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Taking a Closer Look - EMS on Hawaii Island

In this HIRSC exclusive editorial series post, we take a very deep look at Emergency Medical Services (EMS) on the Island of Hawaii and the history and also issues that currently arise with EMS providers on the island.

Published by: HIRSC - Moderating and Administration Team

Exclusive HIRSC Editorial Series in which we take an in-depth look at issues that have an effect on residents here in Hawaii or highlight the many things that make Hawaii Island so unique in many ways and forms.

In this HIRSC Team editorial series, we take a look at Emergency Medical Services (EMS) on the Island of Hawaii, as this week is EMS Week. We also look at the history and the many issues and challenges that currently arise with EMS on the Island.


The history of EMS on Hawaii Island

The history of emergency medical services goes far back to the late 1800s when services were provided by local medical staff from area hospitals on Hawaii Island using horse-drawn carriages. Then it eventually evolved with time as the automobile was introduced and began using motorized wagons that also transported medical staff from area hospitals to those in need.

As more time progressed and population, so grew the need for emergent medical services on the Island of Hawaii. While local hospitals at the time did their best to provide that care to residents on Hawaii Island, it wouldn't be until 1972, when the Hawaii Fire Department (HFD) would step in helping provide that service to many communities in need on the island.

In 1972, HFD would be the contracted provider by the Department of Health to provide EMS care for the Island of Hawaii, making HFD the only Fire-EMS based department in the State of Hawaii, which it still holds to this day.

The first paramedic staffed ambulance on the Island of Hawaii was stationed in Hilo at the Central Fire Station (located on Kino'ole Street in Downtown Hilo) and called Medic 1. The first two HFD personnel to become Mobile Intensive Care Technicians (or MICTs or paramedics) on the Island of Hawaii were Eddie Bumatay and Garfield Arakaki attended training in California and Honolulu alongside two medical staff members from Hilo Hospital; Pauline Higashida and Roy Arakaki. Hilo Hospital Emergency Room (ER) would serve as the first base station hospital on Hawaii Island for paramedic calls or orders. The level of training they received would be equal to the best places in the United States.

HFD Medic unit at the scene of collision. PC: Hawaii Tribune-Herald Archives (1980)

Following that progression, many other EMTs in HFD stepped up and advanced their training to become MICTs, and services on the island would slowly expand islandwide. From the first medic stationed at Central Fire Station, by 1980, it would later add 3 more advanced life support (ALS) ambulances around the island of Hawaii, of which were placed into services at the Kea'au, Waimea, and Kailua-Kona Fire Stations.

However, with growing demand in the South Kona region for ALS ambulance, HFD personnel volunteered to staff to basic life support (BLS) ambulance at the Captain Cook Fire Station to help provide medical services to the South Kona community, which at the time was provided by privately contracted medical services. It was not until the mid-1980s, that the Captain Cook ambulance would become an advanced life support unit and be staffed by firefighter/EMTs and MICTs.

From the mid-1980s through the 1990s, HFD EMS services were further expanded to included advanced life support units in Honoka'a, Kawailani (now Haihai), Pāhoa, South Kohala, North Kohala, Waikoloa, and Ka'ū (Na'alehu) Fire Stations, as the population grew throughout the Island of Hawaii and replacing ambulance services originally provided by private medical providers contracted from the DOH later transferred to HFD.

One of the biggest feats in HFD EMS history happened in 1992 to 1993, HFD would receive Chopper 2, A 1992 Bell 206 JetRanger, Fire-Rescue and Aeromedical Helicopter, to be stationed at South Kohala Fire Station and would revolutionize the EMS care and response on the Island of Hawaii, providing the ability to transport a seriously injured person to an area hospital in a very timely fashion where seconds and minutes matter.

At the turn of the century, HFD EMS Ambulance units on the Island of Hawaii were at 14 units, all of which were ALS units. It was not until mid-2005 when HFD would add the 15th ambulance or medic unit at the Hawaiian Ocean View Estates (HOVE) Fire Station providing much-needed coverage to the lower South Kona and Ka'ū Communities. Days after going into service as BLS, HFD Medic 20 would respond to a major medical emergency in Honomalino, of which a male patient suffered serious injuries after falling in a'a lava rocks, it was credited that if HFD Medic 20 was not service at the time of the incident, that patients injuries would've been deadly due to long response time for Medic 6 stationed at the Captain Cook Fire Station, which at the time prior to Medic 20 coming online, would service the entire South Kona district.

EMS services on the Island of Hawaii remain relatively the same, however, with population growth on the island, so did the demand for additional EMS units on the island, particularly in the Puna and North Kona districts, which those units at the Pāhoa and Kailua Fire Stations would see high call volumes and also long transport times as well due to the location of the nearest hospital.

For years, state and county legislators would push for additional medics on Hawaii Island, however, all legislation would fail or not make in pass committees in the Hawai'i State Senate or House. It was not until 2019, that HFD would be allowed or allocated funding from the State to add its 16th medic unit at the Paradise Park Fire Station (Medic 18), helping bring much-needed relief to Medic 5 (Kea'au) and Medic 10 (Pāhoa) crews, which use to cover the Hawaiian Paradise Park subdivision.

Since going into service in 2019, Medic 18 has become one of six busiest medics on the Island of Hawaii in 2020.


So what can be done in the back of the ambulance and in the field

HFD EMS Providers (EMTs and MICTs) are capable of doing a lot of things in the back of an ambulance, here are some of the things that they are capable of doing or they encounter:

  • Stabilizing a patient suffering a heart attack

  • Shocking a patient to bring back a normal rhythm

  • Giving IV Treatment for a patient who is severely dehydrated

  • Giving birth to a newborn infant on the way to the hospital

  • Providing treatment for those having trouble breathing

  • Providing CPR or Life-Saving Measures to a patient in cardiac arrest

  • Stabilizing a broken or fractured bone on a patient

  • Control bleeding from a gunshot or stab wound

  • Calming a mentally unstable individual

The items listed above are only a handful of things that our EMS providers are capable of doing in the back of the ambulance or out in the field when you call 911.


Challenges being faced by EMS on Hawaii Island

Because the demand for EMS on the Island of Hawaii has grown substantially, it also puts on strain on the crews and equipment to help maintain those services.

Currently, on the Island of Hawaii, HFD is contracted to run 16 Medic units across the island and they are placed at the following stations:

  • Central - Hilo (Medic 1)

  • Haihai - Hilo (Medic 3)

  • Kea'au - Puna (Medic 5)

  • Captain Cook - Kona (Medic 6)

  • Kailua-Kona (Medic 7)

  • Honoka'a - Hāmākua (Medic 8)

  • Waimea - South Kohala (Medic 9)

  • Pāhoa - Puna (Medic 10)

  • Na'alehu - Ka'ū (Medic 11)

  • Keauhou - Kona (Medic 12)

  • South Kohala (Puakō) (Medic 14)

  • North Kohala (Medic 15)

  • Waikoloa - South Kohala (Medic 16)

  • Paradise Park - Puna (Medic 18)

  • Volcano - Ka'ū (Medic 19)

  • HOVE - Ka'ū (Medic 20)

While we have 16 ambulances on the island, it doesn't mean we have enough to cover the call volume that is currently being experienced around the island. Like in Hilo, there are only two ambulances (Central - Medic 1 and Haihai - Medic 3) that cover the entire Hilo area (which include Pana'ewa, Downtown Hilo, Pāpa'ikou, Honomu, and Keaukaha regions), however, thankfully with Hilo Medical Center nearby and allows EMS crews to do quick turnarounds in between calls. While in the North Hilo and Hāmākua districts, while they have two fire stations (Laupāhoehoe and Honoka'a) cover that region, only one fire station has a medic at Honoka'a that covers the entire Hāmākua Coast.

Few more examples, If the Waimea Medic was to run out on a call in their district, now both Medic 14 (South Kohala) and Waikoloa (Medic 16) coverage area had grown to include parts of Kamuela town, vice versa when either one of the units leaves, their district grows by a lot. Medic 15 - North Kohala covers the entire district of North Kohala, and if they go out a 911 call, Medic 9 or Medic 14 (located over 20 to 30 miles away) will be next up to help cover calls in the North Kohala region. On the Kona Coast, Kailua (Medic 7) covers Kalaoa, Keahole, Kua Bay, Kailua Village, and Hōlualoa, Keauhou (Medic 12) covers the Keauhou Mauka, Honalo, Kahalu'u, and Kainaliu, Captain Cook (Medic 6) covers Kealakekua, Captain Cook, Hōnaunau, Kealia, Ho'okena, and Kaohe. If Medic 6, 7, or 12, were to go out on a call, the other medic unit's districts also grow substantially, in some cases they would be covering the entire Kona Coast. There have been cases where Medic 14 (South Kohala) or Medic 16 (Waikoloa) were called to help cover calls in North Kona.

Medic 20 - HOVE covers Miloli'i to Kahuku region of the Ka'ū District and Medic 11 - Na'alehu covers the area which includes South Point, Waiohinu, Na'alehu, Punalu'u Beach Park, Pāhala, and Kapapala Ranch. Medic 19 - Volcano covers the Hawaii Volcanoes National Park, Volcano Village, and Glenwood area. Medic 5 - Kea'au covers the upper Puna region including Mountain View, Kurtistown, Kea'au, and Shipman Industrial Area. Medic 18 - Paradise Park covers the entire Hawaiian Paradise Park subdivision and parts Orchidland Estates and Ainaloa Subdivision. Medic 10 - Pāhoa covers the rest of the Lower Puna District which includes Hawaiian Beaches, Kapoho, Pohoiki, Kehena Beach, and Kalapana.

There are situations where all available medics in the area are all on a call and HFD crews have to wait for an available ambulance to clear from an incident or the hospital transport to respond to that emergency. And there also cases, where another medic from one district is moved to another station to standby until the other units become available. So it becomes a juggling act to ensure EMS resources are available to those who needed.

Of all 16 Medic Units on the Island of Hawaii the following units see the highest call volumes (based on statistics taken by HIRSC Team for 2019 to 2020):

  • Kailua (upward of 2,000+ calls per year)

  • Central (upward of 1,700+ calls per year)

  • Pāhoa (upward of 1,200+ calls per year)

  • Paradise Park (upward of 1,000+ calls per year)

  • Kea'au (upward of 900+ calls per year)

  • Haihai (upward of 800+ calls per year)

Based on the evaluation of the types of calls and people calling 911, based on HIRSC data and scanner logs, believe it or not, the homeless population is not the highest users of EMS (roughly 8%) but more of the local population or residents (roughly 78% calls made) calling for help on the Island of Hawaii. Visitors only accounted for roughly 14% of the calls made.

Due to the high call volumes at several stations on Hawaii Island, HFD officials got creative and began a program called Community Paramedicine, where HFD EMS Captains (MICTs), visit users that have been known to use EMS frequently and conduct a risk assessment or refer them to social services that could help reduce their need for EMS or HFD services frequently. The program has become so successful and has helped a handful of residents reduce the need to call 911 for help.

However, the call volume continues to grow with the population growth, and the need for another ambulance has been pushed once again for the North Kona Community, as the Kailua Fire Station sees the highest volume of medical calls on the Island of Hawaii and also transport times to the Kona Community Hospital can exceed over 20 minutes or more. That call volume not puts a strain on staff but also the equipment and the vehicle (medic) as well. There have been situations where HFD crews had to change over multiple spare units in one day due to strain from the high call volume. Community members, local legislative officials, and also HFD crews continue to push for another ambulance in North Kona and will continue to push for it in the next legislative session. If future legislation succeeds, that new medic unit would be stationed at the Makalei Fire Station (and appropriately called Medic 21).

Another challenge that HFD officials face is vacancies in the EMS Bureau, which leads to the Medic unit being downgraded from ALS to BLS for a period of time, causing the nearest ALS unit to correspond to help provide coverage and also transport to the hospital. HFD officials say the MICT vacancies in the EMS Bureau are mainly due to personnel being promoted up in rank within HFD and also retirements and resignations that have led to EMS positions being vacant, however, thankfully a lot of the HFD Ranks with MICT certifications have stepped in help fill that gap until vacancies can be filled. Officials also did note that the COVID-19 pandemic and health concerns associated with COVID also caused some personnel in EMS to change over to other areas of HFD.

Currently, HFD has a total of 8 Firefighter/EMTs in MICT Training and expected to complete their training in January 2022, another 5 Firefighter/EMTs are expected to begin their MICT Training in August 2021. Once all personnel has completed their MICT Training, that should help fill vacancies within HFD's EMS Bureau.

While HFD currently has 16 Medic units (second-most in the state, behind Honolulu at 21) that currently cover the entire Island of Hawaii, what the community does not realize, not all fire stations on the island have a Medic unit stationed there and it's not an easy feat to get another unit established or online to serve the communities on the Island of Hawaii. In the State of Hawai'i, the Department of Health (DOH) contracts and funds EMS or ambulance services to providers across the state.

Brief background of EMS Providers in the State

In Maui County and Kauai County, ambulances services are contracted to be operated by American Medical Response (AMR) with the Maui Fire Department (MFD) and Kauai Fire Department (KFD) providing co-response services on those islands. While on Oahu, the City and County of Honolulu EMS is contracted to run ambulances services on the island of Oahu with AMR being used as a secondary or backup service for EMS and the Honolulu Fire Department (HNL FD) and Federal Fire Department (FFD) providing co-response services to EMS. And of course, on the Island of Hawaii, the Hawaii Fire Department (HFD) is contracted to run EMS for the island, and AMR is used as a secondary or backup service to EMS as well. HFD is again the only fire department-run EMS within its department operations.

Taking a look at the numbers and nitty-gritty of EMS

In order for EMS providers to establish a new ambulance or medic unit within their systems, providers must submit a request or proposal to the DOH for it to be added in their next fiscal year budget, that will be reviewed by the state legislature; because EMS is a state-funded or appropriated item in the state budget, all proposals must be submitted to DOH, as EMS is managed/handled by DOH and not county agencies.

Once the DOH submits a proposal or request to the state legislature, it then heads to different legislature committees which review the proposal or request and allows the public to testify or weigh in on the proposal/request up before them. If everything goes well and passes all committees and both the senate and house give it a favorable vote, it will head to the governor's desk to be signed into law and adding a line item in the state's budget for that new unit. Once that becomes law and funding has been appropriated, the provider then can put into service the new unit requested or purchase any equipment needed to get that unit online.

According to numbers provided by the DOH, establishing one new ambulance or medic unit in a county costs $1.5 million in the first year, and to maintain services annually, cost $750 to 800k every year.

(Just to give you an example of why it's $1.5 million in the first year)

  • New Ambulance Unit Cost to Build: $260 to $300k

  • Equipment for the new unit (ECG, Gurney, Backboards, etc) and maintenance: $500,000

  • Staffing for unit: $600 to 700k (depending on agency contracts)

HFD - EMS Budget for 2020-2021 is $14.8-million and the appropriated funding covers the purchases of EMS equipment/supplies, equipment maintenance, and salary/wages. (Just to help give you an inside look at the fiscal side of the EMS operations on the Island of Hawaii).

Due to EMS funding being a state-funded item, EMS services on all islands were in jeopardy of being cut as much as 20% across the board, however, thanks to CARES ACT funding and also reconsideration made by state officials, EMS funding was kept intact for 2020-2021 fiscal year budget for the state. As far HIRSC Team is aware of for the 2021-2022 fiscal year, EMS Funding was slightly cut by 4%, however, according to officials on Hawaii County, it would not affect services on the Island of Hawaii.

Give you an additional retrospect to the state funding, it cost $100k to training and license a new paramedic in Hawai'i associated with a state-contracted agency. It would take up to 3 or 4 years to recoup the cost of that training. And if that person leaves after receiving training and license or within 4 years, that money goes away with that person as well.

Why is EMS not a priority in the state budget

One of the reasons why funding a new ambulance can be difficult is because of the many other priorities in the state legislature during that legislative session such as education, public safety, Transit Accommodations Tax (TAT), environmental issues, transportation needs, and also funding the hospitals always take a higher priority over EMS. Unfortunately time and time again, EMS proposals are always put on the back burner and always overlook due to the current priorities set forth. However, former state legislature officials say it always comes to available funding or outlook for the next fiscal year budget.