Durham County

Durham County sidelines Duke EMS. Will patients suffer?

Editor’s note: This artcle has been updated to report that the Durham City Fire Department, not the Durham County Fire Department, is dispatched as first responders to calls on the Duke campus.

It was about 9:30 p.m. on Sept. 7, 2015, when George Grody slumped over in the middle of the Duke Marketing Club’s executive board meeting.

As faculty adviser, Grody was ready to go home, and his students thought he was pretending to fall asleep – until one of them nudged Grody and he didn’t respond.

Grody’s face turned pale and he wasn’t breathing. A student ran out of the classroom into Perkins library and called for help. Four Duke EMS members – Kevin Labagnara, Kristen Bailey, Ritika Patel and Kirsten Bonawitz – were nearby and ran to help.

The student EMTs administered CPR until the Durham City Fire Department and Durham County EMS arrived several minutes later and took Grody to the hospital. He had experienced cardiac arrest and was without a pulse for eight minutes as the crew worked on him. Duke EMS’s fast response time likely saved Grody’s life.

That might not have been the case if it had happened today.

Kevin Underhill, the interim director of Durham County EMS, removed Duke EMS from the county system on Aug. 30. The decision effectively put the student volunteer EMS squad out of service, after it had provided continuous emergency medical care to the Duke University area since 1994.

Durham County EMS officials would not talk, but they did supply Underhill’s letter to Duke University and Duke EMS upon a public records request. Later, Underhill provided a written response to several questions.

In the letter, Underhill cited Duke EMS’s inability to respond to calls 24/7 365 days a year, annual changes in leadership and failure to meet continuing education requirements as the reasons for the decision.

County Manager Wendell Davis, County Commissioner James Hill, the county board’s EMS liaison, and Duke University Police Department Chief John Dailey did not respond for comment. Duke University officials would not answer questions but provided a one-sentence written statement.

“The Durham County EMS and Duke EMS have enjoyed a mutually beneficial relationship over the years,” Kyle Cavanaugh, Duke’s vice president of administration, wrote. “[I]t is our hope that we can reach an agreement that will allow these two entities to again work together well into the future.”

But Duke EMS workers say Durham County EMS’s decision, caused in part by tensions that have simmered between the agencies for years, will hurt emergency care and lead to slower response times, which in turn could could put lives at risk.

Squad’s founding

Duke EMS was founded by three students in 1994, initially answering limited 911 calls, staffing basketball games and treating minor injuries. In 2004, the squad obtained a quick-response vehicle, enabling it to cover the campus and hospital area, often responding before Durham County EMS arrived. The squad did not take patients to the hospital.

The National Collegiate Emergency Medical Services Foundation website said there are 248 collegiate EMS agencies in the U.S., as well as 20 agencies in Canada, Australia, Mexico and Puerto Rico. Unlike Duke EMS, 56 of these agencies have ambulances, meaning they operate as full-capacity EMS agencies.

Student volunteers at Duke EMS are fully licensed emergency medical technicians who undergo 200 hours of class, complete 24 hours of field training, and meet the same training requirements as Durham County EMTs. A handful of students every year are even trained at the paramedic level, which requires almost 1,000 hours of coursework, clinical training and fieldwork.

Duke EMS responded to 580 calls in the 2016-17 school year, before it was cut off. Its average response time from 2014-17 was 4.67 minutes, according to its website.

Durham County responded to 36,496 calls in 2016. Its average county-wide response time was 10.8 minutes in 2016 according to internal documents and 9.64 minutes in fiscal 2016-17 according to the county budget.

Durham County EMS said they do not track response times to specific locations in the county, like Duke University’s campus.

The Durham County Fire Department, which responds alongside Durham County EMS to “high acuity calls for help on-campus” according to Underhill’s email response, had an average response time of 5.46 minutes in 2016-17 as of the county budget.

Points of contention

In his letter, Underhill cited Duke EMS’s inability to respond to 911 calls 365 days a year. According to quarterly and annual reports, Duke EMS operates 300 days a year and is not in operation over school breaks when most students are off campus.

In addition, Underhill criticized Duke EMS for its high turnover in leadership, with Duke EMS selecting a new director every spring. “This makes for inconsistent operational and educational maintenance, and involves ‘catch up’ for new members to meet requirements,” Underhill wrote.

Underhill also noted that Duke EMS’s failure to meet the Durham County EMS System’s continuing education requirements created patient safety, provider safety and liability concerns as well as on-going scheduling issues for meetings and training.

Despite Underhill’s decision to remove Duke EMS from the Durham County EMS system, he did recommend that members still be allowed to provide CPR and first aid at “the many special events, dinners and other relevant activities on Duke’s campus.”

But in an email response to interview questions written on Nov. 29, Underhill wrote that the primary reason for his decision was Duke EMS’s failure to meet continuing education requirements.

“Durham County EMS made multiple attempts to provide the necessary medical continuing education that would bring the student members into compliance with state and County requirements,” Underhill wrote. “According to Duke EMS leadership, the student members were unable to attend EMS continuing education due to course load, MCAT testing, personal responsibilities, etc.”

But two former directors of Duke EMS disputed that.

“We were getting the same continuing education as they were,” said Krishan Sivaraj, director from 2014 to 2015. “To my knowledge, we were as compliant as we needed to be. During my term, no administrator ever came up and said we weren’t being compliant. That was never one of the problems.”

Labagnara, the Duke EMS member who helped save Grody’s life and director from 2016 to 2017, also defended Duke EMS’s compliance with continuing education requirements. “The year I was director we were compliant, and we currently are as well,” he said.

The two former Duke EMS directors and many alumni have also supported the squad. Sivaraj started an online petition which garnered 56 signatures from Duke EMS alumni. Several former Duke EMS members are currently working as doctors and EMTs.

“To expect a college EMS agency to work 24/7 365 is really unreasonable,” Sivaraj said. While he was director, Duke EMS looked at other collegiate EMS agencies that provided similar care and found several weren’t operating 24/7 365, he said. Labagnara added that the requirement was a Durham County requirement, not a North Carolina requirement.

Labagnara attributed Underhill’s decision to a deteriorating relationship between Durham County EMS and Duke EMS.

“Durham County had this dislike of Duke EMS in general.” Labagnara said. “We really didn’t know why – whether we were kids, I don’t know. They were really kind of looking for reasons to take us out of Durham County.”

“It’s a huge disservice to any individual who needs emergency care on Duke’s campus or in Duke’s hospital system,” said Sivaraj. “They won’t get that quality care that we can provide as quickly as they could have if this administrative hiccup hadn’t occurred.”

‘Minutes matter’

Today, George Grody teaches Duke undergraduates about markets and management after living in seven countries while working as a global marketing executive at Procter & Gamble.

He serves as an adviser for Duke EMS and is a strong supporter of the squad’s work training students in CPR and first aid.

“Minutes matter and they’re right here on campus,” Grody said in an interview. “The call goes out, and they’re there. It’s one one of those things that you don’t value until you need it, or lose it.”

Grody doubts he’d be alive if Duke EMS members hadn’t been around the day he went into cardiac arrest.

“I don’t think I’d be here,” he said. “Those students would have gone out there, and said, ‘Does anybody know CPR?’ Those Duke EMS students wouldn’t be there, because [there would be] no Duke EMS, and I don’t make it. I don’t make it.”