Not every item that comes before Contra Costa County supervisors is a matter of life and death, but that's exactly what they dealt with at Tuesday's meeting. At issue was ambulance service for most of the county -- San Ramon Valley and Moraga-Orinda fire districts provide their own -- and the expectations of providers that will compete next year for the contract now held by American Medical Response.

The "request for proposal," as the bid-soliciting tool is known, always includes guidelines so bidders know what they're bidding on. Those were the details supervisors chewed on Tuesday. ... How many positions must be manned by paramedics? How many by emergency medical technicians? What are the expected needs for advanced and less costly basic life-support teams?

This is all part of a big-picture look at how paramedic-led firefighter teams and ambulance providers can avoid service overlaps and respond to EMS needs.

County Medical Director Joseph Barger shared studies that showed basic life-support teams were just as effective as their better-trained counterparts in cases of trauma or cardiac arrest, as long as defibrillators were available. Quick response and delivery to the hospital were often more important to successful outcomes than on-site paramedics.

"I think more is not always better," he said. "There are probably a good third of the patients who do not need any of the ALS interventions before hospital transport."


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He advocated a "tiered" approach to EMS -- sending highly trained paramedics only where they are needed, both for ambulances and firefighters. The key, he said, is a high-quality dispatch system which clearly identifies each emergency's severity. "We could improve in that area," he said.

Not everyone high-fived. Three firefighter paramedics told supervisors that no victims have ever been displeased to be treated by paramedics. ConFire Chief Jeff Carman said highly trained responders are one reason for his staff's high success rate. He cautioned against relying too much on patient outcome studies.

"I'll give you an example," Carman said. "Today we have five calls in Martinez. If none of those result in saving of lives or property, it's easy to say the program wasn't worth what it cost. Tomorrow, if we have five calls and three of them result in saving lives, we now say the system was worth its money."

Further complicating the picture is the likelihood that Doctors Medical Center in San Pablo will close, requiring lengthier, costlier transports to alternative facilities. County EMS Director Pat Frost estimated additional costs at $2 million annually.

Among those deeply involved in this discussion is Erik Rohde, general manager of AMR, which hopes to retain its contract. (AMR's chief competitor, incidentally, is expected to be ConFire.) He agreed that EMS needs rethinking. Ambulance providers' only revenue comes from insurance reimbursements, which don't cover expenses for Medi-Cal and Medicare patients. Relaxed response times and reduced paramedic staffing for lower priorities are two of the few tools available to reduce costs.

What concerns Rohde is whether there is appetite for change. "The most dangerous phrase in the language," he said, "is 'We've always done it this way.'"

The county is expected to ask for public feedback at workshops. You might want to speak up. This is one of those rare discussions that really could be a matter of life and death.

Contact Tom Barnidge at tbarnidge@bayareanewsgroup.com.