Oak Bluffs Ambulance blazes a perpetual medical conduit

Boston MedFlight evacuates the Vineyard’s most direly ill. In forbidding weather, the U.S. Coast Guard steps in. With few exceptions, all other medical transfers off Martha’s Vineyard are done by ambulance crews from Oak Bluffs Fire & EMS.

In distance and frequency, the runs its crews undertake have no apparent comparison elsewhere in New England. Twice a day Oak Bluffs ambulances make 180-mile circuits from Martha’s Vineyard Hospital to Massachusetts General Hospital (Mass. General) and back to the Vineyard. In the summer season, these trips can increase to three or four times per day, Oak Bluffs Fire and EMS Chief John Rose told The Times. Patients frequently require a higher level of care than the Island’s hospital can provide, he said, therefore they must be transferred to a more advanced off-Island medical facility to receive that care. Revenue-wise, the transfers are both a boon and a blight to the department’s budget, depending on the type of transfer. To the patients they service, the transfers are the difference between reaching advanced care they need or, in essence, being medically marooned. When air transport cannot be summoned, these transfers are also the last means of preserving life.

The EMS portion of Oak Bluffs Fire & EMS is known locally as Oak Bluffs Ambulance. It fields four ambulances and 10 full-time paramedics — including the chief, three per-diem paramedics, one full-time EMT and 15 volunteer EMTs. It’s the largest ambulance service on the Vineyard, situated in the Island’s largest town — the same town where the hospital is located. Oak Bluffs provides more ambulance aid to the Vineyard’s five other towns than any other department. In total, it answered 760 calls to 911 in 2016. It’s the only Island EMS service to keep at the ready a special team of paramedics to accompany Coast Guard medical evacuations, and it’s the primary ambulance service to deliver patients to Boston MedFlight aircraft. In 2016 it assisted in a total of 180 air evacuations.

“Our working relationship has always been very good,” Andrew Farkas, chief operating officer for Boston MedFlight said of Oak Bluffs Ambulance, and also pointed out the singular nature of Oak Bluffs’ ambulance transit system. “They fill a unique void,” he said.

Oak Bluffs Ambulance keeps a six-person crew on standby each day to handle off-Island transfers. They start their day at 4:30 am. By 5 pm, nonemergency transfers to Boston are halted as a hedge against ambulances and their crews being stuck off-Island for the night. Between 5 pm and 8:30 pm, patients are ferried over to Woods Hole to meet a Cape Cod Ambulance. After an ambulance-to-ambulance transfer, the Cape Cod crew then delivers the patient to a medical facility — most often Massachusetts General. Oak Bluffs only sends an ambulance beyond Woods Hole past 5 pm if a critically ill patient has no other avenue off the Island. In such instances the department puts the crew up in a hotel after their drop-off.

In 2016 Oak Bluffs Ambulance made 187 Woods Hole transfers, all of which, unlike direct hospital transfers, the department received no compensation for, according to Chief Rose. Medicare only pays the ambulance service that drops off the patient at a medical facility, he said. There is no reimbursement for dropping off to another ambulance.

“Puts them in quite a tough situation,” John Goward, general manager of Cape Cod Ambulance, said.

Billing deficits aside, another reason Oak Bluffs doesn’t deliver more patients to ambulances in Woods Hole and therefore cut down on the treks they make to Boston is because those types of medical handoffs have risks.

“We know that all handoffs in medicine are potential sources of error,” Dr. Paul Biddinger told The Times. Dr. Biddinger is Massachusetts General’s chief of the Division of Emergency Preparedness, and the director of its Center for Disaster Medicine, as well as an associate professor at Harvard Medical School.

Mr. Goward said his company maintains close communication with Oak Bluffs Ambulance, particularly in terms of dialogue between the two company’s paramedics and EMTs, in order to keep the transfers safe.

“If we didn’t have good communication and a great working relationship, it wouldn’t work,” he said.

While trips to Woods Hole may be budget-sapping, the department’s routine trips to Boston have the opposite effect.

“The off-Island medical transports help to fund the acquisition of public safety vehicles and equipment, as well as to cover the costs of staff to run the ambulance service,”

town administrator Robert Whritenour told The Times in an email.

“As the town budget is currently configured, the transports provide a subsidy to the overall service that would have to be replaced if transfers were no longer done. That is to say that if transfer revenues were not available, the town could not operate a local-only ambulance service through only the current appropriation. Additionally, the transfer income pays for all public safety vehicles, not just ambulances. That includes fire trucks, police cruisers, etc. Without this income, there would be a significant tax-rate impact.”

Chief Rose noted that while the runs may plump municipal coffers, such epic use of department’s ambulances translates into similarly epic wear and tear on the vehicles. The resulting maintenance costs consume a sizable portion of additional revenue, he said.

Affiliated Hospital Medical Director Dr. Karen Casper has worked at Martha’s Vineyard Hospital for the past 15 years. For the past two she has been responsible for the quality analysis of Oak Bluffs’ EMS performance. She told The Times that she not only considered Oak Bluffs EMTs and paramedics to be extraordinarily well trained, but trained to levels that exceed national standards. “On our Island we are so lucky to have this level of training,” she said.

She and other hospital staffers have enhanced the skill sets of Oak Bluffs’ EMS crews, as have Boston MedFlight staff, Dr. Casper said.

Under normal circumstances, ambulance transfers off-Island are done in coordination with Martha’s Vineyard Hospital. The transfers follow a particular order, according to Dr. Casper:

The hospital calls Mass. General to review the patient’s case with an access nurse and check for bed space. Since Mass. General is the parent hospital of Martha’s Vineyard Hospital, imaging and other vital data are transferred digitally on a shared system. If needed, the Island’s hospital talks with specialists at Mass. General. When time permits, Oak Bluffs medical crews arrive at the hospital 30 to 40 minutes prior to departure so they can ask questions of the physician managing the patient. Once underway, the ambulance crew, most often consisting of one EMT and one paramedic, keeps the hospital apprised of any change of status in the patient, but otherwise use their own judgment to manage the patient.

“Back in the show ‘Emergency,’ which is only a little bit before I started my career in EMS — back in those days, paramedics had to talk to a doctor and get orders for everything they did,” Dr. Biddinger said. Paramedics like Oak Bluffs’ now use their own judgment when choosing how to intervene in a medical situation, he said. The protocol is called “standing orders.”

“They really only talk to the sending hospital or what’s called their medical control physician — that’s the person who gives the orders — if there’s something that’s extraordinary that’s outside the protocol or something unexpected happens,” he said.

Until the patient is dropped off at another facility, the ambulance remains under the stewardship of the lsland’s hospital via a medical control doctor. Whether the patient was transferred from the emergency room or came from the acute or intensive-care wards, the control doctor would be the attending emergency room physician, Dr. Casper said. Should the patient’s condition deteriorate en route, an Island control doctor may order a diversion to a hospital somewhere between Falmouth and Boston. Dr. Casper said such instances are uncommon — one or two per year. However, as Mr. Goward noted, for Woods Hole transfers, Cape Cod Ambulance crews are under the medical control of a medical director at Cape Cod Hospital. Martha’s Vineyard Hospital and his ambulance company are currently working to shift that control to Island doctors, he said.

Oak Bluffs ambulance crew’s communication with Mass. General is usually minimal, according to Dr. Biddinger.

“The transfers are so routine, in general, that unless someone is critically ill,” he said, “they don’t even call us on the radio to let us know they’re about to arrive; they just show up. Because we received a call from Martha’s Vineyard Hospital already. We know the patient is coming, and we know what to expect.”

The patient volume Oak Bluffs Ambulance manages is staggering, Dr. Casper said.
“I can’t think of a shift where I haven’t transported someone off-Island,” she said.

In 2016 Oak Bluffs ambulance conducted 830 off-Island transfers.

Cardiac catheterization patients, acute neurology patients, and nuclear medicine patients all demand care that exceeds what the hospital can provide, Dr. Casper said. These are some of the types of patients Oak Bluffs Ambulance brings to Mass. General. Many psychiatric patients also require off-Island transfers, she said. Dr. Casper said she considers Oak Bluffs Ambulance such a critical pipeline that the loss of it would put the several aspects of hospital operations in a tailspin at worst and lead to dangerous transfers delays at best. “It would be abominable,” she said.

David Faunce, Southeastern Massachusetts EMS Council executive director, told The Times that Oak Bluffs Ambulance fields extraordinary paramedics. Due to the training they’ve received from Boston MedFlight in particular, he said, they are able to transfer frail patients like trauma victims who may require vents (intubation) and multiple intravenous pumps for various drugs. He also noted that Oak Bluffs paramedics can administer alteplase IV r-tpa, a vital stroke mitigator.

Vineyard Sound is Oak Bluffs Ambulance’s ever-present elephant in the room. In light of this, Chief Rose said his strong relationship with the Steamship Authority is key to keeping Oak Bluffs Ambulance viable. They’ve long been accommodating to both the routine and sudden needs of his department by reserving space on the vehicle decks for ambulances across their schedules, he said.

Also isolated by water, nearby Nantucket currently relies on aircraft, as it has no ambulance conveyance system in place like the Vineyard does, nor, it seems, does anyone else in New England.

“There’s no one that I know of,” Chief Rose said.

“Oak Bluffs is unique,” Mr. Goward said.

“Nobody does that like they do,” Mr. Faunce said.

Other Atlantic islands carry off patients, too
All get the job done in their own way.

Martha’s Vineyard enjoys a robust patient transfer system to off-Island medical facilities, most notably to Massachusetts General Hospital, through the use of ferried ambulances. The system is the fruit of longstanding coordinated efforts by Martha’s Vineyard Hospital and Oak Bluffs Fire and EMS in conjunction with the Steamship Authority. The Vineyard’s system has few peers on other islands, yet from Block Island to Vinalhaven, patients must still reach mainland medical facilities regularly.

Nantucket is farther from the coast than the Vineyard, yet it hasn’t put in place a similar ambulance conduit. For an island with approximately 12,000 year-round residents, only about 3,000 fewer than that the Vineyard’s full-time population, this has meant inconsistent land and sea transit for patients, and a heavy reliance on Boston MedFlight. This past June alone, Nantucket’s fire department assisted in 25 Boston MedFlight evacuations, according to interim Fire Chief Stephen Murphy.

“They really haven’t found a good solution yet,” former Nantucket Fire Chief Paul Rhude said.

Nantucket is the only place left in the commonwealth without advanced life support (ALS), he noted. The only paramedic in the department is the interim fire chief. Interim Chief Murphy said he is not allowed to practice as a paramedic, given the strictures of the department’s ambulance license.

Former Chief Rhude, now the fire chief of Cotuit, said Nantucket’s department only recently purchased an ambulance that can plug into the electrical system of a Steamship Authority vehicle ferry and keep the ambulance’s temperature tolerable during a summer-month crossing. He said the department’s staff is too slim to handle regular off-island ambulance excursions, therefore Nantucket Cottage Hospital has sought deals with private companies. But the 26-mile cruise from Hyannis to Nantucket Harbor eats up over two hours each way, time that no private ambulance company has found a way to bill for. As a result, the few that have tried to provide service to Nantucket have bowed out after brief stints, Chief Rhude said.

Lack of mutual aid is the key to understanding Nantucket’s EMS capacity, Interim Chief Murphy said. Unlike the Vineyard, Nantucket is one town and not a composition of towns like the Vineyard. There is no other department on the island to summon for extra help. Sending an ambulance to the mainland results in “one less piece of equipment here to protect visitors and residents,” the interim chief said. Due to fog, he recently sent one of the department’s four ambulances to meet another in Hyannis, but emphasized that it was a rare trip, and that Boston transfers like the routine ones Oak Bluffs does were out of the question for his department.

“We’re working very hard to come up with a permanent solution,” Jason Graziadei, Nantucket Cottage Hospital’s public information officer, said.

Mr. Graziadei said the hospital has had to “plead and cajole” various parties lately to get patients off Nantucket. He said the Nantucket Sheriff’s Department has been helpful in that regard.

Block Island is 13 miles south of Narragansett, R.I. It has approximately 1/15th the population of the Vineyard. Like Nantucket, it’s alone in the water.

“We have no mutual aid,” Beth Rousseau, Block Island Fire and Rescue secretary, said.

Ms. Rousseau, who is also the department’s EMT trainer, said flying patients off is the preferred mode of transit, but that fog can hamper airlifts. When Hartford LifeStar can’t safely execute an evacuation, or when the severity of the transfer may not justify putting a patient in the air, Ms. Rousseau said, one of her department’s ambulances makes the 55-minute crossing from Old Harbor Dock to Point Judith. Occasionally, they just take patients across on the high-speed ferry absent an ambulance. In either case, the medical journey is free.

“We do not bill at all,” she said.

The island’s department is completely volunteer, and receives no municipal support. It funds itself through donations, she said.

From Vinalhaven, one of the largest islands in Maine, it takes an ambulance about an hour and 15 minutes to travel on a Maine State Ferry to Rockland and then drive to Penobscot Bay Medical Center, Vinalhaven Ambulance Director Patricia Lundholm told The Times. Vinalhaven is 12.5 miles out in the Atlantic, and like Block Island and Nantucket, it’s without the benefit of mutual aid. Ms. Lundholm said this keeps her two ambulances busy. For critical cases, Ms. Lundholm said she sends patients out on fixed-wing aircraft to Owls Head, or calls in a Lifeflight of Maine helicopter to evacuate patients to Bangor or Lewiston. If aircraft and ferries are unavailable, Ms. Lundholm cited one more option.

“Every once in awhile we use a lobster boat when we can’t get anything else,” she said.