The Suffolk County police officer ministering to a stricken Martin O'Brien in his Ridge retirement home in April 2003 was becoming increasingly annoyed, calling every few minutes on his cell phone, asking when an ambulance would be there.
After the Ridge Fire Department failed to answer an alarm from county dispatchers, the call kicked over to Rocky Point, then to Middle Island, records show, but neither department could provide an ambulance. After 37 minutes, Yaphank volunteers arrived at O'Brien's home.
By the time he made it to St. Charles Hospital in Port Jefferson, a stroke had already done serious damage, and the next day he suffered a heart attack.
"The doctors told me, 'If you'd gotten here sooner, we could have done a lot more for you,'" O'Brien, 84, said. Before the stroke, he walked three miles a day; afterward, he was happy just to make it as far as the bathroom.
Ridge, long one of Long Island's slowest ambulance services, finally took steps to deal with the problem this summer, hiring paid ambulance crews to staff the firehouse around the clock. Its average response time has dropped from 14 minutes to about 81/2, which is lower than the county average.
"I apologize for back then, not being able to answer the call," Chief Michael Gianmugnai said. "We're working very hard on it."
While officials say they can still muster volunteers for fires, overwork and burnout are driving Long Island medical volunteers away and forcing a rapidly growing number of agencies to turn their work over to paid crews. And in Suffolk, resident deaths have spurred lawmakers and health officials to push for more coordination and a bigger role for government in protecting the public.
Long Islanders today generally receive faster ambulance service by more highly trained crews than when the system was studied by Newsday in 1988 and found to be "outdated and chaotic," plagued by long response times and uneven levels of care.
Though neither county collects dispatch records for all the calls answered, available Suffolk County records show it took an average of 9 minutes and 39 seconds for an ambulance to reach the scene of an emergency call last year, a significant improvement from the 12-minute average Newsday found in 1988. In Nassau, where most calls are answered by paid county police ambulances, records from 52 fire departments show callers waited 7 minutes, 23 seconds for volunteer ambulances last year. Newsday's 1988 analysis did not track volunteers, but found police ambulances took 10 minutes to arrive.
But delays continue to bedevil the system. In Suffolk, where medical duties are shared by 72 fire departments and 26 ambulance companies, residents who suffered cardiac arrest outside of a hospital over the last four years had only a 2.1 percent chance of surviving, health officials found, giving the county one of the nation's poorest records on a measure that experts tie directly to the speed of emergency response.
A Suffolk health department study found that those who dial 911 with medical emergencies are likely to get their first help from county police, who carry oxygen and defibrillators and usually arrive before the ambulance. Those and other discouraging statistics have left the volunteers on the defensive this year, resisting tighter regulations pushed by county lawmakers and health officials.
Nassau emergency medical officials say they do not have the money to study cardiac-arrest survival rates. But volunteers are turning a steadily increasing share of their burden over to county police ambulances, which Newsday found now handle more than half of medical calls.
Police have added at least two ambulances just since last year at the request of beleaguered southern Nassau fire officials. That development has spurred the usually diffident county fire commission, made of volunteer representatives, this year to ask for its first study of the county's emergency medical system, one so decentralized that no agency tallies how many calls for help came in countywide.
"We're starting to do a whole look at delivery," said Peter Williams, the former commission chairman. "The one thing I can tell you from statistics is that calls are going up every year -- they are not going down."
Fire-safety advances and an aging population have transformed emergency work here, just as they have across the United States. Once, ambulance runs were just a small part of the service fire departments provided, but they began to outnumber fire calls by the early 1970s. Between 1980 and 2000, civilian deaths to fire dropped by 70 percent and building fires by more than half throughout New York, while medical emergencies multiplied. Today, when a Nassau or Suffolk resident calls for help, it's almost three times as likely to be a medical problem as it is a fire call.
But fire departments still typically train many more firefighters than they do emergency medical technicians, records show. And fire alarms still tend to get the quickest, most reliable response, according to a Newsday analysis of more than half a million dispatch records and incident reports from the two counties from 2000 to 2005. Overall, Suffolk volunteers got to fire alarms about a minute faster than medical alarms, while in Nassau the gap was two minutes.
In the Village of Lynbrook, for example, residents waited an average of 8 minutes, 54 seconds for an ambulance last year, while fire emergencies got an engine in an average of 4 minutes, 58 seconds. That may be because of the startling difference in the burden its emergency medical company members carry: Lynbrook's roughly 25 medical company volunteers handled 1,326 calls last year, while the department's remaining 192 members tackled 367 fire alarms.
Calls for help are also much more likely to go unanswered if they are for medical emergencies, according to Suffolk dispatch records.
One out of every five medical emergencies required a second call to prompt volunteers to turn out, while only one in 20 fire alarms needed a second summons.
Last year, Suffolk dispatchers had to seek help from a neighboring agency on 5,252 medical calls because the original department didn't answer them. That phenomenon is so unheard of for fire calls that the county database has no place to record it.
"There are no non-responses to fires," said David Fischler, Suffolk's former commissioner of fire, rescue and emergency services. "It doesn't happen."
Saturday, April 12, 2003, the day Martin O'Brien suffered his stroke, is a perfect example. The Ridge Fire Department got three calls for help that day.
An early-morning fire call about trouble with a transformer drew three chiefs and two fire trucks, records show. When a gas detector alarm went off in the afternoon, the second assistant chief went, accompanied by two more fire trucks. Only O'Brien's medical call went unanswered.
That year, Ridge received 1,439 ambulance calls and missed 170 of them; it answered all 453 fire alarms. Even with full-time paid crews, they still miss one in 10 ambulance calls, according to the county.
Tougher training standards
While the improving standards of care by Long Island's ambulance volunteers has benefited the public, it has also strained departments' ability to keep their ambulances staffed.
State law requires significantly more training for EMT certification than for a firefighting certificate -- 150 hours of instruction, with refresher training every three years, compared with about 35 hours for firefighters and periodic drills at each department's discretion.
And volunteers complain frequently about the time-consuming drudgery of medical calls. By the time an EMS team has interviewed and treated a patient, transported him to the hospital, filled out the medical paperwork and cleaned up the ambulance, at least an hour has passed.
By contrast, most fire calls end within a few minutes because they are for false alarms or minor incidents that don't require so much as the unfolding of a hose, records show.
Firefighters cross-trained in emergency medicine say they think twice before answering medical calls.
"Look, if my pager goes off at 6:30 in the morning for a fire, I know I could be home in 20 minutes," said one longtime Suffolk volunteer who asked not to be named. "If it's a rescue call, I'm definitely going to be late for work. You have to make choices."
For all their effort, emergency medical volunteers tend to find themselves at the bottom of the pecking order in their firehouses, where pride traditionally has centered on the big rigs and those who ride them.
Holbrook Fire Commissioner Michael Timo recalled that when he started as an ambulance volunteer 20 years ago, "I was told right from the get-go, if you're branded as a Band-Aid person, you'll never make it to chief ...
"It's almost looked upon as being less than masculine. You're told, 'If you want to be a real man, go to a fire instead.'"
In most Long Island departments, fire chiefs aren't required to have emergency medical certification, even though department bylaws place them in charge of both fire and medical scenes. In some departments, such as South Farmingdale, emergency medical volunteers aren't allowed to run for chief.
Most chiefs respect the expertise of their medically trained volunteers and defer to them, said Guy Cassara, a former captain in the Lindenhurst Fire Department who serves as vice chairman of Suffolk's Regional Emergency Medical Services Council, which helps coordinate medical response in the county.
"The problem here is that every chief in every department can do whatever they want for that department -- that's home rule," he said.
In Suffolk, that philosophy has led to a situation where dispatchers must consult a notebook filled with widely varying instructions each agency has left about how long dispatchers must wait for them to say they're on their way to a call before seeking help from another agency. In places like Middle Island, it's as quick as four minutes, but in Miller Place, it's as long as 10 minutes.
Suffolk volunteers, especially on the East End, have repeatedly appealed a new rule by Cassara's council that would standardize the procedures, saying local chiefs are best equipped to make their own decisions.
And as volunteer agencies hire more EMTs to ease the stress on their members, the home-rule philosophy means those crews usually aren't allowed to leave their districts -- in other words, someone who dials 911 may not get help from the community next door, even if paid crews are sitting in quarters waiting for a call.
If paid crews are needed, it makes more sense for them to be hired by a countywide "support structure" that could send them anywhere volunteers can't respond, Jeanne Alicandro, Suffolk's emergency medical services director, told county legislators in 2003.
Alicandro, who reports to the county health commissioner, and the emergency services council had urged lawmakers to form a government commission that could compel volunteer agencies to make changes. Their proposal won no support, but it did spur volunteer fire and ambulance officials to call for Alicandro's removal. County officials have begun interviewing for her replacement.
The Fire Chiefs Council of Suffolk County asked that Alicandro, who had previously run the medevac service at Stony Brook University Hospital, be replaced "with another individual who, at the very least, has a minimum of five years experience riding with an active EMS provider."
Still, fire officials are responding to the growing pressures in other ways, like abandoning a tradition that once required medical volunteers to fight fires before they could ride ambulances. These days, chiefs may ask newcomers to do the EMS training first.
"That's where the work is," said former Cold Spring Harbor Chief Louis England.
'This is a horror'
But residents like Charlotte Lisi of Melville contend this affluent region can afford to do better.
Lisi was out shopping on the evening of Dec. 23, 1999, when her husband of 35 years suddenly had difficulty breathing and dialed 911. By the time an ambulance arrived, 13 minutes later, Anthony Lisi, 60, was sprawled in the doorway in full cardiac arrest. He was never revived.
Charlotte Lisi sued the fire department, but the case was dismissed after a judge found no evidence of negligence. Eighteen Melville volunteers had dropped what they were doing to race to Lisi's home that day.
But this grieving widow doesn't question her local volunteers' dedication; she and her husband always gave at fund-drive time.
What bothers her is the six minutes the ambulance had to wait for them to come to the station before it could get under way. Paid in-house crews might have been on their way to her husband within a minute if they'd been on duty that night.
Melville, with twice the nation's median household income, already pays $210 per resident for its volunteer fire department each year -- well above the average cost of fully paid departments. A fire district official noted that it already had some paid EMTs when Anthony Lisi collapsed and is now exploring hiring more.
"We have beautiful firehouses, magnificent equipment that's the best in the country -- and no manpower," Charlotte Lisi said. " ... This is a horror."
Stacey Altherr was the principal researcher on this story; she was later joined by staff writers Tom McGinty and Eden Laikin.