Call 911 for medical help in Pinellas County, and get ready for some company.
First there's the fire department's rescue truck with at least one paramedic, plus a colleague.
Then there's the private ambulance with two attendants.
You might even get a fire engine with an additional three or more rescuers.
And you get this posse whether you are trapped inside your mangled SUV, have overdosed on pills or just sprained your ankle.
It's a Rolls-Royce response — with a Rolls-Royce price tag.
In Pinellas, the cost of a 911 medical response last year started at $400. Taxpayers picked up more than half the tab.
By comparison, in Hillsborough County many medical calls get only an ambulance, with the cost starting at $226, plus mileage. Not a dime of that is local tax money.
The difference is that Pinellas — unlike most communities nationwide — sends fire rescue units and ambulances to virtually every medical call, no matter how small.
Now, with money tight, Pinellas officials are considering a bold step: Send fewer fire rescue units to minor medical calls.
It's called priority dispatch.
Advocates say it could save money — millions of dollars up front and perhaps $10-million over a decade.
Pinellas fire rescue units went to 133,688 medical calls last year, seven times the number of fires they handled. Go to fewer calls, the thinking is, and you need less equipment and personnel. So the county could cut tax support to local fire districts.
That could mean a bloody political fight.
But all involved concede that with local tax dollars stressed, the current system may be unsustainable. And each time emergency vehicles are on the road with lights and sirens, the danger of an accident follows in their wake.
"It's crazy," said Chuck Kearns, director of the county's EMS & Fire Administration. "It's risking people's lives. It's wasting people's money. It's not necessary."
• • •
In the world of emergency medical response, there are two camps — fire rescue and ambulance — that traditionally compete for calls. In Pinellas, both groups say the system is flawed.
And both argue the other side needs to change.
"The biggest problem is trying to get people to get past their little kingdoms and do what's best for the taxpayer," said Seminole fire Chief Dan Graves, president of the Pinellas County Fire Chiefs Association. "Nobody is guiltless in this game."
The players are Sunstar Emergency Medical Services, a private company based in Tyler, Texas, and the county's 19 publicly run fire rescue districts. Both respond to calls with paramedics capable of delivering advanced life support care.
Sunstar has an exclusive contract with the county, and its passengers are charged fees for hospital rides. The county collects the money, which goes to pay Sunstar — $32.7-million this year.
Pinellas' fire rescue districts — from St. Petersburg down to little ones like Belleair Bluffs — operate paramedic units funded by a countywide property tax. That operation will cost taxpayers $38.5-million this year.
Fire rescue usually arrives sooner than ambulances and can manage incident scenes, but rarely ferries victims to hospitals.
When this expensive apparatus gears up, the response is often disproportionate to the medical need.
Take 911 medical calls from nursing homes. Residents fall or something worrisome turns up in a blood test. What these residents nearly always require, at most, is a trip to the hospital to be checked out.
Last year Sunstar ambulances provided 6,273 hospital transports in response to 911 calls from nursing homes. And fire rescue went to each call, too.
The minimum response, an ambulance and a fire rescue unit, cost $400 last year — $224 from taxpayers for the fire rescue unit and $176 from patients and their insurance for the ambulance.
Now consider Hillsborough County, which prioritizes calls and doesn't send fire rescue to every scene.
Take that nursing home patient. She fell and injured an elbow, but is alert, breathing fine and isn't bleeding. She'll get an ambulance only — though typically not one with a paramedic — and be charged as little as $226, plus $10 per mile, for a ride to the hospital for an X-ray.
There's no local tax money involved.
In Hillsborough last year, more than 10 percent of medical 911 calls — 7,927 — were given the lowest priority. An ambulance responded, but not fire rescue.
• • •
In priority dispatch, 911 call takers ask a series of brief medical questions to gauge the severity of the call.
The goal, said EMS director Kearns, is "to send the right response, the right way, the first time."
In Pinellas, 911 call takers determine the location of the caller and the nature of the emergency. They don't assess whether a medical call is critical. Instead, fire rescue units are immediately dispatched.
Then the call is routed to Sunstar paramedics, who send an ambulance and determine whether the situation is serious. If it's not life-threatening, they can downgrade the call, possibly slowing the response.
In 2007, 41 percent of fire rescue medical responses were downgraded after Sunstar's over-the-telephone evaluation, but by that time units were already on the road, lights and sirens on.
"Sending fire rescue units to nearly 100 percent of medical 911 calls puts them in a small minority of systems," said Alan Craig, deputy chief of Toronto EMS and a noted researcher in the field. "That's a very unusual practice."
Depending on how you define urgent and critical, only 5 to 30 percent of 911 medical calls merit paramedic response, Craig said. Only 1 to 3 percent are truly dire, requiring resuscitation.
When fire personnel aren't medically necessary, Craig said they can offer other valuable skills, such as managing hazards at incidents. The question, he said, is whether what they add is worth the risk and expense.
"Does the community want two vehicles responding with lights and sirens to obviously minor calls and going through intersections and possibly colliding with other traffic?" Craig said.
Graves, president of the fire chiefs association, worries that reducing fire rescue units would mean fewer resources for other jobs, like fighting fires, and longer response times to medical calls.
"It's just kind of a domino effect," Graves said. "Response time is definitely going to suffer."
• • •
Today's system took root after the 1978 death of Ronnie Redwine, a case where the failure to respond sparked public outrage.
A car struck the 16-year-old on Park Boulevard, throwing him 100 feet. As he was dying, Pinellas Park paramedics refused to respond because Redwine's body lay just outside the city limits. As seconds ticked away, two private ambulance companies were contacted. Neither had units available.
Redwine's death led to an act of the state Legislature and a public referendum that culminated in 1988 with the establishment of the current system.
The reforms included an agreement that the closest available unit would respond to calls, even if that meant crossing from one city into another.
From Redwine's death a robust, resource-rich, system grew. But it's often redundant, sometimes ridiculously so.
"We're guilty on both sides," said interim County Administrator Fred Marquis, who helped develop the system. "It's crazy sometimes what ends up showing up."
• • •
Twenty years later, change would require the political will to take on entrenched interests.
Politicians are wary of crossing fire unions and being seen as weak on public safety; the county has long done business with the private ambulance industry.
Turf battles are likely. Fire officials point out that ambulances make unnecessary runs, too. About 30 percent of ambulance calls, for instance, don't result in a patient transport.
One option fire officials like is getting involved in the transport business themselves. In many places, fire rescue units handle both emergency medical care and hospital trips.
That could offer Pinellas fire personnel a buffer against reduced staffing levels.
Union chief John Little, president of the Pinellas County Council of Firefighters, supports having fire rescue handle transports and dismisses priority dispatch as a power grab.
"They are trying to take calls away from us so that they can take money away from us," Little said.
Sunstar's chief operating officer Mark Postma is open to reducing the number of ambulance runs that don't result in hospital transports. But he's opposed to fire rescue units ferrying patients to hospitals.
"We have a contract with Pinellas County to do transports," Postma said, "and we would like to see that stay in place."
When officials have tried to confront the system's inefficiencies in the past they became bogged down in issues of union clout and job security, said County Commission Chairman Bob Stewart.
But it's worth trying again.
"We ought to ask the tough questions and come up with a transparent decision as to what serves us best," Stewart said. "That's a long-term project."
Given the challenge, an abrupt overhaul is impossible, said Assistant County Administrator James Dates, who is working on the move to priority dispatch.
The key is starting small, adjusting responses to obviously noncritical calls, getting both sides to change their practices and renegotiating county contracts with the fire districts to trim the number of funded rescue units.
"This is something that has been talked about and talked about and not really pushed to the forefront," Dates said. "Now we have to look at it. We can't wait any longer."