American Medical Response in DC

As the days tick past American Medical Response draws closer to going “live” with their new public/private partnership with the District of Columbia Fire and EMS Department.  After a story posted earlier this week about a traumatic cardiac arrest that sat for close to 30 minutes without a transporting unit being available, it is clear that the time is now for something to change in the nation’s capital. The coming months are going to be very telling for the future of EMS not only in DC but throughout the country.  From a personal stand point, I am very excited to see in what direction everything goes.  There is a lot of influence in the AMR DC operation from my old stomping grounds in Springfield, Massachusetts.  Their Operations Manager, a guy by the name of Mark Nuessle, was one of my first supervisors when I hit the streets back in 2000.  About a half a dozen people who are being brought in from around the country to help with the hiring and training process of close to 200 new employees have some sort of tie to Springfield as well.  It really speaks volumes about the system that I came from. With the involvement of national resources, I also think that this partnership says a lot about AMR’s ability to strive for success.  Often seen as the biggest of big business in prehospital medicine, when AMR steps up to the plate like they have recently on the east coast, they deserve a lot of credit.  Some critics of private EMS will speak of the “lost jobs” from the closing of companies like Transcare or like Falck’s recent move to pull out of Pennsylvania but AMR has been there to pick up the pieces.  Closures like this do not mean that jobs are going away.  People still have to do the work, it just means that a company with a better ability to operate in today’s health care climate are stepping up to the plate to provide the service.  In fact, AMR is adding close to 200 jobs to the Washington, DC market in particular, and that is a huge step forward for the private sector. I cannot...

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...

Band-Aids and Broken Systems in DC

The city council in Washington DC passed an ordinance this past week to contract with private ambulance companies to provide additional ambulance coverage to handle an overflow of lower priority calls.  The response from the paramedic’s union is the usual rhetoric one would expect: “If we don’t show up people are going to die!”  Wrong, folks.  If nobody shows up that might happen.  Does it have to be a DCFEMS ambulance?  Absolutely not. For the life of me I cannot figure out how a system the of Washington, DC’s can operate without a safety net.  How is there nobody there to pick up the overflow?   In Springfield, Massachusetts for example, a city of 150,000 people we had a relief valve for when the volume outpaced the resources.  Other companies signed agreements and participated in the 911 system when we needed them to and guess what?  Because of the structure of our system, and the allowance that we could select who was part of the system in my seven years in management I never heard a complaint about the level of care that was provided in any instances of backup response.  Sure, you ran into the occasional response time issue however much like the proposed DCFEMS changes those units were commonly handling lower priority calls.  It is much easier to get a truck who is making a turnaround at a hospital to pick up a CPR call or a shooting than it is the toe pain or another suicidal person. The key to a partnership like this is structure and oversight.  While some might complain that the hastily made plan by the city council might lack just that, but creating and instituting these measures should not be difficult.  For example, a great place to start is to set standards for who you will let in on the action.  Is it smart to let every mom and pop shop descend into the neighborhoods of DC to provide emergency care?  Absolutely not, but there are plenty of services in the heavily saturated DC area who could more than handle the volume. And let’s not lose sight of the fact that although the patch on one shoulder...

The Response Time Debate

The Response Time Debate

Mar 5, 2015

Read Justin Schorr’s post by following this link! Everybody loves a good internet debate, right?  This afternoon I engaged in one of those with my good friend and Chronicles of EMS star Justin Schorr about response times and their impact on EMS.  Sparking the debate was an article that Justin shared that discusses the impact of response time compliance on a large city in the United States covered by a fire based EMS system backed up by two private services. In his post, Justin disclosed that he is a firefighter/paramedic and a “card carrying member” of the IAFF.  Staying in the same mentality, I need to disclose that I worked for a private EMS service for 12 years that held a busy urban 9-1-1 contract.  I now work for a municipal ALS only third service that intercepts a number of BLS level fire departments.  Also, as some might have heard, I am associated with the EMS Compass performance measures initiative.  The views in this post are my own and in no way reflect those of anyone associated with the project. The debate that Justin and I had revolved around two topics: the importance of response times, and the importance and relevance of ALS first response.  I am going to break down those two topics separately. Do response times matter? In most EMS systems, response times are king especially when it comes to those serviced by the private sector.  “Just get there, and we have nothing to worry about.”  All that matters is an ambulance shows up, and is most cases stakeholders want somebody on that ambulance to have a paramedic patch on their sleeve.  What happens from there does not really matter unless somebody complains. It is funny that this topic comes up now, because currently sitting on the desktop of my computer is an almost completed blog post about anecdote vs evidence.  The concept that response times matter to patient outcomes is one of the most anecdotal statements that has ever been made.  There are three different arguments that I feel support this. First think about the path that the majority of our patients take when they arrive at an emergency room.  Think about...

Fear and Disclosing in Chicago

Fear and Disclosing in Chicago

Sep 25, 2014

Recently, EMS 1 posted a story on Facebook with the headline “Equipment cutbacks put Chicago medics, firefighters at risk” with the subheading provided by EMS 1 of “What were they thinking?”  The short version of the story is that self-contained breathing apparatus or SCBA’s for short are being removed from all 75 of the Chicago Fire Department’s ambulances.  Furthermore, 70 paramedics getting ready to graduate from their academy will not be issued fire helmets, boots, and bunker gear.  A Chicago fire medic and their union want us to believe that because of this decision, people are at risk, and people are going to die!  As someone who has worked for 14 years in non-fired based EMS, I would like to share a differing opinion based on some of the statements made by various people in the article. First of all, let’s talk about what the presence of SCBA’s means for someone who might not be fully trained and acting only as a single role paramedic, and not as a dual trained fire medic.  The mere presence of this equipment encourages bad decisions to be made, either by “old school” leadership who doesn’t care what anybody thinks because they are “in charge, and we need people inside, now!” or by the medics themselves who take unnecessary risks because they think that they can handle something that they really cannot by donning this equipment that they have limited training to use. As someone who has worked many fire scenes both as a field provider and in an EMS leadership role, I have been in very few fire related situations that have required me to “stage at a distant location” or not have a stretcher right at the front of a fire scene as Pat Fitzmaurice, a veteran Chicago paramedic claims.  While we would usually park a block or so away from the scene we would do so to allow responding fire units to lay in with their 5” lines from hydrants because it was a common occurrence that if you parked your unit too close to a fire scene (maybe a half a block away) you were just asking to be boxed in by laid hose...

Just Another Typical Day

Just Another Typical Day

Sep 24, 2014

One thing that I have realized over my years in EMS is that the concept of a “typical day” is a foreign one.  There is something that we can pinpoint from just about every single shift that made that shift a unique one.  Sometimes it is a bizarre patient, or maybe a complicated medical call.  Other times, it is a major incident that gets your system talking for weeks and months to come. Earlier this week, my department had one of those calls that would occupy the last segment of shows like Emergency!, Third Watch, or Chicago Fire.  It was intense, with close to forty patients on scene.  While the call took a bit longer than the fifteen minutes that it would have on TV, it was well run, went smoothly, and for the most part was wrapped up in less than an hour.  The remarkable thing to me though is what happened after the call. There were no high fives from anyone.  There was no freeze frame of a group of paramedics with credits rolling over them.  Everything returned to normal much like it was an hour before the incident happened.  After that last patient was loaded into the back of the ambulance, everyones focus turned towards gathering up their remaining equipment, loading it back into their units, and going back in service. When major incidents happen, that does not mean that everything else going on within the system stops.  When the towers fell on September 11, 2001, people in New York City were still getting shot.  They were still having heart attacks.  When my staff and I were making our way through downtown Springfield after the tornado hit looking for patients, there were still psych calls and people with abdominal pains who had not even realized what happened in their own back yard.  And when we were tending to our forty patients, there were still calls going on in our coverage area.  A little more than an hour after our incident started, it was over.  My partner and I cleared up, and on our way back to the station, we listened to three more calls get dispatched that were your just run of...

Pit Crew CPR

Pit Crew CPR

Sep 22, 2014

A few months ago, I was approached by some friends at a local fire department who were looking for some help developing and rolling out a pit crew CPR system for their people.  I was quick to offer my help after watching the success that Louisville EMS has had over the last year and a half since rolling out their new CPR program.  I felt like I had a good knowledge base and a number of resources, especially after the events of EMS World in New Orleans back in 2012. The EMS officers from the fire department put in a tremendous amount of work developing a new procedure that utilized the department’s strength in numbers, and played off their established fireground culture where every piece of apparatus arriving at the scene of a fire has an assigned role. After the procedure was developed, the rest of the project was dropped in my lap.  They asked me to develop a class that talked about the importance of high performance CPR, the pit crew mentality, and stressed the values that our state had adopted by adding pit crew CPR to the upcoming BLS protocol updates.  I took a couple of months, and developed what I felt was a strong presentation complete with evidence, videos, and plenty of theory. Last week, that fire department opened their doors to anyone who was willing to listen.  They put together a free class complete with a free dinner which, as Greg Friese will tell you, is a great way to get people in the door.  Much to my surprise, ninety people attended the class from a number of different departments.  The feedback from some of the attendees has been great, and I have even been approached by three more departments who want to develop their own SOP, and push CPR in their organization. The entire project was a lot of fun for me.  I have found a love for teaching, and being able to talk about something like running a better cardiac arrest is something that I have become very passionate about.  I could not have done the job that I did without the connections that I have made through...

Establishing a Strong Base

Establishing a Strong Base

Sep 16, 2014

System design has always fascinated me. Throughout my career, it has become more and more obvious to me that design of an EMS system goes far beyond what trucks are on the road, and who is on each of them.  Each aspect of the system from top to bottom effects every other aspect of it.  Those who make the big bucks to make the decision need to find the best balance possible.  Need more medic trucks?  Push to run a “one and one” style system.  Short on units?  Investigate the possibility of first response, or downgrading calls to allow longer response times.  While some look at unit hour utilization and time on task as two of their biggest determinant for the effectiveness of their system it is starting to become apparent to me that much of the success of an EMS system starts at its base when that phone is answered and those first first units are dispatched. Both major systems that I have worked in have utilized Emergency Medical Dispatch (EMD) and Priority Medical Dispatch (PMD) to determine response.  Or at least they have claimed to.  I feel like at this point in my career, I have experienced both ends of the spectrum and I have seen both the good and the bad. Previously, the quality of phone triage was poor.  Even if the right questions were asked, much of the determinant of response rested in the hands of a dispatcher who would read the notes of the call, shoot from the hip, and make the decision based on what they felt was going on.  If the call was for a pediatric patient, for example, the response would almost always be with lights and sirens for no other reason than “because its a kid.”  Calls were rushed and pushed to the dispatcher’s screen in a minute or less in an effort to churn them out. The system I am currently working in has a perception that they take a bit more time when prioritizing calls.  They will sit on the waiting screen sometimes for as much as two or three minutes to allow the dispatchers to make the best decision possible in order...

AMR and Las Vegas Fire

AMR and Las Vegas Fire

Sep 10, 2014

For today’s post I was going to share my thoughts about the ongoing fight between American Medical Response and the Las Vegas Fire Department.  Some might say that with the Las Vegas City Council’s approval of the 5 year contract between the two, the “fight” was resolved.  Then, I read the editorial by Glenn Cook that I am going to share below.  There are certainly some alarming constraints that any ambulance provider opting into this deal will have to deal with, including what some may consider a gag order when it comes to speaking with the media. What could Las Vegas Fire and their chief William McDonald be so afraid of that would make them add this stipulation to the contract?  Ultimately, AMR did what they had to in order to keep their doors open for their 450 employees and their company.  I still feel that this move is more about generating income for the city and the fire department.  I have plenty more that I could say about this but I will defer today’s post to Glenn Cook and his editorial titled “City to AMR: Shut up and drive.” This is what defeat looks like.   This is what happens when a business, trampled by government yet still dependent on government approval to operate, dares to defend itself and alert the taxpaying public to obvious wrongs. This is what happens when city functionaries decide to expand their empire, regardless of cost, regardless of harm.   Wednesday’s Las Vegas City Council meeting was all about a proposed downtown soccer stadium. But amid the sports circus, the council presided over another significant action, one that officially killed the city’s dual-response medical transport system.   Private ambulance business American Medical Response fought the Fire Department, and the Fire Department won.   Earlier this year, Fire Chief Willie McDonald put his boot on the neck of AMR, which had been paying Las Vegas nearly $400,000 per year to handle most patient transports within city limits. He ordered his paramedic units to drive more patients to hospitals, so that the city could boost its bleeding general fund with transport fees. McDonald also cut off AMR from emergency communications and put...

Mergers and Acquisitions

Mergers and Acquisitions

Aug 22, 2014

Every day, I try to put aside some time for combing the internet and reading a variety of industry related articles.  This week an older article from FireRescue1.com from July of 2012 that former Washington DC fire chief Dennis Rubin reposted called “5 reasons not to merge fire and police” caught my eye.  The article presents arguments against combining police and fire departments.  I read through the article and was able to draw a parallel between this topic and the argument against merging fire and EMS.  Keep in mind that this is in no way a reflection of every single fire-based system on the map.  Some do it very well but for each of those effective, progressive fire based EMS systems, I feel like I have found two who do it very poorly or worse, do not understand or care what they are getting into when they take over ambulance response.   I invite you to read the full article by clicking here  but here are some of the chief’s observations and my thoughts on them. “There are a multitude of examples where communities have fused the police and fire departments into one public safety agency.  The motivating logic seems to be that neither department is busy enough to command the tax share needed t operate separate agency. The initial belief is that merging two costly departments into one will create a more efficient department, thereby saving big public bucks.” EMS and fire are often combined for the exact same reason.  The fire departments are not busy enough so in theory, combining fire and EMS gives them the ability to handle an additional piece of the public safety workload.  The workload that EMS brings in, however, is often ignored or it is not realized to be as involved and time consuming as it is. However, the transition of police duties into the fire and rescue department comes at a steep price that you will not find on a budget line-item spreadsheet.  Intangibles such as organizational stress, personnel, resistance, and demoralization of the rank-and-file members of both departments are the major factors that will ensure this type of plan’s failure.” Take a close look at any fire and...