Questions on protocol, patient choice and quality control held up town approval of New Canaan Volunteer Ambulance Corps' (NCVAC) proposed contract renewal with Norwalk Hospital paramedics.

The corps presented a five-year deal for the hospital's paramedic services at the Board of Selectmen meeting April 22. The board postponed its decision, seeking clarification on those points before voting.

"My main concern is that we optimize medical services," said selectman Sally Hines in a later interview with the News~Review about the questions she raised during NCVAC's presentation. "We never got a clear protocol for handling patient choice. I'm looking here for transparency."

Patients in town typically have a choice between Stamford and Norwalk hospitals, unless it is a trauma, said EMS commissioner Susan Dahill in her presentation to the selectmen. In those emergencies, patients go to the nearest hospital that best meets their needs.

She said roughly 90 percent of NCVAC's transports went to Norwalk Hospital and the remaining 10 percent went to Stamford Hospital last year.

The primary subject of discussion was how New Canaan EMTs would handle patients with a

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specific type of heart attack and need an emergency angioplasty.

Stamford Hospital has the capability to perform the procedure, known as primary angioplasty in myocardial infarction, or PAMI. Norwalk Hospital awaits state accreditation.

PAMI candidates typically have an ST-segment elevation, diagnosed with an electrocardiogram (EKG), and other symptom clusters, according to an article in the Journal of the American College of Cardiology .

Hines' concern was that neither NCVAC nor the hospitals have a formalized guideline for treating PAMI patients while Norwalk Hospital lacks the capability.

"I'm not a physician, nor do I play one on TV or on the Board of Selectmen, I'm quoting from medical journals," she said, and referred to an article from The New England Journal of Medicine . "If performed in timely manner, PAMI is superior from thrombolysis (an anti-clotting medication) There's a door-to-balloon time of less than 90 minutes, so timing is of the essence.

"After contacting EMS, there's not protocol where the paramedics would do the appropriate EKG evaluation and if indeed there were an ST elevation, then the most timely treatment, as of now would be to triage the patient and take him directly to Stamford Hospital. So it seemed to me that it would make the sense to have a protocolized procedure to maximize the patient care," she said.

NCVAC member Melanie Barnard said the corps always works in the best interest of the patient.

"Regardless of protocol, we will always do that," she said at the meeting. "Rest assured, our patients will go to the place that's best for them."

The paramedic contract does not factor in to where the patient goes, Barnard said in a separate interview with the News~Review. She said the patient's preference and/or needs drive that decision. In most cases, she said, that's either Stamford or Norwalk Hospital.

"The patient comes first second third and last. It's the only thing that matters to us. That means the patient will go wherever is best to treat their condition at that point. And it has nothing to do with a paramedic contract," Barnard said. "It really was two separate issues they were discussing but it somehow got melded into one."

Norwalk and Stamford hospitals each had submitted proposals to NCVAC, Dahill said, but the corps wanted to stay with Norwalk Hospital because of their good, longstanding working relationship. NCVAC and Norwalk paramedics have worked together since 1992.

She said the bids were also comparable about $1.86 million over five years for Norwalk Hospital and roughly $1.80 million for Stamford Hospital.

Hines said she also wanted the contract to include a standardized procedure for how NCVAC handles the patient's choice in hospitals.

"(Patients) may direct which hospital they go to, and there seem to be different anecdotes floating around," she said, referring to tales of some patients not going to the hospital they requested.

The third issue she raised was the need for an on-going, objective evaluation of patient care and satisfaction.

"Nobody's criticizing NCVAC, but it's something moving forward to optimize patient care," Hines said.

She said she had the "highest respect" for the recommendation, but wanted her concerns addressed in the contract before approving it.

"The contract, to me, seems to be very straight-forward," Hines said. "You can deal with this in several ways, such as an addendum."

The Board of Selectmen plants to review the proposal again at one of its meetings this month.