Paramedic candidate Christopher Turnbull stands in the central hub of the assisted living facility, his Navy-blue bullet-proof vest a contrast to the leisurely buzz of activity around him. He scours a pile of medical records while his partner looks over their patient.
She is an older woman in a wheelchair who has been recovering from a broken leg, and the staff called 911 when she started showing signs of a fever. Turnbull asks the patient’s nurse about her symptoms, her healing process and what medications she is on. He’s worried the fever might be due to sepsis, a type of wound infection that can prove especially deadly for older patients. His demeanor is calm and relaxed, even as his supervisor watches and evaluates.
Turnbull is transferring to the New Castle County Emergency Medical Services Division from Cumberland Goodwill Fire & Rescue in Carlisle, Pennsylvania. He worked there for several years, but he isn’t guaranteed a job with NCC EMS. While he was officially hired months ago on the first day of his employment, he must undergo six months of probation to make sure he’s a good fit. If this happens, he’ll be released to full duty.
Paramedics are the SWAT of the medical field: Whereas emergency medical technicians (EMTs) are trained by the Delaware State Fire School and respond by ambulance to every 911 medical call, paramedics selectively respond as backup in more critical emergencies. Unlike EMTs, paramedics in New Castle County can insert IVs, administer injections and medications, and even tell hospitals to prep specialized treatment teams. NCC paramedics train for 12 times as long as EMTs, allowing them to reverse a lot of conditions on-site that aren’t part of EMT training. Paramedics also rarely transport patients themselves. If they need to travel to a hospital with a patient, they ride in an ambulance with the EMTs.
paramedics in New Castle County are employed by the county EMS division.//Photography by Jim Coarse
Unlike EMTs, who are a mix of volunteers, firefighters and private contractors, paramedics in New Castle County are employed by the county EMS division. Like police officers and career firefighters, they are salaried and do not charge for their services. This central organization ensures a uniform level of excellence and coordination of coverage, and lets paramedics focus on their patients instead of their wallets.
New Castle County’s system isn’t universal. Plenty of paramedic agencies are private, and it’s not uncommon to see multiple private agencies competing for business in the same area. New Castle County’s system seems to be working: Out of more than 21,000 EMS agencies in the United States, New Castle County is one of only 183 to be accredited through the Commission on Accreditation of Ambulance Services, considered the gold standard for EMS agencies.
NCC EMS needs transfers like Turnbull because it is stretched to its limits. With half a million residents, the county is covered by only 18 to 20 paramedics at any given time: nine two-person teams during the day, eight teams at night, plus two sergeants patrolling and assisting on especially severe calls.
In 2017, NCC EMS paramedics responded to a staggering 36,000 calls, up more than 50 percent in the last 10 years. That number was expected to rise beyond 40,000 for 2018. Studies of EMS data show a sharp increase in narcotic- and age-related medical emergencies, with no evidence of slowing down.
For the past few years, NCC has requested an increase in funds to match rising demand and expand its ranks through a full-time, yearlong paramedic academy. Fees for the academy would include salary with benefits for all attendees, which would allow them to focus all their attention on their studies without worrying about making ends meet.
In 2018, New Castle County was finally able to fund a 2019
Up until last year, the county has denied the request. The agency’s last academy was in 2015, but it only had enough funds to fill existing vacancies, not expand.
In 2018, New Castle County was finally able to use profits from a new property tax to fund a 2019 paramedic academy. If the recruits make it through their classes and six months of field training, the county will release them to full duty so they can relieve their beleaguered comrades by the middle of 2020.
Until then, the agency has to rely on brutal overtime hours, spending $1.4 million in overtime in 2017. The lack of downtime between calls has forced maximum shift length with overtime to be reduced from a double—24 hours—to a shift-and-a-half in the hopes of preventing dangerous mistakes due to burnout or exhaustion.
Those dangers aren’t limited to the patients. In fall 2018, New Castle County paramedics began encountering a new drug, called 5F-ADB. When this synthetic cannabinoid is mixed into heroin or fentanyl, it can lead to dangerous side effects that include stroke, seizures, anxiety, delirium, agitation, acute psychosis and aggressive behavior.
When first responders apply overdose reversal medications like Narcan, some patients have attacked their rescuers. Police are dispatched to every overdose, but might not arrive before the overdose reversal medication kicks in. Paramedics must stay on their toes; there’s no telling whether a paramedic will encounter a case like this in the first hour after a vacation or during an overtime shift.
Sgt. Richard Moerman has worked plenty of those overtime shifts. He’s used to them from his past life managing grocery stores. Moerman became an EMT more than 20 years ago as a side job to alleviate boredom and fell in love with the work. When his EMT company was forced to increase its training standards, he chose to go above and beyond and enter a paramedic program. “Once you start EMS,” he says, “you realize it’s something that you want to do all of the time.”
Moerman is a transfer, like Turnbull, and served in upstate New York and New Jersey before settling in Delaware. His patrol takes him around the southern half of New Castle County, but he lives in Kent County to keep some distance from his work. “Delaware is such a small state that we’re getting bad calls, and then we find out that it’s somebody’s relative or somebody we know knows them.”
He loves his work, and the community it builds. “A lot of the people who I hang out with are in the emergency services too: police officers, paramedics or EMTs, firefighters,” he says, “It’s like a big family … We all work together, we all see each other day after day.” Whenever two emergency vehicles pass each other, they always wave.
He’s seen a lot in his nearly two decades, including the steep rise in call volume and its effects on the division. If it wants to match demand, Moerman says, it will need at least two to three more units.
On the job, no one in the EMS office is exempt from doing runs, including senior officers. Chief Lawrence “Larry” Tan still responds to calls that are larger or are near the New Castle office. He was one of the responders to the head-on collision in July 2017 that left five members of a family dead.
Tan has been with NCC EMS almost since its inception. He started in the 1970s as a volunteer firefighter while he was still in high school. From there, he became a paramedic and rose through the ranks, becoming chief in 2004. The county EMS conference room proudly displays a half-dozen group pictures of EMS over the decades, and Tan is in most of them.
Chief Lawrence “Larry” Tan still responds to calls.//photography by Jim Coarse
Tan says the housing crisis shares the blame for the agency’s punishing workload. A large part of NCC EMS’s budget comes from property taxes, and the market fell apart just as accidental overdose rates were approaching catastrophic levels. This lack of funding has made the county reluctant to award Tan the funds he needs, but he has found other creative solutions.
Under Tan’s supervision, and with the help of EMS Medical Director Dr. Robert Rosenbaum, NCC EMS has worked to improve efficiency and outcomes by linking EMS and hospital systems. Paramedics are specially trained to work with hospital emergency physicians and specialists, relaying vital information and even calling for specialized trauma teams before patients arrive. This coordination not only saves patients valuable time, but it allows paramedic teams to turn around and re-enter the field faster.
Which is not to say that busy paramedics are bad, as a whole. A 2004 report by USA Today’s Robert Davis suggests that cities with fewer paramedics save more lives because those paramedics get more experience. Moerman says recruits who do their hands-on training in New Castle County get more experience than those who do their training in Pennsylvania, where the training company is located. The county’s higher call volume, he says, provides the paramedics with more meaningful experience for testing their new skills.
When Moerman arrived at the scene of one overdose at a rundown roadside motel, he was met with two crowds—one of concerned neighbors peeking out from behind their doors, and one made up of first responders. While two paramedics took turns helping the patient breathe through a mask, an ambulance, firetruck and two police cruisers waited outside for direction. The room where the patient lay was so cramped that only Moerman and the two other paramedics could fit, but the others still had to stay until the call finished. After the paramedics revived the patient, the police helped convince her to go with the EMTs to the hospital, where she could get more help. The alternative, they reminded her, was jail.
the county is prepared to train between 15 and 24 new paramedics.//Photography by Jim Coarse
Cpl. Leah Reed is a member of Medic 2, one of the stations near that motel call. It’s also tied for the county’s busiest unit. “This is a fairly busy station, which I like because it keeps you moving,” says Reed, “The runs that we had yesterday are not the same as today and won’t be the same as tomorrow. There’s a variety, so it’s kind of hard to get bored.” She and her partner, paramedic Mike Ferrero, have worked this station for over a year.
“It’s almost like the military,” says Ferrero. “Some of those guys and girls go over there, and they get trained, but they don’t see anything…Some of the basic [medical] transport companies fall victim to that. Their jobs are easier because they’re doing less acute care, but they’re not really using any of their skills. So, if something happens…” He leaves the outcome to the imagination.
Experience, however, can only do so much. In 2017, single paramedics and sergeants responded to more than 4,000 calls. On those occasions, either a paramedic had to leave his or her partner with a patient to respond to another call alone or the only available paramedic was one of the patrolling sergeants. Research shows that, even with experience, these single-responder calls can put multiple patients at risk. “As calls go up,” says Tan, “there could be a time where there are no paramedics available for a call.”
That means the funds for the new academy couldn’t have come at a better time. According to Tan, the county is prepared to train between 15 and 24 new paramedics, pending final approval by the New Castle County executive. The academy, only the second in 10 years, opened registration in September and was set to begin early this year.
The process will be intense: a yearlong, 1,800-hour training program where the recruits are paid a salary with benefits to ensure they can focus on graduating the 12-month program, as well as the six-month field supervision program. At the end of the process, each will be reviewed, interviewed, and either hired or let go.
They’re a close-knit department, and Tan takes each case seriously. “We really have a commitment to take care of people,” he says, “because at the end of the day our standard is, ‘If we are releasing you to full duties as a paramedic, would I want you working on me or my family?’”
The training program will be over 1,800 hours.//PHOTOGRAPHY BY JIM COARSE
This exceptional amount of training means the recruits will not be hitting the streets on their own until mid-2020. Until then, the existing staff will have to rely on continually updating best practices fueled by detailed data analysis, the responsibility of Rosenbaum.
When New Castle County joined the Cardiac Arrest Registry for Enhanced Survival in 2009, Rosenbaum used that cardiac arrest data to isolate problem areas and hone best practices.
The result has been a resounding success. According to recent data by the American Heart Association, cardiac arrest patients in New Castle County are nearly 40 percent more likely to survive a cardiac arrest than the national average. If the arrest was witnessed and the heart rhythm was shockable, a New Castle County patient’s chance of survival is nearly twice the national average.
NCC curriculum will be 300 hours above the national standard.
The constant learning isn’t easy for the paramedics, but they are united in their pursuit of high-quality performance. “As an agency that routinely provides excellent care,” says Rosenbaum, “we’re looking to reach that even greater level. Let’s do it faster—that fast and at that speed, reliably, 100 percent of the time.”
According to Sr. Cpl. Sherri Portello, New Castle County’s high standards are often a barrier to entry. Despite the draw from a wide geographical area, years of experience as a paramedic elsewhere don’t guarantee acceptance, she says. “They can’t hang here. It’s a higher standard, and we hold them to that higher standard.”
Portello and her partner, Sr. Cpl. Jorge Vasquez, both graduated from Delaware Tech’s 2005 paramedic training program. Vasquez, who is originally from Colombia, was convinced to join EMS by his “cop family” in-laws. “They told me, ‘You need to be in the public sector. You should be outside helping people. There’s nobody who speaks Spanish.’”
Classes were grueling, Vasquez says, especially with English being his second language. But he and Portello became study partners and helped each other graduate. Now, Vasquez can use his native tongue to reassure patients who also struggle with English. “I’ve had a lot of calls where someone is very sick, and nobody speaks English,” he says. “As soon as I speak you can see their face relax.”
Vasquez says it’s all part of what they learned in the academy. Federal standards for paramedic training require 1,500 hours, placing the NCC EMS curriculum 300 hours above the national standard. Vasquez is proud of that fact. “We’re very proficient here. We’re trained to do this job by ourselves … It’s better to have a partner to bounce ideas off of—more hands to do more things. But if push comes to shove, we could do it if we have to. Not every county can say that.”
Portello agrees. “I think, anyone who talks about EMS, it’s a national standard. Not to talk bad about other cities or states, but we are above the standards.”
Their greatest asset in the field is their advanced ability to read and interpret body monitors. Most emergency transport vehicles contact hospitals and update them on patient conditions, but New Castle County paramedics are also trusted to alert them that a specialized treatment team might be needed. Many hospitals wait for a doctor to make an assessment, but trusting paramedics to make that call means an immediate response. That can save lives. Where many hospitals rush to reopen the artery of a heart attack patient within a 60- to 90-minute window, a patient in New Castle County may have the valve reopened in as little as 20 minutes.
While the new academy begins classes, the current NCC EMS staff will continue to work against rising call volume and severity. After six months of supervision, Turnbull completed his requirements for certification and was released for full duty on Dec. 5.
For Moerman, it’s more than just a job. “You’re not going to make millions of dollars being a paramedic or EMT; I can tell you that much…This is definitely a calling.”