The Shot Across the Bow at DCFEMS

The recent resignation of Dr. Juliette Saussy the medical director of Washington DC Fire and EMS has been a boulder dropped in the lake of EMS that is sending ripples far and wide.  After her announcement and the letter accompanying her resignation was made public it seem that just about everyone has had a look at what she had to say, and what it means to specific services as well as our industry.  Not wanting to feel left out, I felt that it was my turn to do the same.

There was not much in Dr. Saussy’s letter that surprised me.  Many of the issues that she brought to light were ones that have been there for years, and have been known about for years but commonly were just brushed under the rug.  To expand on that a bit, a lot of the problems pointed out in the letter closely resemble problems pointed out to me by friends working in a number of different surfaces around the country.

You cannot blame Dr. Saussy for the decision that she made.  As medical director, the ultimate responsibility of who does and does not practice within her system rests on her.  She is a woman with a long standing reputation as an innovative, aggressive, and involved medical director.  Her capture by DCFEMS was one that should have been seen as a huge step forward for the department.  The only question that fire department leadership should have been asking following the hiring should have been “Tell us what to do next, doctor.”  Instead, Dr. Saussy was met with resistance and the usual “that will not work here.”  She was forced to go head to head with a union that has done so much to hold back its department, not to mention its “sister” union representing the single role providers serving Washington, DC.

And then there is the proposed plan involving American Medical Response.  First, let me start out by saying that while some might not like AMR or their business practices, they really are one heck of a company.  I worked with them for 12 years, and although some of the leadership in the division that I worked for left a lot to be desired, as a complete organization AMR is pretty damn good at what they do.  The success or failure of a specific system, however, rests more on the street level providers than it does the management overseeing them.  I know the Operations Manager of DC AMR personally, and I have no doubt that their division has strong leadership.  Now it is up to him to put the right people on the street to represent his department.

While I have not seen the official plan of action that DCFEMS and AMR have put together, from what I read it is going to work something like this: When a low acuity call comes in, a fire engine staffed with a dual role fire medic will be dispatched to the scene to make a field triage following up on the emergency medical dispatch triage that had already occurred on the phone.  If that fire medic determines the call to in fact be one of low acuity, AMR will be called, will respond, and will transport the patient to an appropriate facility.  Otherwise, a DCFEMS unit will respond.

Now, again, I have not as of yet seen this plan on paper so I am piecing this together on rumor and internet statements that I have read, but the long and the short of it is DCFEMS will retain all control over who gets transported and how.  This brings us back to Dr. Saussy’s letter.

“In an attempt to hold this system accountable, lawyers have sued the last several medical directors over the providers’ lack of competency, lack of training, and poor medical decision-making.  Not only can I not very competency, there is no valid indication that they have received any form of real training or continuous education.”

“The Training Academy, while well intentioned, is not staffed with the proper number of quality educators necessary to assure that our providers are “competent.”  I have said this from the beginning and stand by this statement.  Again, the sense of this being a top priority seems to be overshadowed by other issues.”

As you can see, one of the Doctor’s biggest complaints was training and proven proficiency.  Without either of these, how is a plan like the one jointly worked out by AMR going to work?  If DCFEMS is completely unable to establish any sort of benchmark measurements as to how good their field medics are, and they lack the training and competency for the job that they do now, how can any medical director feel comfortable signing off on the care they are to provide under that doctor’s direction?  More importantly, how can they sign off on system enhancements that determine mode of transport, destination decisions and sick vs. not sick triage decisions when they cannot function in the system that they currently operate?

DCFEMS is broken.  Smashed into little bitty pieces.  The numbers say it, and the doctor’s inside view of the department says it.  This department cares more about 15% of its work than it does the other 85%.  Add to that, many of them are not even qualified to lead a department that does 85% of that work.

The small victory out of this is that somehow, DCFEMS gets fixed and gets done the right way.  This might be a great opportunity for AMR to break that stigma that private EMS is for some reason inferior to other models.  Frankly, that erroneous claim should have been smashed to bits years ago by the company’s involvement in systems like Alameda County, one of the largest at large ambulance contracts in the country.  The small victory involves DCFEMS turning the EMS system over to somebody who has a clue of how to run one, or maybe even to hire a chief with an EMS background.

The larger victory here is that other departments and communities around the country will start to look at their own system and say, “Maybe the issues that DC is experiencing have similarities to the problems that we are experiencing.”  Although anecdotal, I can name quite a few systems that are not successful, or measure their perceived success incorrectly much like DCFEMS does, pulling the wool over the community’s eyes and selling them the snake oil of response times.

Dr. Saussy has fired a shot across the bow of our entire industry. Let’s see what everybody else is willing to do with it.