From Worst to First?

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JEMS On line (www.jems.com) has an article about the Washington, DC Fire/EMS system titled Worst to First?. I read it with some interest, followed by a touch of disbelief. I find it hard to believe that anyone seriously thinks that these reforms are going to turn DC Fire/EMS from a laughing stock in EMS to a premier, envy of all the other EMS services, service.

In the best tradition of the Lame Stream Media, I’m going to cherry pick some sections and give you my take on what is being said.

The Rosenbaum family agreed to drop its $20 million lawsuit if the city convened a task force to undertake a top-to-bottom look at the city’s EMS system and then implemented the task force recommendations for improvement.

In January 2007, Adrian M. Fenty became the city’s new mayor, and former Atlanta fire chief, Dennis Rubin , took the helm of DCFEMS. Both vowed to turn the city’s EMS system into “a world-class service.”

This sounds promising. The family of a guy that died at the hands of the EMS system and a district owned hospital sued, not for money, but for reform and improvement. In this lawsuit happy era, I applaud this.

In April 2007, the city created a 13-member EMS Task Force. In September 2007, the EMS Task Force released six broad recommendations and 50 action items to flesh out those recommendations.

That’s a lot of reform and improvement, isn’t it? 50 action items seems like a lot.
I won’t go through all of them, which I’m sure you’ll appreciate.

Transition DCFEMS to a fully integrated all-hazards agency;

Can somebody tell me what an “all hazards” agency is? The fully integrated part sounds terrific, just as it did in San Francisco and New York City. Look how well those turned out.

One more and I promise I’ll quit.

Improve the level of compassionate, professional, clinically competent patient care through enhanced training and education, performance evaluation, quality assurance, and employee qualifications and discipline;

Did they miss any buzz words here? I think not, but maybe I missed one myself.

During his mayoral campaign in 2006, Fenty promised to address problems within DCFEMS by separating EMS from the fire department. But the task force didn’t include that as one of its suggestions. Instead, the panel offered two major proposals designed to improve the role of EMS within the DCFEMS structure, culture and capabilities: Strengthen EMS leadership within the department and cross-train fire and EMS personnel to create “a fully integrated, all-hazards agency.” (See “D.C. to Crosstrain Staff: Task Force on EMS makes recommendations,” December 2007 JEMS .)

“I was the only person [on the panel] who didn’t support all the recommendations,” says task force member Richard Serino, chief of Boston EMS, which has produced some of the best patient outcomes in the nation. “Good work was done, but it could have been better. This provided a golden opportunity for D.C. to have one of the best EMS systems in the country, but the recommendations didn’t go far enough.”

OK, let’s see. The chief of one of the EMS systems often cited as having really good patient outcomes, one which has studies published fairly frequently, suggests that DC should do what the now Mayor campaigned on in 2006. The blue ribbon panel decides that they don’t want to do that, they just want to mend the current system. I wonder if the deciding factor here was the optimal system design and implementation or political considerations? I’d have to think that politics played a big part here, but I’m just guessing.

As of May 2008, DCFEMS reported it had completed 27 of the 50 action steps and work was underway on 21 more. As of Oct. 1, the tally was the same, but information had been added detailing how work on some of the as-of-yet completed recommendations was proceeding.

There’s a saying for this. It’s called “Cutting the distance to the goal line in half, but never quite getting into the end zone”. There’s a legitimate reason for some of that. The broad strokes are easy to do, it’s the details that bog you down and delay projects like this.

To achieve the second recommendation, DCFEMS had to appoint a medical director (at the rank of assistant fire chief) who would report to the fire chief, but who could be removed only by the mayor. Last summer, Rubin recruited Atlanta Fire & Rescue’s medical director (and JEMS editorial board member) James Augustine , MD, who is now the department’s acting medical director and assistant chief. “Few communities have had the opportunity for a complete redesign and rebuild of its EMS system,” says Augustine.

Doctor Augustine, I’d venture to say that few communities have had such serious cause to redesign and rebuild their EMS systems. When you are rock bottom, there’s nowhere to go, but up. I wish the good doctor the best of luck in his efforts. Then again, the tenure of medical director for DC Fire/EMS is usually measured with a stop watch, not a calendar. I think Doctor Augustine will be the fifth medical director in four years. Or is it the fourth in five years? Does it really matter?

DCFEMS now also has an EMS supervisor for each of its six geographic battalions and for a seventh citywide special-operations battalion, and they work the same shifts as the firefighters.

“Previously, EMS supervisors worked different shifts than fire officers and the dual-role firefighters who comprise the vast majority of our EMS workforce, creating a de facto bifurcation within our operational chain of command,” Sa’adah says. Now, a unified battalion management team led by a battalion fire chief and an EMS battalion supervisor (a captain) manage each battalion’s operations.

I wonder if anyone took the time to compare the EMS providers, even the cross trained ones, work load with the suppression personnel’s work load? There might be a reason that EMS providers should work shorter shifts.

Notice also that the EMS supervisor is a lower rank, with lower pay and status, than the fire supervisor has. I know, the fire supervisor has more people to supervise and all that, but this just doesn’t seem like parity to me.

Although, as captains, the EMS supervisors are ranked below the battalion fire chief, Sa’adah insists, “We don’t see this as a subordinate position; they work as a team.”

I’m sure you don’t, but I’ll bet the firefighters and single role EMS providers get the message loud and clear. Equal, but some are more equal than others.

Before the restructuring, fire officers—but not EMS supervisors—competed for promotions via a biannual promotional process. “EMS promotions were somewhat subjective,” he says.

Words fail me. What did they do, draw names out of hat? Use a dart board?

“For the first time, all eligible members can compete for these positions,” Sa’adah says. Incumbent single-role EMS supervisors must only pass the exam to keep their positions, and the department will fill other vacancies “in rank order from the competitive roster.”

I wonder if incumbent fire supervisors have to take a test to keep their job? More equality at play.

Cross-training of the department’s single-role EMS personnel as firefighters was scheduled to begin in October 2008, but is on hold pending passage of enabling legislation that would allow us to offer new switchover benefits,” Sa’adah said Nov. 1.

Even more equality.

Current single-role EMS personnel will be offered several options. “No one will be required to complete firefighter recruit training,” he says. Those who cross-train should receive a “significant” pay increase as they integrate into dual-role positions and are sworn in as firefighters, and single-role paramedics who are supervisors will retain those positions after they cross-train. EMTs and paramedics who choose not to cross-train as firefighters will be moved into the equivalent position on the firefighter pay scale.

So, can an EMS only supervisor supervise a cross trained FF/medic on a medical call? Or can they only supervise single role EMTs and medics? If the FF/medic accompanies the ambulance to the hospital can the supervisor supervise him or her then?

DCFEMS firefighters don’t have an option: They must become EMTs or paramedics. Since 1987, DCFEMS has hired only firefighters who are also EMTs but still had 109 without that credential on Oct. 1.

I’ll bet the fire fighters union will have something to say about this.

A tale of two unions
Two unions currently represent DCFEMS employees: American Federation of Government Employees Local 3721 represents single-role EMTs and paramedics, and International Association of Fire Fighters Local 36 represents fire-suppression and dual-role personnel.

Local 36, which gains members as single-role EMS providers cross-train, has supported the transition plan. President Lt. Daniel Dugan, EMT, says, “I believe we’re now delivering EMS care better than we’ve ever delivered it in the past.”

But Local 3721 President Kenneth Lyons, EMT-P, says, “I see an agency that is more dysfunctional one year after issuance of the recommendations. The recommendations were to make it more medically centered, but instead of having a fire department that understands an EMS perspective, we have a fire department trying to run EMS as a fire department.”

Lyons says DCFEMS “is getting rid of the EMS medical professionals who are civilians—who came on to do what the agency does 85% of the time: EMS—by offering them better pay and benefits and by attrition.” Very few civilian EMTs and paramedics, he says, “have chosen to go to the fire side and those went for better pay and benefits.”

I can’t say I’m surprised at any of this. I’ve seen this all before. I sort of feel like Bill Murray in Groundhog Day, if you know what I mean.

EMS is not the fire service. The fire service is not EMS. Yes, I know it works in some places, and quite well. It seems that all of the places where it works tend to be on the smaller side. That’s just my impression you understand.

The EMS Task Force recommended: “All employees shall have the same basic pay and benefits,” and directed the city to develop a plan “to transition to pay and benefits parity between current single-role medical providers and dual-role providers.”

The city released its plan in May, but Lyons faults its definition of “parity” because it offers 4–12% increases to single-role EMS providers who become dual-role, thereby “punishing” those who chose to continue as single-role providers. “Anything less than parity is not parity,” he says.

Sounds about right.

In mid-2008, DCFEMS employed the Maryland Fire & Rescue Institute (MFRI) to perform a “baseline assessment” of the skills of all DCFEMS ALS personnel and to provide remedial training to those failing to demonstrate competency. Sa’adah declined to say how many paramedics and EMT-Is received this remedial training.

Wouldn’t release the numbers? A reasonable person might reasonably think that there is something to hide here.

According to Sa’adah, a working group with representatives from DCFEMS and area hospitals developed a new turnaround policy that now “starts the clock when our provider hits the [hospital’s] threshold, and the hospital has 25 minutes to do triage and take over custody of the patient. If the hospital hasn’t done that in 25 minutes, the patient can be moved to the waiting room.”

“DANGER WILL ROBINSON, DANGER” So, the patient is just moved to the waiting room? No triage first?

“Our units respond from fixed locations, but we use Deccan’s LiveMUM to transfer resources as necessary throughout the day,” Sa’adah says.

Well, which is it? Fixed or not fixed? It would seem that it can’t be both.

Stay Tuned
After reviewing the city’s progress on implementing the EMS Task Force recommendations, the Rosenbaum family dismissed its suit in February 2008. But DCFEMS didn’t stop the work to implement those recommendations.

Premature. Now there is no incentive to follow through on any of this. Until the next law suit, that is. Governments don’t change easily, immense amounts of pressure need to be put on them. Once the pressure is off, things tend to drift back to the status quo. If it were me, I’d mandate five more years of monitoring, at the least. It takes at least that long for institutional change to take effect.

“We hope folks will stay tuned in. We feel strongly that we will meet the challenge to become a premier system, a world-class service,” Rubin adds.

Dugan says, “I think we’re going to have one of the best systems in the country and, boy, are we looking forward to that after being on the bottom for so long.”

Time will tell. It will be interesting to look at DC Fire/EMS in three years and see what response times are, what the protocols look like, who is doing what, and who is making how much.

Stay tuned indeed.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

15 COMMENTS

  1. For what it’s worth, I’ve known Rafael Sa’adah for nearly twenty years. If there’s someone within DCFEMS who can make these changes work, it’s him. He’s a very bright, well-educated, clear-thinking individual, an excellent leader and a guy who’s not one to worship sacred cows.All that said, the “acting” in front of is title is a little worrisome. DCFEMS has a habit of transferring senior personnel just when they become most effective. Let’s hope that doesn’t happen.

  2. “In the spirit of transparency, DCFEMS regularly posts response-time data on its Web site.”Of course, if you go to the website and click on EMS Performance Statistics, you’ll see that “response time” is reported as “dispatch to scene”. In other words, “wheels up” to “wheels down”. Transparency? I don’t think so. If you want to impress me, report “call received” to “patient’s side”.

  3. My bad. They do report “call received” to “scene arrival” at the very bottom of the page. It’s not perfect, but at least they’re not hiding the call processing intervals.

  4. Here is my thought, Tom. “Scene Arrival” by who? I talked about this in Wear and Tear Part I. I contend that since the vast majority of calls result in transport, that arrival of the transport unit is what counts. As a friend of mine said many years ago, “Transport IS part of the treatment”. We can fart around on scene entertaining ourselves for as long as we want, but most of the time when we leave, the patient is going with us. Many times the patient doesn’t care what we do at the scene or doesn’t want us to do anything but give them a ride to the hospital. It may be an ego basher, but it is the plain old truth. Get five pieces of apparatus there and if none of them has a bed, they just aren’t going to do that much most of the time.

  5. I guess I would say “arrival by the first rescuer capable of competently evaluating the ABCs and initiating life saving treatment, including FBAO removal, suctioning, ventilation, chest compressions, and defibrillation as required.” Personally, I think that’s more important than the time the transport ambulance arrives on scene.

  6. I foresee continued failure. Just a guess. It looks to me like they are trying to treat the symptoms, not the underlying cause- the culture.When the citizens, the City Leaders, the firefighters/officers begin to see EMS as a truely equally important service as fire; Then maybe they can start to actually fix problems instead of change things and hope for a better outcome.We’ll see.Mr Fixit

  7. Tom, do you assume that all calls are life threatening or do you think that there should be no triage? This of course goes back to what types of calls FD first responders should be sent to. Mr. Fixit, sadly I think you are right.

  8. Its a no win situation either way anymore due to finances, the times we live in etc. there’s the big city EMS which has always been pretty decent- and then a few years ago they(the city) started having the FD report with them- we(even those of us who don’t live there but commute) all are afraid they will eventually merge the two- which goes back to the premise “if it ain’t broke don’t fix it!” Like I said its a no win either way

  9. That’s a good point. Of course, the vast majority of calls are not life threatening. So yes, there should be triage, and response times are not as important for the non-life threatening calls.

  10. Unfortunately Tom, response times are easy to measure, so they are used to gauge EMS system effectiveness. Most of the complaints we get are about just that, regardless of the nature of the emergency or if there even is an emergency.

  11. Yes, they are often used to measure a system’s performance, especially by people who have no idea what a quality EMS system is supposed to look like. That’s why someone with a clue should be administering the QA/QI program! To me, a better guage of an EMS system’s performance is how many witnessed caridac arrest patients with an initial rhythm of VF walk out of the hospital neurologically intact.I realize these are a minority of patients, but I don’t care! Too many “leaders” in Fire/EMS use that as an excuse for not measuring it as a quality benchmark. As a consequence, they measure almost nothing! Certainly not their success rates with tracheal intubation.I find complaints about the Utstein template to be far more palatable from EMS systems who have been reporting data accurately for years. They’ve earned the right to complain and look for new ways to measure clinical quality.

  12. Tom, the only real benefits of using Utstein are that it’s easily quantifiable, reproducible, and standardized. I don’t know what it tells anyone about the quality of an EMS system any more than response times do. It’s far harder to measure reduced mortality from MI, CHF, CVA, and other medical problems. It’s almost impossible to measure something that doesn’t happen. How about measuring the difference in ICU days among a patient population? Pretty much impossible.

  13. TOTWTYTR,”As of May 2008, DCFEMS reported it had completed 27 of the 50 action steps and work was underway on 21 more. As of Oct. 1, the tally was the same, but information had been added detailing how work on some of the as-of-yet completed recommendations was proceeding.”Then, near the end.”After reviewing the city’s progress on implementing the EMS Task Force recommendations, the Rosenbaum family dismissed its suit in February 2008. But DCFEMS didn’t stop the work to implement those recommendations.”I realize that this is not clearly cause and effect. However, when you consider that these are politicians, who suddenly had their motivation removed, it is hardly a surprise.I suppose it is only my lack of appreciation of the alleged benefits of placing all hazards in the same barrel, and then scraping from the bottom of that barrel. These benefits seem to be appreciated most in city budget meetings and IAFF meetings. Where is the medical benefit to patients? Having a bunch of non-transport EMS personnel available to stop the dispatch clock does not improve patient care. Does it really even improve the ability of the FD to put out fires?I do not see anything to suggest that DCFEMS is not piling the fertilizer as high as they can. All of those, who see cross-training as the answer are claiming success. If the goal is to improve the quality of patient care, burying the patients in fertilizer does not seem to be the way to get there.

  14. Ok, so great minds think alike…before I even read your response, I had an image of the robot, waving arms saying, “Danger! Danger Will Robinson!”I’m with you 100% with this one…but then you probably already knew that. The few “effective” dual-role Fire/EMS systems I know are smaller communities…and even then, there’s sometimes issues unique to that delivery system…especially if there’s a real fire.One note on Deccan Live MUM (a Move Up Module, works with their new Tritech Visicad system…one I’m familiar with, and rather like): Minneapolis Fire does the same thing. It’s fairly programmable. MFD doesn’t do move ups except in certain situations (like multiple working fires). In that situation, LiveMUM recommends moving fire crews to other stations to maintain geographic coverage. We use it in a more dynamic fashion, to maintain geographic coverage almost constantly (different threshold).Actually kinda slick…if they actually choose to use it (some services, the battalion chief can choose not to move up crews, leaving parts of the city uncovered).

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