REPORT AND RECOMMENDATIONS: CRITICAL CARE TECHNICAL ADVISORY GROUP (TAG) NEW YORK STATE EMERGENCY MEDICAL SERVICES COUNCIL MAY 2017 ALBANY, NY

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1 REPORT AND RECOMMENDATIONS: CRITICAL CARE TECHNICAL ADVISORY GROUP (TAG) OF THE NEW YORK STATE EMERGENCY MEDICAL SERVICES COUNCIL MAY 2017 ALBANY, NY Approved as amended by vote of the SEMSCO May 10, 2017 (17 in favor, 3 opposed, no abstentions) EDUCATION FUNDING TECHNICAL ADVISORY GROUP OF THE FINANCE COMMITTEE OF THE 1

2 INTRODUCTION: The Education Funding Technical Advisory Group (TAG) was established by Steven Kroll, Chair of the New York State Emergency Medical Services Council at the Council s September 2016 meeting. The TAG was established to examine ongoing concerns about the future viability of the EMT-Critical Care (CC) level of certification in New York State. Eighteen members were named to the TAG including Patty Bashaw, Frank Chester, James Deavers, Robert Delagi, Daniel Dennis, Gary Ferrucci, Mickey Forness, Debra Fults, Travis Howe, Donald Hudson, Howard Huth, David Kugler, John Malinchock, Lewis Marshall, Mike McEvoy, John McGuire and Kevin O Hara. Andrew Johnson, represented the Bureau of Emergency Medical Services. On September 7, 2016, the TAG met electronically to review an extensive report of current and historical training trends across New York State at the Paramedic, CC and AEMT levels. Members of the TAG requested additional data to clarify specific questions and asked the Bureau to solicit feedback from REMACs and Regional Councils on their perspectives regarding the future of the CC in their respective locales. The Bureau reported it had sent this solicitation in The TAG received one direct response from the North Country Regional EMS Program Agency who surveyed their currently practicing CCs. No other REMSCOs, REMACs or Program Agencies provided direct input. The TAG subsequently met multiple times both electronically and in person. CHARGE: Owing to shortages of paramedic training in many rural, primarily volunteer based areas of New York State, a Cardiac Technician, level of care was created by the SEMAC in A redeveloped curriculum in 1992 renamed the level Critical Care Technician which was ultimately memorialized in NYS Codes, Rules and Regulations as Emergency Medical Technician Critical Care (14 NYCRR 800.6). The purpose of the CC level of care was to assure the availability of ALS level care throughout New York State. The TAG was charged with examining the past and present operation of the CC program in NY with the goal of making recommendations on the CC future. There were no preconceived or specified outcomes delineated. The TAG was instructed that, any and all options were on the table. REVIEW: The TAG initially reviewed CC use in each region, the current CC curriculum, administrative burden and costs of sustaining CC education curriculum and exam development and maintenance, original course participation, refresher course attendance, use of CME refreshers and the comparative scope of practice and availability of AEMT educational programs. Additional data were requested and reviewed as the TAG deliberations proceeded. In our final analysis, three clearly identifiable categories were determined to encompass the voluminous data available to the TAG: 1. Significant declines in CC course enrollments. 2. Substantial evolution in CC curriculum. 3. Comparative scopes of advanced EMT practice. DECLINING CC COURSE ENROLLMENTS: Total numbers of EMTs, AEMTs and Paramedics certified each year have steadily increased whereas the total number of CCs has continually declined since The total number of original CC courses has also declined whereas there has been an increase in the total number of eligible CC Course Sponsors since 1997 while Paramedic level sponsors have remained the same. Little disparity seems to exist between students enrolled and students who become CC certified, suggesting that changes in testing or course administration are unlikely to account for declining course enrollments or completion. CC refresher program enrollment and completion have also steadily declined. The following charts illustrate the changes over time, including a breakdown of trends by Region. 2

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11 Total certified providers by level in NYS 2016 The TAG also examined course funding over time for patterns that may have influenced willingness of sponsors to run CC classes or student enrollment. While CFR, EMT and the previous EMT-Intermediate levels saw reduced funding, the CC and Paramedic original and refresher training courses had substantial increases in NYS reimbursement levels. A review of SEMSCO Finance Committee recommendations showed that the increases to CC funding were intended to increase participation in the CC and Paramedic programs because of the observed declines in course offerings and enrollment. 11

12 The TAG also examined the average ages of various levels of providers, looking for any potential influence on CC course participation. CCs tend to be older than Paramedics and CC age is increasing suggesting that people are not entering the CC level of certification: What seemed most closely connected to declining CC enrollments was the actual numbers of CC level agencies. Currently, of the total 58,703 certified EMS providers in NYS, only 1,631 are CCs. These providers are concentrated in four areas as shown on the chart below. A complete breakdown of CC providers appears in Appendix I, broken down by combination, paid and volunteer agencies. 12

13 EVOLUTION OF CC CURRICULUM: The current National EMS Educational Standards, approved by SEMSCO in March 2011, recognize EMR (called CFR in NYS), EMT, AEMT and Paramedic levels. There is no current national equivalent of the NYS CC level and while SEMSCO and SEMAC voted to maintain the CC level in 2011, SEMAC directed the Bureau to review the CC level of care in order to determine whether it should remain in NYS. The lack of a national CC equivalent currently poses issues with the transportability of CC certification: 1. NYS CC providers are unable to obtain reciprocity in other states. At times, a CC may be able to obtain reciprocity at the AEMT level. In many cases, CCs applying for reciprocity are able only to obtain EMT level recognition in other states. 2. In mutual aid responses, both within and outside of New York State, CCs are unable to practice at their NYS recognized level of care. Within NY, CCs are not recognized or authorized to practice by the NYC region. Nationally, educational initiatives at all levels have increasingly sought to standardize curriculum. While some elements of education such as the Common Core used in elementary and high school education are controversial, the concept of standardized curriculum is considered a best practice and is supported by New York s Governor. The lack of any national CC equivalent means that NYS DOH owns the entire responsibility for both the CC curriculum, Final Practical Skills Exam (PSE) and the CC written certification exam. The administrative burden and expense of writing, revising and maintaining an entire curriculum led NYS to transition EMT-Intermediates to the national AEMT level several years ago. The CC level was, at that time, kept intact. Presently, the CC curriculum is in need of extensive updating and the written examination bank requires considerable revision. With lack of any national equivalent, the costs ($880,941 for curriculum updates, $134,843 for exam updates) and administrative burden of both tasks is unaffordable. Even without necessary revisions, the current CC written certification exams add significantly to the total cost of NYS written testing as, lacking any national equivalent, they are required to be included as a separate item in testing RFPs and contracts. Additionally, the CC PSE is extremely burdensome, outdated and does not meet National Standards for the skills tested. Under the current National EMS Educational Standards and Scope of Practice Model, the AEMT level of care is intended to assure the availability of ALS service in rural and underserved areas. The AEMT level of care was not available in 1978 when the CC was created in New York State to address the very same concern of assuring ALS availability. 13

14 COMPARATVE SCOPES OF ADVANCED EMT LEVEL PRACTICE: The TAG was interested in scopes of practice for the AEMT, CC and Paramedic and where scopes currently overlap. To examine current practice, 10,581 medication administrations by CCs and Paramedics were collected from the Image Trend State PCR data bridge spanning a one-year period in the Mountain Lakes EMS Region. In 7,534 instances, Paramedic administered medications were actually within the AEMT scope of practice. In 67 instances, CC administered meds were at the AEMT level and in only 17 instances did CCs administer medications at the Paramedic level. These data suggest that the majority of ALS medications administered by CCs and Paramedics are actually within the current AEMT scope of practice. This finding reinforces the suitability of the AEMT level of care as a mechanism to assure delivery of ALS in rural and underserved areas. A chart comparing scopes of practice between the National and NY AEMT and Paramedic levels is included here for reference. Note that this is not an all encompassing listing: Skill Comparison AEMT and Paramedic NYS vs National Standards The left column lists the National Standard skills. The column directly to the right is the NYS skills that are included in the NYS Standards. Areas that are highlighted in Red are those areas that were added to the NYS Standards and may not be included within the National Standards. Areas highlighted in Blue are areas where NYS is above the National Standards. Skills denoted with an A are skills are already being taught in certain areas of NYS, but are not required statewide. Of note, with the increased number of skills added to the EMT level, less ALS provider skills are needed. NYS Above NYS New NYS w/additional Training Skill - Airway/Ventilation/ AEMT NYS Paramedic NYS Oxygenation AEMT Paramedic Airway - esophageal X X X X Airway supraglottic X X X X Airway nasal X X X X Airway oral X X X X Bag-valve-mask (BVM) X X X X BiPAP/CPAP X X Chest decompression - needle X X Chest tube placement assist X A only Chest tube monitoring and X A management Cricothyrotomy needle X X 14

15 Cricothyrotomy percutaneous X Demand valve manually X X X X triggered ventilation End tidal CO 2 X X X monitoring/capnography Gastric decompression NG X X Tube Gastric decompression OG X X Tube Head tilt - chin lift X X X X Intubation nasotracheal X X X Intubation - orotracheal X X X Jaw-thrust X X X X Jaw-thrust - Modified (trauma) X X X X Mouth-to-barrier X X X X Mouth-to-mask X X X X Mouth-to-mouth X X X X Mouth-to-nose X X X X Mouth-to-stoma X X X X Obstruction direct X X laryngoscopy Obstruction Manual X X X X Oxygen therapy Humidifiers X X X X Oxygen therapy Nasal X X X X cannula Oxygen therapy X X X X Nonrebreather mask Oxygen therapy partial X X rebreather mask Oxygen therapy simple face X X mask Oxygen therapy Venturi X X mask PEEP therapeutic X X Pulse oximetry X X X X Suctioning Upper airway X X X X Suctioning tracheobronchial AI X X X Skill - Airway/Ventilation/ Oxygenation Ventilator Automated transport (ATV) Skill- Cardiovascular/Circulation Cardiac monitoring multi-lead (interpretive) Cardiac monitoring single lead (interpretive) Cardiopulmonary resuscitation (CPR) AEMT NYS Paramedic NYS AEMT Paramedic X X X X AEMT NYS AEMT Paramedic X X NYS Paramedic X X X X X X 15

16 Cardioversion electrical X X Carotid massage X X Defibrillation automated / X X X X semi-automated Hemorrhage control direct X X X X pressure Hemorrhage control X X X X tourniquet Internal; cardiac pacing X A monitoring only MAST/PASG X X X X Mechanical CPR device X X Transcutaneous pacing - X manual Skill-Immobilization AEMT NYS AEMT Paramedic NYS Paramedic Spinal immobilization cervical X X X X collar Spinal immobilization long X X X X board Spinal immobilization manual X X X X Spinal immobilization seated X X X X patient (KED, etc) Spinal immobilization rapid X X X X manual extrication Extremity stabilization - manual X X X X Extremity splinting X X X X Splint traction X X X X Mechanical patient restraint X X X X Emergency moves for endangered patients Skill-Medication Administration - Routes Assisting a patient with his/her own prescribed medications (aerosolized/nebulized) Aerosolized/nebulized (beta agonist) X X X X AEMT Int. X NYS AEMT State SOP X Paramedic NYS Paramedic X Buccal X X Endotracheal tube X X Skill-Medication Administration - Routes AEMT NYS AEMT Paramedic NYS Paramedic Inhaled self-administered X X (nitrous oxide) Intramuscular (epinephrine or X X X glucagon) Intranasal (naloxone) X X Intravenous push (naloxone, dextrose 50%) Intravenous push (epinephrine) L X X Intravenous piggyback X X Nasogastric X X Oral (glucose) X X X X 16

17 Oral (aspirin) X X X X Rectal X X Subcutaneous (epinephrine) L X X Sublingual (nitroglycerin) L X X Auto-injector (self or peer care) X X X X Auto-injector (patient s own X X X X prescribed meds) Skill - IV Initiation/Maintenance Fluids AEMT NYS AEMT Paramedic NYS Paramedic Access indwelling catheters X and implanted central IV ports Central line monitoring X A Intraosseous initiation X X X X Intravenous access X X X X Intravenous initiation - X X X X peripheral Intravenous maintenance of X X X X non-medicated IV fluids Intravenous maintenance of X X medicated IV fluids Skill - Miscellaneous AEMT NYS AEMT Paramedic NYS Paramedic Assisted delivery (childbirth) X X X X Assisted complicated delivery X X X X (childbirth) Blood glucose monitoring X X X X Blood pressure automated X X X X Blood pressure manual X X X X Eye irrigation X X X X Eye irrigation Morgan lens X X Thrombolytic therapy initiation Thrombolytic therapy monitoring Urinary catheterization Venous blood sampling X X Blood chemistry analysis A A 17

18 CONCLUSIONS: CC provider numbers have been steadily declining since 1997 and appear headed towards extinction. The number of CC original and refresher courses offered has also declined while the number of course sponsors have remained stable. The decline in course offerings is likely related to declining enrollments. Simultaneously, the CC program is in need of extensive curriculum updating and the CC practical skills exam and written test bank requires considerable redevelopment. Unlike all other levels of NYS EMS certification, CC has no national equivalent from which curriculum and test items can be drawn. The resulting administrative burden and cost to NYS to keep the CC program current is unaffordable using the monies currently allocated to EMS training and education. Lack of any national equivalent to NYS CC affects providers seeking reciprocity and limits portability of the CC in disaster both within and outside of NYS. The CC program was created to assure delivery of ALS to rural and underserved areas. The current National EMS Educational Standards suggest that the AEMT level of care exists to fulfil that same purpose. An analysis of scope of practice of the AEMT suggests this skill set may be a suitable replacement for CC level care in some locales. Such a decision lies at the EMS agency level, based on the needs and desires of their community. Use of AEMTs is supported by an analysis of data from one rural region of NYS over a one-year period where the majority of ALS medications administered by CCs and Paramedics were available at the AEMT level of practice. It is important to note that the conclusions of the TAG are not unanimous. Some members of the TAG favor keeping the CC level of care intact. The majority of TAG members agree with the conclusions and recommendations described herein. Effects associated with sun setting the CC level of care are unknown. It is the belief of the TAG that some CC level agencies and CC providers would elect to transition to AEMT level while others would be interested and willing to complete a bridge course to Paramedic level if such a program was affordable, accessible and not overly onerous. A survey conducted by the North Country EMS Regional Council supports both of these contentions as illustrated by the following responses: 18

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30 Additionally, given the current funding dollars spent at the CC level, considerably more AEMTs could be trained each year were providers and agencies to elect to transition to AEMT level. The following numbers illustrate such a reallocation: Original Courses AEMT Training $ 22, $ 47, $ 38, $ 16, AEMT PSE $ 3, $ 8, $ 7, $ 2, CC Original $ 159, $ 156, $ 139, $ 205, $ 166, CC PSE $ 14, $ 14, $ 12, $ 17, $ 19, Total Training Dollars $ 201, $ 229, $ 198, $ 244, $ 186, AEMT Students CC Students Total AEMT + CC Potential if all were AEMT Since January of 2017, sixteen ALS agencies have ceased operations and many more are struggling financially. Many NYS CC and Paramedic agencies operate currently with 1 to 5 providers on their membership roster. The AEMT level of care may be more affordable and appropriate for many of these agencies. The reduced costs and less time commitment might allow for more AEMTs than current declining numbers of CCs. RECOMMENDATIONS: [Note: recommendations amended by SEMSCO see p. 31] The TAG proposes SEMAC and SEMSCO approve four actions to gradually sunset the CC level of certification in NYS. These actions would allow continued CC certification renewals, affording REMSCOs and REMACs a prolonged period in which to sustain or reconfigure their systems, based on Regional needs. They would also address the immediate inability of NYS to shoulder the administrative burden and financial costs of revising and maintaining the CC curriculum, Practical Skills Exam and Written CC Certification Exam. The proposed actions are: 1. DOH no longer approve original CC courses starting after September 1, DOH no longer approve CC refresher or CC rapid refresher courses starting 18 months from item #1 above. 3. Continue the CC CME refresher program. 4. DOH create an automatic advanced standing CC to Paramedic bridge program open to any currently on-line NYS CC. Such a bridge program should include on-line didactic content with availability of skills and testing a local course sponsors. 30

31 By vote of the New York State Emergency Medical Services Council on May 10, 2017, the preceding recommendations were reordered, amended and approved to read in final form as follows: SEMSCO approves four actions to gradually sunset the CC level of certification in NYS. These actions would allow continued CC certification renewals, affording REMSCOs and REMACs a prolonged period in which to sustain or reconfigure their systems, based on Regional needs. They would also address the immediate inability of NYS to shoulder the administrative burden and financial costs of revising and maintaining the CC curriculum, Practical Skills Exam and Written CC Certification Exam. The proposed actions are: 1. Continue the CC CME refresher program. 2. DOH no longer approve original CC courses starting after January 1, DOH no longer approve CC refresher or CC rapid refresher courses starting 18 months from item #2 above. 4. DOH create an automatic advanced standing CC to Paramedic bridge program open to any currently on-line NYS CC with 3 years of continuous practice 1. Such a bridge program should include on-line didactic content with availability of skills and testing a local course sponsors. DOH will operate this bridge program for a minimum of 10 years from January 1, [Items highlighted in yellow were added by SEMSCO] 1 the term continuous practice is substituted here for SEMSCO s active practice. The motion makers and SEMSCO voting body indicated their desire to utilize language in the dissemination of this action consistent with 10 NYCRR 800.3(w) to avoid any misinterpretation of intent. (see: 31

32 Appendix I Breakdown of advanced level providers by Agency: Combination agencies Paid agencies Volunteer agencies 32

33 Combo Agencies Monday, November 07, :48:40 PM 4 = EMT 7 = CC 8 = Paramedic 9 = AEMT agency_name city EMTs AEMTs CCs Paramedics Altamont Rescue Squad, Inc. Altamont Colonie Emergency Medical Services, Town of Latham Smithfield Eaton Volunteer Ambulance Corp, Inc. Morrisville Level of Care: 07 Broome Volunteer Emergency Squad, Inc. Binghamton Cortlandt Regional Paramedics Cortlandt Manor Union Volunteer Emergency Squad, Inc. Endwell Vestal Volunteer Emergency Squad Inc. Vestal Broome Volunteer Emergency Squad, Inc. Binghamton Union Volunteer Emergency Squad, Inc. Endwell Soldiers & Sailors Mem Hosp of Yates Co. Penn Yan Irondequoit Ambulance, Inc. Rochester Vestal Volunteer Emergency Squad, Inc. Vestal Gates Volunteer Ambulance Service, Inc. Rochester Hampton Bays Volunteer Ambulance Corp, Inc. Hampton Bays Page 1 of 21

34 Tully Ambulance, Town of Tully Cato, Ira, Meridian, Victory Ambulance Corps, Inc. Cato Southern Cayuga Instant Aid, Inc. Poplar Ridge Four Town First Aid Squad, Inc. Moravia Warrensburg Emergency Medical Services, Inc. Warrensburg Scotia Fire Department, Village of Scotia Marathon Area Volunteer Ambulance Corps, Inc. Marathon Johnsburg Emergency Squad, Inc. Johnsburg Riverhead Volunteer Ambulance Corps, Inc. Riverhead Fair Haven Ambulance, Village of Fair Haven Pompey Hill Volunteer Fire Dept, Inc. Pompey Chautauqua Fire District #1 Chautauqua Fredonia Fire Department, Village of Fredonia Genesee Valley EMS, Inc. Caledonia Maine Emergency Squad, Inc. Maine Page 2 of 21

35 Berkshire Emergency Squad, Inc. Newark Valley Champlain EMS, Inc. Champlain Level of Care: 07 Thousand Islands Emergency Rescue Service, Inc. Clayton Phelps Ambulance, Inc. Phelps Berkshire Emergency Squad, Inc. Newark Valley Madison Ambulance, Village of Madison Greene Emergency Squad, Inc. Greene Brewerton Volunteer Fire Department Ambulance, Inc. Brewerton Sherburne Fire Department Emergency Squad Sherburne Town of Watertown Ambulance Service, Inc. Watertown Ski Windham Operating Corporation Windham Delmar Volunteer Ambulance Service, Inc. Delmar Level of Care: 09 Walworth Ambulance, Inc. Walworth Norwich Fire Department, City of Norwich Canandaigua Emergency Squad, Inc. Canandaigua Page 3 of 21

36 Orchard Park Fire District EMS, Inc. Orchard Park New York State Office of Fire Prevention and Control Albany Dannemora Fire Department Dannemora Level of Care: 07 Lyon Mountain Volunteer Fire Company, Inc. Lyon Mountain Morrisonville Schuyler Falls Vol. Ambulanc Service, Inc. Morrisonville Wading River Fire District Wading River Wilmington Ambulance Service, Town of Wilmington Saranac Lake Volunteer Rescue Squad, Inc. Saranac Lake Indian River Ambulance Service, inc. Philadelphia Bolton Emergency Medical Services, Inc. Bolton Landing Centereach Fire District Centereach Brockport Volunteer Ambulance Corps Brockport Old Erie Emergency Services, Inc. Jordan Malone E.M.S., Inc. Malone Chatham Rescue Squad, Inc. Chatham Page 4 of 21

37 Clausson Raught Community Rescue Squad, Inc. Copake Greenport Rescue Squad, Inc. Hudson Valatie Volunteer Rescue Squad, Inc. Valatie Onondaga County Sheriff's Office Camillus 1 14 Florence Ambulance Service, Town of Camden Union Hill Volunteer Ambulance Corps, Inc. Union Hill 33 0 Raquette Lake Volunteer Ambulance Squad, Inc. Raquette Lake Holtsville Fire District Holtsville Arlington Fire District Poughkeepsie Beacon Volunteer Ambulance Corps, Inc. Beacon La Grange Fire District EMS Poughkeepsie Pleasant Valley Fire Department Rescue Squad Pleasant Valley Fairview Fire District Poughkeepsie Gowanda Ambulance Service Corp. Gowanda Lancaster Volunteer Ambulance Corps, Inc. Lancaster Page 5 of 21

38 Elizabethtown Lewis Emergency Squad, Inc. Elizabethtown Newcomb Volunteer Fire Department, Inc. Town of Newcomb Ausable Forks Volunteer Ambulance Service Corporation Ausable Forks Lake Placid Volunteer Ambulance Service, Inc. Lake Placid Tupper Lake Volunteer Ambulance & Emergency Squad Tupper Lake North Country Life Flight, Inc. Saranac Lake Northampton Ambulance Service, Town of Northville Level of Care: 07 Leroy Ambulance Service, Inc. LeRoy Durham Ambulance Inc. Oak Hill Level of Care: 09 Indian Lake Volunteer Ambulance Corps, Inc. Indian Lake Inlet Volunteer Emergency Services, Inc. Inlet West Winfield Fire Department West Winfield Mohawk Valley Ambulance Corps, Inc. Mohawk Carthage Area Rescue Squad, Inc. Carthage Page 6 of 21

39 Evans Mills Volunteer Ambulance Squad, Inc. Evans Mills Henderson Fire Department, Inc. Henderson South Jefferson Rescue Squad, Inc. Adams Lewis County Search and Rescue, Inc. Lowville Greater Lenox Ambulance Service, Inc. Canastota Southern Madison County Volunteer Ambulance Corps, Inc. Hamilton Smith Ambulance Service Inc. DeRuyter Cazenovia Area Volunteer Ambulance Corps, Inc. Cazenovia West Webster Fire District West Webster Greece Volunteer Ambulance Service Rochester Henrietta Volunteer Ambulance Service, Inc. Rochester Honeoye Falls Ambulance, Village of Honeoye Falls Penfield Vol. Emergency Ambulance Service, Inc. Penfield Perinton Volunteer Ambulance Corps, Inc. Fairport Gates Volunteer Ambulance Service, Inc. Rochester Page 7 of 21

40 Irondequoit Ambulance, Inc. Rochester Brighton Volunteer Ambulance, Inc. Rochester Greater Amsterdam Volunteer Ambulance Corps, Inc. Amsterdam St. Johnsville Volunteer Ambulance Corps, Inc. St. Johnsville Mineola Volunteer Ambulance Corps, Inc. Mineola Long Beach Fire Department, City of Long Beach Bellmore Fire Department Bellmore East Meadow Fire District East Meadow Vigilant Engine and Hook and Ladder Co., Inc. Great Neck Glenwood H&L E&H Company, Inc. Glenwood Landing Glen Cove Volunteer EMS Corps, City of Glen Cove Lawrence Cedarhurst Fire Department, Inc. Lawrence Oceanside Fire Department Oceanside Friendship Engine and Hose Company, Inc. Merrick Plainview Fire Department Plainview Page 8 of 21

41 Syosset Fire District Syosset New Hyde Park Fire Department New Hyde Park Port Washington Fire Department Port Washington North Bellmore Fire Department North Bellmore Central Oneida County Volunteer Ambulance Corps, Inc Clark Mills Prospect Volunteer Ambulance Inc. Remsen Waterville Area Volunteer Ambulance Corps, Inc. Waterville Fayetteville, Village of Fayetteville Lafayette Fire Department, Inc. Lafayette Greater Baldwinsville Ambulance Corps, Inc. Baldwinsville Manlius Ambulance / EMS Service, Village of Manlius Marcellus Ambulance Voluntary Emergency Svcs, Inc. Marcellus Minoa Ambulance, Village of Minoa Northern Onondaga Volunteer Ambulance, Inc. Liverpool North Area Volunteer Ambulance Corps, Inc. North Syracuse Page 9 of 21

42 Skaneateles Ambulance Vol. Emergency Service, Inc. Skaneateles Syracuse University Ambulance Syracuse Level of Care: 09 East Area Volunteer Emergency Service, Inc. East Syracuse Western Area Volunteer Emergency Service Camillus Dewitt Fire District Dewitt Richmond Fire Department #1, Inc. Honeoye Victor Farmington Volunteer Ambulance Corps, Inc. Victor Canandaigua Emergency Squad, Inc. Canandaigua Blooming Grove Volunteer Ambulance Corps, Inc. Washingtonville New Windsor Volunteer Ambulance Corps, Inc. New Windsor Port Jervis Volunteer Ambulance Corps, Inc. Port Jervis Highlands Ambulance Corps, Inc., Town of Highland Falls Wallkill Volunteer Ambulance Corps, Inc., Town of Middletown Kiryas Joel Volunteer EMS, Inc. Monroe Page 10 of 21

43 Medina Fire Department, Village of Medina Central Orleans Volunteer Ambulance, Inc. Albion North Shore Volunteer Emergency Squad, Inc. Cleveland Donald McFee Memorial Ambulance Service, Inc. Mexico Southern Oswego Volunteer Ambulance Corps Central Square Northern Oswego County Ambulance, Inc. Pulaski Philipstown Volunteer Ambulance Corps, Inc. Cold Spring Rensselaer Volunteer Ambulance Service, Inc. Rensselaer North Greenbush Ambulance Association, Inc. Wynantskill Hoosic Valley Rescue Squad, Inc. Schaghticoke WF Bruen Emergency Squad, Inc. Rensselaer Congers Valley Cottage Vol. Ambulance Corps, Inc. Congers Haverstraw Ambulance Corps, Inc. Haverstraw Nanuet Community Ambulance Corps, Inc. Nanuet New City Vol. Ambulance Corps Rescue Squad Inc. New City Page 11 of 21

44 Nyack Community Ambulance Corps, Inc. Nyack Pearl River Alumni Ambulance Corp. Pearl River Ramapo Valley Ambulance Corps, Inc Suffern South Orangetown Ambulance Corps, Inc. Tappan Spring Hill Community Ambulance Corps, Inc. Spring Valley William Paul Faist Volunteer Ambulance Corps, Inc. Chestnut Ridge Chevra Hatzoloh of Rockland County, Inc. Monsey Sloatsburg Community Ambulance Corps, Inc. Sloatsburg Gouverneur Volunteer Rescue Squad, Inc. Gouverneur Massena Volunteer Emergency Unit, Inc. Massena Ogdensburg Volunteer Rescue Squad, Inc. Ogdensburg Potsdam Volunteer Rescue Squad, Inc. Potsdam Tri Town Volunteer Rescue Squad, Inc. Brasher Falls Level of Care: 07 Clifton Park Halfmoon Emergency Corps, Inc. Clifton Park Ballston Lake Emergency Squad, Inc. Ballston Lake Page 12 of 21

45 Community Emergency Corps Ballston Spa Galway Ambulance Corps, Inc Galway Malta Ambulance Corps, Inc. Malta General Schuyler Emergency Squad, Inc. Schuylerville Moreau Emergency Squad, Inc. Moreau Waterford Rescue Squad, Inc. Waterford Wilton Emergency Squad, Inc. Saratoga Springs Niskayuna Fire District #1 Niskayuna Richmondville Volunteer Emergency Squad, Inc. Richmondville Schuyler County Volunteer Ambulance Association Watkins Glen South Seneca Community Vol. Ambulance Corps, Inc. Ovid North Seneca Ambulance, Inc. Waterloo Bath NY, Volunteer Ambulance Corps of Bath Farmingville Fire Department Farmingville Page 13 of 21

46 Southampton Village Volunteer Emergency Ambulance Service, Inc. Southampton Smithtown Fire Department Smithtown Level of Care: 07 Coram Fire Department Coram Middle Island Fire Department Ambulance Company Middle Island Bay Shore Brightwaters Rescue Ambulance, Inc. Bayshore Exchange Ambulance Corporation of the Islips East Islip Melville Volunteer Fire Department, Inc. Melville Amityville Fire Department, Village of Amityville Rocky Point Fire Department Shoreham Islip Fire Department Islip Terryville Fire Department Port Jefferson Sta Lindenhurst Fire Department Lindenhurst Northport Fire Department Northport Islip Terrace Fire Department Islip Terrace Page 14 of 21

47 Center Moriches Fire Department Ambulance Company Center Moriches East Farmingdale Volunteer Fire Company, Inc. East Farmingdale North Amityville Fire Company, Inc. Amityville Level of Care: 07 Centerport Fire Department Centerport West Babylon Fire Department Rescue West Babylon Ambulance Committee of the Moriches, Inc. East Moriches Central Islip Hauppauge Volunteer Ambulance, Inc. Central Islip Holbrook Fire District Holbrook Mastic Beach Ambulance Company, Inc. Mastic Beach Ridge Fire Department Ridge Westhampton War Memorial Ambulance Association, Inc Westhampton Beach Setauket Fire Department, Inc. East Setauket Commack Volunteer Ambulance Corporation, Inc. Commack Gordon Heights Volunteer Fire Department, Inc. Middle Island Page 15 of 21

48 East Northport Fire Department East Northport Brookhaven Ambulance Company, Inc. Brookhaven Nesconset Fire District Nesconset Brentwood Legion Ambulance Service, Inc. Brentwood Selden Fire Department Ambulance Selden West Islip Fire Department West Islip Port Jefferson Volunteer Ambulance Corps, Inc. Port Jefferson East Brentwood Fire Department Brentwood Dix Hills Fire District Dix Hills Sound Beach Fire Department, Inc. Sound Beach North Lindenhurst Volunteer Fire Department, Inc. North Lindenhurst Lakeland Fire District Ronkonkoma Community Ambulance Company, Inc. Sayville Jeffersonville Volunteer First Aid Corps, Inc. Jeffersonville Mamakating First Aid Squad, Inc. Wurtsboro Page 16 of 21

49 R & R Volunteer Ambulance Corp Roscoe Tusten Volunteer Ambulance Service, Inc. Narrowsburg Candor Emergency Squad Candor Owego Fire Department Emergency Squad Owego Owego Fire District, Town of Endicott Spencer Emergency First Aid Squad, Inc. Spencer Level of Care: 07 Trumansburg EMS, Village of Trumansburg Groton Fire Department Groton Dryden Ambulance, Inc. Dryden Diaz Memorial Ambulance Service, Inc. Saugerties Ellenville First Aid and Rescue Squad, Inc. Ellenville New Paltz Rescue Squad, Inc. New Paltz Woodstock Fire Co. #5 Emergency Rescue Squad, Inc. Woodstock Bay Ridge Rescue Squad, Inc. Queensbury North Warren Emergency Squad, Inc. Chestertown Page 17 of 21

50 Lake George Post 374 American Legion Emergency Squad, Inc. Lake George West Glens Falls Emergency Squad, Inc. Queensbury Argyle Emergency Squad, Inc. Argyle Cambridge Valley Rescue Squad, Inc. Cambridge Easton Greenwich Rescue Squad, Inc. Greenwich Fort Edward Rescue Squad, Inc. Fort Edward Granville Rescue Squad, Inc. Granville Salem Rescue Squad, Inc. Salem Level of Care: 07 Skenesborough Emergency Squad, Inc. Whitehall Macedon EMS Department, Village of Macedon Ontario Volunteer Emergency Squad Ontario Newark Arcadia Volunteer Ambulance, Inc. Newark Croton on Hudson Emergency Medical Services, Village of Croton on Hudson Dobbs Ferry Volunteer Ambulance Corps, Inc. Dobbs Ferry Eastchester Volunteer Ambulance Corps, Inc. Eastchester Page 18 of 21

51 Sleepy Hollow Volunteer Ambulance Corps Sleepy Hollow Ossining Volunteer Ambulance Corps, Inc. Ossining Port Chester Rye Rye Brook Volunteer Ambulance Corps, Inc. Port Chester Scarsdale Volunteer Ambulance Corps Scarsdale Tarrytown Volunteer Ambulance Corps, Inc. Tarrytown Harrison Volunteer Ambulance Corps, Inc. Harrison Penn Yan Area Volunteer Ambulance Corps Penn Yan Brutus Ambulance,Town of Weedsport Barnard Fire District Rochester Coxsackie Ambulance Service, Town of Coxsackie Macedon Ambulance Service, Town of Macedon New Berlin Ambulance Service, Village of New Berlin Columbia County EMS Hudson Corinth Ambulance Service, Town of Corinth Day EMS, Town of Hadley 0 20 Page 19 of 21

52 Broome County Emergency Medical Services Binghamton Bethlehem Ambulance, Town of Bethlehem Level of Care: 09 Cobleskill, Town of Putnam County Bureau of Emergency Services Cobleskill Carmel Chevra Hatzalah, Inc. Brooklyn ALS Services, Inc. Brooklyn Brooklyn College Emergency Medical Squad Brooklyn Patchogue Fire Department Ambulance Co., Inc. Patchogue East Quogue Fire Department East Quogue Ronkonkoma Fire Department Ronkonkoma Kings Park Fire Department Kings Park Mastic Volunteer Ambulance Company, Inc. Mastic St. James Fire District St. James Stony Brook Fire Department, Inc. Stony Brook Wyandanch Wheatly Heights Ambulance Corps Wyandanch Page 20 of 21

53 North Babylon Volunteer Fire Company, Inc. North Babylon Copiague Fire District Copiague Deer Park Volunteer Fire Department, Inc. Deer Park Southampton Volunteer Ambulance, Inc. Southampton Manorville Community Ambulance, Inc. Manorville Shirley Community Ambulance Shirley North Patchogue Fire District North Patchogue Medford Volunteer Ambulance, Inc. Medford Flanders Northampton Volunteer Ambulance Co., Inc Flanders Grand Island Fire Company, Inc. Grand Island Jericho Fire Department Jericho Carle Place Hook, Ladder & Hose Co. No. 1 Carle Place Greater Valley EMS, Inc. Sayre Greater Valley Emergency Medical Services, Inc. Sayre Page 21 of 21

54 Paid Agencies Monday, November 07, :45:17 PM 4 = EMT 7 = CC 8 = Paramedic 9 = AEMT agency_name city EMTs AEMTs CCs Paramedics Capital District Ambulance Service, Inc. Physician's Ambulance Service, Inc. New York Presbyterian / Queens Albany Albany Flushing NYU Hospitals Center Brooklyn Lamoille Ambulance Service, Inc. Johnson Level of Care: 07 Western Turnpike Rescue Squad, Inc. Albany Albany Schenectady Greene Co. Ag. Societies, Inc. Altamont Albany Department of Fire & Emergency Services, City of Albany Port Authority of New York and New Jersey Police Jamacia TransCare New York, Inc. Brooklyn Fire Department of New York (aka: FDNY) Brooklyn New York State Police Aviation Unit Latham Albany County Sheriff's Department Advanced Life Support Clarksville Page 1 of 16

55 Guilderland Emergency Medical Service Guilderland Watervliet Arsenal Fire Department Watervliet Medical Transport Service of Allegany County, Inc. Scio Plum Island Ambulance Greenport Troy Bureau of Fire, City of Troy Ossining Volunteer Ambulance Corps, Incorporated Ossining Northern Dutchess Paramedics, Inc. Rhinebeck Windham Ambulance Service, Town of Hensonville Superior Ambulance Service, Inc. Binghamton Binghamton Bureau of Fire, City of Binghamton Eastern Wayne Emergency Medical Services Savannah 12 1 Corning Ambulance Service Inc. Corning Genesee Valley EMS, Inc. Caledonia Monroe Medi Trans, Inc. Rochester Salamanca Ambulance Service, City of Salamanca Page 2 of 16

56 Mount Sinai Hospital New York Olean Fire Department, City of Olean Cairo Ambulance Service, Town of Cairo Level of Care: 09 Montrose VA Fire Department Montrose Ravena Rescue Squad, Inc. Ravena Level of Care: 09 TransCare Westchester, Inc. Brooklyn Wyoming County Emergency Services Warsaw Phillgrey, Inc. Massena New York Presbyterian EMS New York TC Ambulance Group, Inc. Brooklyn TC Ambulance North, Inc. Brooklyn TC Ambulance Corp. Brooklyn Rockland Mobile Care, Inc. Chestnut Ridge Amsterdam Fire Department, City of Amsterdam Starnet Emergency Services, Inc. Armonk Page 3 of 16

57 Greene County Emergency Medical Services, Inc. Cairo TCBA Ambulance, Inc. Brooklyn Sullivan Paramedicine, Inc. Hurleyville Jamestown Fire Department, City of Jamestown Dunkirk Fire Department, City of Dunkirk Chautauqua County Ambulance Service Jamestown Catskill Ambulance Service, Town of Catskill W.C.A. Services Corporation Jamestown Dover Ambulance Service, Town of Dover Plains TC Hudson Valley Ambulance Corp. Poughkeepsie First Response Ambulance, Inc. Inwood Emergacare NY, LLC Yonkers North Tonawanda Fire Department, City of North Tonawanda Primary Care Ambulance Corp. Staten Island Wyckoff Heights Medical Center Ambulance Service Brooklyn Page 4 of 16

58 New York City Police Department Emergency Service Unit Brooklyn Hunter EMS, Inc Bay Shore MediSys Ambulance Service, Inc. Jamaica Erway Ambulance Service, Inc. Elmira Heights Livingston County EMS Mount Morris Wayne County Lyons Fletcher Allen Coordinated Transport, LLC Burlington Northern Ambulance Corps, LLC Malone Level of Care: 07 Rotterdam Emergency Medical Services, Inc. Schenectady Center for Emergency Medicine of Western PA West Mifflin Seniorcare Emergency Medical Services, Inc. Bronx Crest Transportation Services, Inc. Brooklyn Air Methods Corp, subsidiary Rocky Mountain Holdings LLC Selkirk Priority One Ambulance, Inc. Staten Island Richmond Medical Center Staten Island Page 5 of 16

59 Momentive Performance Materials USA, Inc. Waterford Emergency Ambulance Service, Inc Bohemia SABIC Innovative Plastics, US, LLC Selkirk World Racing Group, Inc Ambulance Service Weedsport Montefiore Medical Center E.M.S. Bronx Ace Ambulance Service, LLC Inwood Mercy Flight, Inc. Buffalo Emergency Medical Transport of CVPH, Inc. Plattsburgh Plattsburgh Fire Department, City of Plattsburgh Varin's Ambulance Service Inc. Plattsburgh TLC Medical Transportation Services, Inc. Syracuse Rockwell Falls Ambulance Service, Inc. Lake Luzerne Bath Veterans Administration Fire Department Bath Elizabethtown Community Hospital Transport Elizabethtown Columbus Ambulance Service, Town of Sherburne Page 6 of 16

60 West Point Fire Department Ambulance West Point 40 1 Richmond County Ambulance Service, Inc. Staten Island Lebanon Valley Auto Racing Corporation West Lebanon Cattaraugus County Sheriff's Office SRT Little Valley Level of Care: 09 Hackensack University Medical Center Hackensack 6 Osceola Ambulance Service, Town of Camden TLC Emergency Medical Services, Inc. Syracuse Utica Ambulance Service, Inc. Utica Empire State Ambulance Corp. Suffern Med Trans Corporation Trans Am Ambulance Services, Inc. Manhasset Olean Comprehensive Ambulance Service Bi County LLC Bohemia 15 6 Comprehensive Ambulance Service Suffolk, LLC Bohemia Comprehensive Ambulance Service Long Island, LLC Bohemia 15 6 Community Care EMS, LLC Brooklyn 2 Page 7 of 16

61 Darien Lake Holdings LLC Level of Care: 09 Margaretville Memorial Hospital Ambulance Squad Darien Center Margaretville Avarint, Inc. Springville 1 1 Level of Care: 09 St. Luke's Roosevelt Hospital Center New York MedicEast Corp Bronx NYU Lutheran Medical Center Brooklyn NYPD Aviation Unit Brooklyn LaSalle Ambulance, Inc. Buffalo Town's Ambulance Service, Inc. Buffalo Beacon Transportation, Inc. Rochester National Ambulance & Oxygen Service, Inc. Rochester National Ambulance & Oxygen Service, Inc. Rochester Corning Ambulance Service, Inc. Corning Corning Ambulance Service, Inc. Corning Eastern Paramedics, Inc. Syracuse Page 8 of 16

62 Alamo Ambulance Service, Inc. LaGrangeville LaSalle Ambulance, Inc. Buffalo Mercy Flight, Inc. Buffalo Town's Ambulance Service, Inc Buffalo International Paper Ticonderoga Ambulance Service of Fulton County, Inc. Gloversville Broadalbin Volunteer Ambulance Corps, Inc. Broadalbin Hunter Area Ambulance Service Tannersville Little Falls Ambulance Little Falls Ilion Ambulance Department, Village of Ilion Guilfoyle Ambulance Service, Inc. Watertown Fort Drum Emergency Medical Services Fort Drum Avon Rotary Lions Ambulance Service, Inc. Avon Mount Morris Town Ambulance Mt. Morris Vineall Ambulance, Inc. Oneida Page 9 of 16

63 Monroe Medi Trans, Inc. Rochester South East Quadrant Mobile Critical Care Unit, Inc. Penfield Nassau County Police Department Mineola North Shore University Hospital Ambulance Service Syosset Nassau University Medical Center East Meadow Twin City Ambulance Corporation Amhurst AmCare Ambulance Service, Inc. Rome Camden Ambulance Service, Town of Camden Edwards Ambulance, Inc. Chadwicks Utica Fire Department, City of Utica Oneida Fire Department, City of Oneida Syracuse Fire Department, City of Syracuse Carrier Dome Health Squad Syracuse Citizens Hose Company Shortsville Finger Lakes Ambulance EMS, Inc. Clifton Springs Page 10 of 16

64 Finger Lakes Racing Association, Inc. Farmington Mercy Flight Central Canandaigua Mobile Life Support Services, Inc. Newburgh Oswego County Ambulance & Hearse Service, Inc. Fulton Oswego Fire Department, City of Oswego Oneonta Fire Department, City of Oneonta Cooperstown Medical Transport, Inc. Cooperstown Troy Ambulance Service, Inc. Cohoes Rockland Paramedic Services, Inc. Chestnut Ridge R.B. Lawrence Ambulance Morristown Level of Care: 07 Akwesasne Mohawk Ambulance Akwesasne Saratoga Harness Ambulance Saratoga Springs Parkland Ambulance Service, Inc. Schenectady Schenectady Ambulance Service, Inc. Schenectady Schenectady Fire Department Schenectady Page 11 of 16

65 Knolls Atomic Power Lab Ambulance Schenectady Schoharie County Critical Care Team Cobleskill Corning Ambulance Service, Inc. Corning Hornell Fire Department Ambulance, City of Hornell Monticello Raceway Management, Inc. Monticello Bangs Ambulance, Inc. Ithaca Shandaken Ambulance Service, Town of Shandaken Lyons Ambulance, Town of Lyons Empress Ambulance Service, Inc. Yonkers Greenburgh Police Department, Town of White Plains Perry Emergency Ambulance, Inc. Perry Clinton Ambulance, Town of Churubusco Level of Care: 07 Suffolk County Yaphank Mamaroneck Ambulance District, Town of Mamaroneck Ashland Ambulance, Town of Ashland Page 12 of 16

66 Utica Fire Department Ambulance, City of Utica Auburn City Ambulance Auburn New Square Ambulance Service, Village of New Square Watervliet, City of Watervliet White Plains Rescue Medical Team, City of White Plains Albany County Sheriff's Office EMS Unit Clarksville Glens Falls Fire Department Ambulance, City of Glens Falls Green Island, Village of Green Island Niagara County Sheriff's Office Emergency Response Team Lockport Saratoga Springs Fire Department, City of Saratoga Springs Covert Ambulance, Town of Interlaken Providence Ambulance Service, Town of Middle Grove Greenfield Ambulance Service,Town of Greenfield Center Lebanon Ambulance Service, Town of Earlville 4 2 Nelson Ambulance Service, Town of Cazenovia 2 1 Page 13 of 16

67 Prattsville, Town of Level of Care: 02 Lexington, Town of Prattsville Lexington Pittsfield, Town of Pittsfield Springville Emergency Medical Services, Village of Springville Elmira City Police Department SWAT Elmira 0 1 Level of Care: 09 Erie County Emergency Services Division of EMS Niagara, Town of Alden EMS, Town of Webster Emergency Medical Service, Town of Cheektowaga Niagara Falls Alden Webster Citywide Mobile Response Corp. Bronx Maimonides Medical Center Brooklyn Hunter Ambulance, Inc. Inwood Midwood Ambulance & Oxygen Service, Inc. Brooklyn Lenox Hill Hospital New York St. Lukes Roosevelt Hospital Center New York Page 14 of 16

68 NYC Police Relief Fund EMS Long Island City Lifeline Ambulance Service, Inc. Brooklyn New York Hospital Medical Center of Queens, The Flushing Flushing Hospital Medical Center Flushing Long Island Jewish Medical Center New Hyde Park Jamaica Hospital Ambulance Department, The Jamaica Century Ambulance Service, Inc. Locust Valley New York Racing Association, Inc. Jamaica North Shore Ambulance and Oxygen Service, Inc. Corona Staten Island University Hospital Staten Island Brookhaven National Laboratory Upton Stony Brook, University Hospital, SUNY at Stony Brook Suffolk County Police Department Brentwood Tonawanda Fire Department, City of Tonawanda Tonawanda Emergency Medical Unit, Town of Kenmore Page 15 of 16