When Ramon Soliz came home from work on a Monday afternoon in early June, he found his 92-year-old mother Francisca unconscious in the living-room recliner. Soliz made several attempts to wake her as his house quickly filled with relatives concerned that she could be dying. Soliz said he remembers his sister calling 911 while he tried to revive their mother.
"Honestly, I thought she was gone," said the 62-year-old, who houses and takes care of Francisca. "We laid her down. I talked to her. I called her. I yelled at her."
For more than half an hour, the Soliz family waited for an ambulance to show up to their Ridgeview-Webster neighborhood in southeastern San Diego and take Francisca to a hospital. At the scene, fire-department first responders communicated with the emergency vehicle, which was stuck in traffic.
The situation was extremely tense, Soliz said. "We sat here and the ambulance wouldn't show. She's my mom. That situation would make anybody nervous."
When the ambulance arrived, emergency medical technicians (EMTs) apologized, Soliz said. "One of the guys said there was a major accident on [Highway] 805, and they were driving from Chula Vista. They were trying to come this way because the people over here, the nearest [ambulance] was on another call."
In the end, Francisca regained consciousness, was transported to the hospital as a precaution and returned home the next day.
"We're fortunate that it was nothing serious, but she could have been in a worse situation," Soliz said. "I know the day could come when she might not wake up."
The city's private ambulance provider, Rural/Metro, is required under its contract to arrive within 12 minutes 90 percent of the time or face up to a $50,000 fine. Each call that exceeds 24 minutes is subject to a $5,000 fine.
However, the ambulance provider was never fined for taking more than 34 minutes to get to the Soliz family's home.
Since 2011, a loophole in its contract has allowed the ambulance company to arrive late without penalty to more than 20,000 of the city's most serious emergency 911 calls, according to documents obtained from the San Diego City Emergency Medical Services Department.
Over the same time period, Rural/Metro was exempted from hundreds of 24-minute-response-time violations, in some cases taking more than 40 minutes to respond to an emergency call, according to city EMS documents.
That lost time can mean irreversible damage for someone suffering from a severe medical condition, said San Diego Medical Services Director Jim Dunford.
"For every 15 minutes that goes by, mortality rises," he said of stroke and heart-attack victims. "The long-term consequences of not getting an artery reopened in a timely manner is you have a higher risk of not having a complete return to normal."
So, why is the city allowing Rural/ Metro to get away with this? Under the company's contract, response-time requirements are exempt for all ambulances dispatched after 12 ambulances are on the road. In the contract, the exemption is called "unusual system overload."
The Mayor's office indicated a willingness to answer CityBeat's questions about the city's contract with its ambulance provider and what it means for the safety of citizens, but didn't do so by press time.
Rural/Metro spokesperson Michael Simonsen downplayed the company's responsibility for the loophole. "It's unfair to put it on Rural/Metro when the city agreed to and signed everything that's there," he said.
Limiting late arrivals would likely mean putting more ambulances on the road. However, it's not clear if the Scottsdale, Ariz.-based ambulance company could afford that.
Rural/Metro recently filed for Chapter 11 bankruptcy reorganization after sealing a deal with lenders to significantly reduce its debt. As part of the deal, the company will receive $135 million from lenders and bondholders to stabilize operations.
In San Diego, Rural/Metro staffs between 23 and 36 ambulances based on the city's "peak" and "non-peak" needs, Simonsen said, adding that the company would never limit services to save money.
"We don't manage to the exemptions," he said. "We manage the system how it is. We base it on the time of distance, all those things that go into managing an EMS system."
In a 2011 report on Rural/Metro's ambulance service, San Diego City Auditor Eduardo Luna warned of abuse of the contract loophole. At that time, Rural/Metro was arriving within 12 minutes more than 90 percent of the time, even without the advantage of exemptions.
That changed in the first quarter of 2012, when the ambulance company's use of exemptions for the most serious emergency calls more than doubled, according to city EMS documents.
In 2011, Rural/Metro claimed an exemption 4,727 times. In 2012, the number of exempted late arrivals more than doubled to 11,432.
As a result, the company's response-time rate before exemptions plummeted to 83.4 percent. Without the loophole, the company would have faced a $50,000 fine. With the exemptions, the company got credit for meeting the deadline 96 percent of the time.
Since then, the company's actual 12-minute response time for the city's most serious emergency calls has not risen above 86 percent, according to the most recently available city documents. Officially, the company continues to enjoy a response-time rating that has been as high as 97.4 percent when exemptions are factored in.
"They have met the city's required contact terms," San Diego Fire Chief Javier Mainer said. "Regretfully, when the city wrote the contract, the city didn't write a very tight contract."
While use of the exemptions has recently shot up, the loophole has been part of the city's ambulance contract since 1997, when Rural/Metro and the city of San Diego formed a public-private partnership called San Diego Medical Services Enterprise. The city lauded the partnership as a national model for innovation. However, in 2011, the partnership dissolved after the ambulance provider was accused of embezzling more than $17 million from the city. In the end, the company paid $1.4 million to the city for legal fees, and the case was dropped.
The city planned to start a competitive-bidding process, but then-Mayor Jerry Sanders delayed it, and Rural/Metro was given a temporary, two-year contract. During contract negotiations, the city unsuccessfully requested that Rural/Metro scrap the "unusual system overload" exemption.
"I was part of the meeting where they said, We want to get rid of that,'" Mainar said. "Rural/Metro said they were not able to get rid of that because it would cost a lot more money."
Rural/Metro never refused to get rid of the exemption, Simonsen said. "My take is that everything was up for negotiation at that time. It takes two to come to an agreement, right? It was discussed. But we didn't say, No.' We said, Let's talk about it.'"
Rather than battling over the exemption, the city agreed to a contract that would bring in about $10 million a year from Rural/Metro and allow the company to charge patients more than $1,800 for an ambulance ride, according to data from the city EMS department. The regional average for a comparable ride is less than $1,500.
The city has since drafted a new request for proposals (RFP) with the help the Abaris Group, an industry consultant that recommended eliminating the exemption loophole.
However, Mayor Bob Filner has again put the RFP process on hold in an attempt to explore having the city's fire department take over the most critical EMS transport services. This year, the City Council agreed to put $100,000 into the budget to explore the option and approved another year-long extension for the ambulance company with no changes to its contract.
The fire department wants to increase the number of ambulances on the road, providing one for each of the city's 47 fire stations, said Frank De Clercq, president of the city's firefighters union.
"It's imperative that people get moved quickly when they're critical," he said. "When there's a large geographical area with a minimal amount of transport units available, there's going to be some delays.
"On the private-sector side, they have a fiduciary responsibility to their stockholders to provide a profit," he added. "They want to get that done with less units. If they modify how many are on the street, there's more of a profit to be sent to their stockholders."
At the same time, at least a few city officials have signaled the issue needs urgent attention.
"Every second counts in an emergency, which is why I'm advocating the city put the ambulance contract out to bid without delay so we can ensure San Diegans receive the fastest and most effective response when they call 911," said City Councilmember Kevin Faulconer.
Council President Todd Gloria recently requested that a comprehensive review of the EMS system be docketed for a meeting of the City Council's Public Safety & Neighborhood Services Committee.
"It has become clear that we cannot wait for a new contract or new system to more closely examine this critical service," Gloria said.
While the city continues to study its ambulance services and flirt with the RFP process, people like Soliz will have to take whatever he gets, whenever it comes.
Soliz said he has nothing against the EMTs that work for Rural/Metro, but his experience has made him wary of the profit-driven ambulance model.
"If it's a private company, they're looking at money, their budget—and where they can cut the costs, they will," he said. "I'm not saying they have no regard for life, but that's just business, you know?"