At about 4:30 p.m. on Wednesday, Sept. 17, a 66-year-old man living somewhere in the city of San Diego suffered a cardiac arrest. During a 911 call, emergency medical staff reported hearing agonal respirations, an extremely serious condition that often precedes death.
The San Diego Fire Department's first responder arrived within eight minutes, but the patient, needing transport to the nearest hospital, would have to wait 17 minutes and 33 seconds for an ambulance to show up.
This is one of roughly a dozen reports detailing incident response times from the last two months forwarded to CityBeat by concerned employees of Rural / Metro, the city's private ambulance provider.
"We take it personal," one paramedic said on the condition of anonymity. "And a lot of time, patients will tell you how long they've been waiting. They're like, What took you so long?' It's embarrassing."
With the stakes so high, the city requires the Scottsdale, Arizona-based Rural / Metro to arrive within 12 minutes 90 percent of the time or face up to a $50,000 fine per quarter. While that means that as many as one in 10 patients could see longer waits, for years, it wasn't a concern as Rural / Metro was credited with consistently meeting the standard around 97 percent of the time.
"Rural / Metro has always met this requirement since beginning of the service in 1997," spokesperson Michael Simonsen said. "There are times, due to unforeseen circumstances, that prevent the ambulance from achieving the most optimal response. The system design is constructed to take these situations into account."
As it turns out, San Diegans haven't exactly been getting A-plus service.
Until July, thousands of calls were being exempted from response-time requirements. Under a now-removed contract stipulation known as "unusual system overload," if 12 ambulances were already dispatched, additional ambulances wouldn't be subject to response-time rules.
Without the exemption, Rural / Metro's response-time compliance would have dipped into the low 90s last year and in some cases would have been out of compliance, according to a city audit conducted earlier this year.
However, in the three months since the city nixed the loophole, Rural / Metro hasn't significantly increased its staffing levels, according to company data. In July and August, it staffed slightly more ambulance hours compared with last year, but demand also increased at an equivalent rate.
The company added a half-time ambulance at the San Ysidro border crossing, an area of concern for city officials, but, otherwise, its fleet has remained the same. Rural / Metro staffs ambulances at 23 of the city's 47 fire stations and an additional vehicle at the airport. The company also provides 14 part-time roving ambulances. At peak times, it will run anywhere from 23 to 36 ambulances.
There's no reason to significantly increase staffing because the city has always received proper service, Simonsen said.
"Rural / Metro always managed the San Diego system as if the unusual-system overload exemption did not exist. Rural / Metro constantly monitors demand for service in the city and makes staffing adjustments as necessary based upon detailed analysis ensuring that we reach the patient as quickly as possible."
In the run-up to a contract extension this past May, city officials conducted an extensive audit of the loophole's impact on Rural / Metro's performance numbers. Without the exemption, in the last three months of 2013, Rural / Metro fell slightly below 90- percent compliance for Level 1 life-threatening calls in the city's southern zone, with specific problems identified at the border. In January, that number dropped to roughly 88 percent. The city's other three zones came in between 90 and 93.5 percent.
In response to this data, Rural / Metro announced it would post a 12-hour ambulance at the border, a cost of about $313,788 for the vehicle—for which the city agreed to pony up $110,462.
For the first time since the company started 17 years ago, city Emergency Medical Services officials will present Rural / Metro's response-time numbers without the system-overload exemption. A report detailing the company's performance from July through September is expected at the City Council's Public Safety and Livable Neighborhoods Committee meeting on Oct. 29.
"You'll no longer see compliance above 97 [percent] like you did in the past," said Alyssa Ross, program manager for the fire department's Emergency Medical Services. "You'll see a decrease of five or more percentage points because they're no longer getting that exemption that inflated their numbers into the high 90s."
There's something else you won't see. Two categories for non-life-threatening calls, such as broken arms or hip fractures, will no longer be calculated individually or by zone. As part of the contract extension, calls that are urgent but not life-threatening, categorized as Level 3, and non-emergency 911 calls, categorized as Level 4, will be averaged together with Level 1 calls into one citywide category.
This averaging means that Rural / Metro's response-time requirement for Level 3 or 4 calls could fall well below 90 percent, as long as the total average meets compliance.
While it wasn't publically reported, EMS officials have confirmed that the May audit revealed that without the system-busy loophole, Rural / Metro also fell below a 90-percent response time for Level 3 calls. CityBeat has requested, under the state Public Records Act, the documents that would back that up, but the city has yet to respond.
As the city was softening rules for its ambulance provider, a report from the city's Independent Budget Analyst raised concerns. With Level 1 calls making up about 86 percent of total volume, Rural / Metro will have a "substantial cushion" for meeting compliance in the citywide category, the report found. The IBA strongly recommended continuing to keep separate response-time data for individual categories.
Individual percentages for Levels 3 and 4 calls will not be part of the upcoming committee report, but that data will be available upon request, Ross said. The City Council "expressed an interest in having it available if they asked for it," she said.
Concern surrounding Rural / Metro's frequently changing contract terms has been met with reassurances by city officials that a new competitive-bidding process would result in a stronger contract and possibly a new ambulance provider.
In 2011, in the wake of allegations that Rural / Metro embezzled more than $17 million from the city, officials dramatically restructured the ambulance provider's contract and prepared a request for proposals (RFP) from additional providers. However, former Mayor Jerry Sanders never released the RFP, and his successor, Bob Filner, put the process on hold to consider allowing a bid by the San Diego Fire Department.
Now, after more than two years of delays, the city's competitive-bidding process for 911 ambulance service has hit another substantial roadblock.
In August, state officials declined to approve the RFP, arguing that the county-run Emergency Medical Services Agency must be in charge of the process. With the backing of the city, the county recently appealed the decision, but no date has been set for a hearing.
City officials have said they believe the bidding process will be delayed by months, raising significant questions about what will happen when Rural / Metro's contract expires at the end of June 2015.