proud of the ability to provide for free a service that can cost upwards of $700 per ambulance ride, although he admits “we’re struggling.”

Free ambulance service is a dividend of the kind of volunteerism that Maine is famous for, but which is in short supply these days. Communities are recruiting harder than ever. But only the most determined volunteers stick with it because of the huge commitment of time and training required of emergency medical personnel.

“It’s hard to get a crew together,” explains Smith. “With jobs and responsibilities and there’s so much training they have to do.” Smith said he relies on a dozen volunteers in St. George to handle the 250 calls a year for service. “They’re all pretty active. It works, but if they’re off out of town during the day, it’s pretty hard to man a call ... At times, we have to go to another town for mutual aid.”

The growing need to hire paid professionals is putting an end to free service.  But not all towns can afford round-the-clock professional service and some towns have found regionalization to be an affordable way to supplement volunteerism with professionals.


“The days of volunteerism are gone, no one has the time to volunteer,” said Wesley Lash, selectman in the town of Friendship (population 1,200), the latest town to throw in the towel on free ambulance service.  In April, Friendship began contracting with neighboring Waldoboro (population 4,900) for paid service. That ended a free service that was begun by the women of Friendship more than sixty years ago.

Friendship still houses an ambulance in town and continues to rely on a half dozen volunteers to supplement the service from Waldoboro. But it was a sad day in the fall of 2005 when the women’s auxiliary decided to disband.

“The last couple of years or so, we knew we had to do something,” explained  Phyllis Conary, treasurer of the Women’s Ambulance Auxiliary and a member since the 1950s. “After doing free service for so long you hate to say you can’t do it anymore and have to change. But we knew we had to do it.”

The ambulance service was started in 1942 when many of the men were off at war. The first ambulance was a second-hand bread delivery truck. For many decades, it was entirely a women-run service. “We had fundraisers every summer. Rummage sales, food sales, donations from different people and organizations that kept us going,” said Conary.

At one time, membership of the auxiliary numbered more than 100, but in recent years it had dwindled to fewer than half a dozen. Some were getting on in years. Contracting with Waldoboro nearly doubled the budget from about $20,000 to $37,000, but the budget would have been even higher had patient billing not begun.

Lash says the volunteer situation might be better if the state were to relax the training requirements, which are the same regardless of the size of department. “They require the same amount of training, it doesn’t matter if you’re a town of 1,200 people or a city of 65,000,” he said.

The same training is required because the general public expects the same top-notch emergency care whether they’re stricken by a heart attack two blocks from Maine Medical Center or high on the ski slopes of Sugarloaf.

In the old days, emergency care involved basic first aid - stopping bleeding, splinting broken bones, and maintaining vital signs. Nowadays, a well-trained ambulance crew is equipped to administer drugs intravenously, perform a tracheotomy, and stabilize heart attacks, just to name a few sophisticated tasks.

But it’s a lot to ask of a volunteer. The basic level of EMT certification requires 120 hours of training. The intermediate program requires 280 hours. And paramedic training, which includes classroom and clinical interventions, requires upwards of 800 hours to  complete. Training is also required to maintain certification.

All this expertise is wasted if it’s not also delivered speedily. When Friendship switched over, there was understandable concern that response times from Waldoboro would be much slower. “People were quite disturbed that the ambulance would be 15 minutes away,” explained Mike Poli, a paramedic in Waldoboro, who had previously worked for Friendship. They discovered that response times weren’t much difference because the town still housed an ambulance and Friendship volunteers were still available.

“The shift was mostly administrative,” said Poli. “They’re getting the same service, the same people in the same location.”


Another town that abandoned its all-volunteer service is the town of Arundel (population 3,600) in York County. It saw its roster of volunteers dwindle to the point where “the same seven people showed up at every call,” said Deputy Chief Renald Tardif. Because the town couldn’t meet mandatory minimum staffing requirements for hospital runs, it had to turn those calls over to a neighboring town, which cost Arundel $600 in lost revenue for each trip.”We were losing money,” said Tardif. So at a special town meeting three months ago, the town voted to begin paying volunteers a per diem fee and to ramp up staffing so it could handle hospital runs. The annual cost to taxpayers jumped from $40,000 to $250,000, a price that will come down as billing brings in revenue. The vote wasn’t even close, said Tardif.

“Sixty people showed up. ...They wanted it [paid service], there was no hesitation... I never thought we’d get all of it.”

The income from billing could reduce average annual costs to about $70,000 per year, he said. “It’ll never pay for itself, but it will offset three quarters of the cost.”


One of the few towns that does not seem to have trouble attracting volunteers is the New Hampshire border town of Lebanon (population 5,000). The town boasts a roster of 50 volunteers – about equally divided between certified drivers and trained EMTs - which is up from charter group of about five. “We built it up over the years,” explained Assistant Rescue Chief Jason Cole. The service has grown to the point that it has needed to call mutual aid just three or four times in the past five years, he said. Nearly every call is responded to by “six or seven” people. “Some [volunteers] just stand by until the ambulance comes. We’re very, very fortunate.”

The town-run service is only six years old, having been started when Frisbee Memorial Hospital in Dover, N.H. ended its practice of providing ambulance coverage in 2001. There were other privately-run ambulance services the town could have contracted with, but the town believed it could provide better service on its own because it already had a corps of trained first responders who were eager to take on additional responsibilities, Cole said.

Because the town was starting almost from scratch, it took pains to cultivate volunteerism every way it could.

The key to growing the volunteer pool is providing a wide range of community services, Cole said. Rescue squad members provide blood pressure clinics and also go into schools and day care centers to teach bicycle safety classes, injury prevention, CPR and first aid. They are paid a stipend that averages about $300 per year.

“We do a lot within the community to help out.  People want to be a part of it,” Cole said.  The rescue squad receives between 15-30 appreciative cards and email per month, he said. “We share them with the volunteers. They have a sense of pride.”


The towns of Cumberland, Yarmouth, North Yarmouth and Falmouth relied on all-volunteer squads – helping each other with mutual aid when needed – until the late 1990s.  Coverage was sometimes thin, particularly by fully-trained paramedics who could handle any situation. “Volunteer paramedics became a dying breed,” said Chris Bolduc, Cumberland Rescue Chief. It used to be that volunteers  being – on-call for one week a month – responded to just a few calls a week. But the call volume grew to where some volunteers were called out 2-3 times a night. The breaking point with volunteers came when neighboring communities repeatedly couldn’t muster the bodies to respond to calls and relied on Cumberland. “We were called out on 140 mutual aid calls one year,” explained Bolduc. “It was a turning point. We decided ‘we can’t do this anymore.’  We needed to come up with a new way. It really wasn’t mutual aid anymore ... I was losing people.”

Call volumes and the sophistication required to handle them continued to grow. Partly this was due to the aging of the population and the development of assisted living complexes, senior housing and age-restricted housing. Eventually, all four towns hired day-time paramedics to supplement their volunteer rosters. Coverage during the night continued to be problematic, according to Bolduc. But individual towns couldn’t justify each hiring another full-time paramedic for coverage at night when call volumes are down. So they decided to share the cost of night-shift staffing. Three years ago,  all four towns joined to hire two additional paramedics, who would share the calls from all four towns during the night.  “The regional program works well,” said Bolduc. Having begun sharing staff the next step may be to share equipment, said Bolduc. Among them, the four towns own seven ambulances. With joint ownership, they could probably manage quite well with just five, he said.

The collaboration among suburban communities north of Portland is the kind that could be expanded, says Donnell Carroll, executive director of Southern Maine Emergency Medical Services, a training and education service.

“Absolutely,” Carroll said. “Especially paramedic coverage. The smaller towns can’t afford to hire one themselves.  They don’t do enough volume [of calls]. By regionalizing the paramedic service, that gets them in.”  Without a regional service, small towns are easily overwhelmed by those occasional times when multiple calls come in at once. It is not uncommon, even in small towns, to have to respond to three calls at more or less the same time, as happened one day recently in Carroll’s hometown of Gray, he said.

Sacopee Valley

Another example of regionalism is the five towns at the confluence of the Saco and Ossipee Rivers in southwestern Maine that banded together in 1967 to form the Sacopee Rescue Unit. The unit handles about 700 emergency calls a year in the towns of Porter, Parsonsfield, Cornish, Hiram and Baldwin.  The unit has a roster of 35 volunteers, about half of whom work per diem shifts. Funding comes from billing patients and $5,000 contributions from member communities.

The pool of volunteers isn’t as healthy as it appears because many are veterans getting burned out after ten or more years service, and recent recruitment efforts haven’t been very successful, said Chief Lori Edgerly. She was expecting to have to move toward full-time professional staffing, but decided first to make a more ambitious recruitment effort, offering to provide training locally. To everyone’s surprise and gratitude 14 people signed up.

“It was an overwhelming response ... that gave me a lot of enthusiasm about volunteerism,” said Edgerly. “Basically, if we hadn’t gotten that amount, we’d be looking at going to a full-time rescue squad next year.”

She’s hoping to retain a large number of the new recruits, though she realizes high turnover is a fact of life. Even obtaining a basic EMT license requires a commitment of about six months to acquire the 120 hours of training. And three-hour calls are the norm in the rural five-town coverage area.
          Edgerly says the regional funding mechanism “works well” especially if the full-time staffing becomes necessary. Going to full-time staffing would probably more than double the unit’s $125,000 budget. The unit received $5,000 funding from each town. “If I needed $20,000, I’m sure I’d get that, I’m sure it would be there. It’s not just one town, it’s split among five towns. These smaller towns that do it on their own. I don’t know how they could do it.”
                               The day is fast approaching that St. George will end its all volunteer service, predicts Smith, the ambulance director. “Probably, eventually, we’ll put someone on per diem,” he said. He thinks he’ll probably discuss a collaborative arrangement with the neighboring communities of Thomaston and South Thomaston, though he hasn’t yet.  And as proud as townsfolk are about their volunteer service, they’ll probably support a paid service with some tax dollars. “I think they’d be willing to help at any time if we ask,” he said.