DC fire chief Adrian Thompson called the case of David Rosenbaum “an aberration.” Rosenbaum was the retired New York Times journalist who, attacked and severely beaten near his home, died after emergency medical personnel mistakenly assumed he was drunk and failed to provide appropriate care. But for many with inside knowledge of DC’s emergency medical service, the only aberration in Rosenbaum’s needless death was that the District’s inadequate emergency care had come to light.
“The incident with Mr. Rosenbaum came as no surprise to many of us,” says paramedic Kenneth Lyons, a 23-year veteran. “We’ve seen incidents like this all the time, and we continue to see them because we are a dysfunctional agency.”
DC’s emergency medical system (EMS) is dysfunctional, insiders say, because for decades it has been underfunded and its personnel often undertrained. EMS crews are sent to medical emergencies with old equipment, outdated medical protocols, and shortages of supplies, from oxygen to IV needles. They have to make do without vital anti-seizure and pain medications that EMS agencies elsewhere use.
Members of the civilian EMS also say they’re underpaid and disrespected by the fire-department officials under whom they work. EMS training is inconsistent and often unreliable—some EMS personnel can’t read blood pressure accurately, read an electrocardiogram, or make informed medical judgments at the scene of an emergency.
A quick survey shows that the Rosenbaum case was far from unique:
• In February 2006, a month after Rosenbaum’s death, Monica Yin, 54, fell on the ice in front of her Northwest DC home and struck her head. She bled profusely. Her housemate called 911. When a fire truck with firefighter emergency medical technicians (EMTs) arrived, they asked if Yin had been drinking. They were told no. A firefighter asked Yin her name. When Yin didn’t answer, the firefighter told her, “I’m going to tell them at the hospital that you are uncooperative, so when you die it will not be my fault.” Eventually Yin was transported to George Washington University Medical Center, where she had stitches to close her head laceration.
That was Yin’s second encounter with District EMTs. In 2002, she had become disoriented and sick to her stomach at home. Witnesses say the emergency crew treated Yin disrespectfully; at one point a firefighter shook Yin and said he thought she was “faking it.” At no time, the witnesses said, did the EMTs take Yin’s vital signs. Friends finally drove her to GW hospital, where a CT scan revealed a leaking brain aneurysm. She had emergency surgery and remained in the ICU for three days, then in the stroke unit another eight.
• In March 2006, two months after David Rosenbaum’s death, Cassandra Bailey of Northeast DC died after District Fire and Emergency Medical Services (FEMS) responders took 90 minutes to come to her aid. Bailey’s blood pressure had dropped sharply after treatment at a dialysis center. Staff at the center made repeated 911 calls and got repeated assurances from dispatchers that help was on the way—which kept people at the center from driving Bailey to the hospital. She died at the hospital that evening. She was 38.
• Last April 2, a DC fire company was dispatched to aid a man having a seizure at 10 G Street, Northeast, but it went to the wrong location. Finally arriving at the scene, the crew found 35-year-old Jeremy Miller on the ground in front of an office building with a security guard performing CPR on him. Miller arrived at the Howard University Hospital emergency room 34 minutes after the 911 call and was pronounced dead.
• On the night of December 2, 39-year-old Edward Givens was lying on his living-room floor in Northeast DC experiencing chest pain and difficulty breathing. He yelled for family members to call 911. Three DC firefighter EMTs arrived a little before midnight, checked Givens’s vital signs, and administered an electrocardiogram; they said the reading was normal. Givens told firefighters he’d eaten a hamburger earlier.
Although his symptoms were strong indications of a heart attack, the firefighter EMTs told him he likely was suffering from acid reflux and advised him to take Pepto-Bismol. A little before 6 am, family members found Givens, the father of two children, dead. FEMS issued a statement saying the department was investigating to determine if proper care had been rendered.
Says paramedic Lyons, head of American Federation of Government Employees Local 3721 and a longtime advocate of reform in DC’s EMS: “If the public realized every time they dialed 911 in the District they were rolling the dice, they would demand a change.”
How did a vital agency charged with saving lives become so inept?
Until the mid-1950s, the District’s emergency medical system—at the time called the ambulance service—was operated by the DC health and fire departments and local hospitals. The hospitals supplied doctors, interns, and physician assistants to staff the ambulances. In 1957, the ambulance service was placed under the control of the DC Fire Department and firefighters began staffing District ambulances. Many firefighters had little emergency medical training—they performed what’s called “scoop and swoop”: They arrived at the scene, picked up the patient, and went to the nearest hospital.
Between 1957 and 1968, the number of emergency medical calls doubled. By 1973, they had gone up another 50 percent. Meanwhile, many DC firefighters openly expressed disdain for ambulance duty. They complained about long waits at hospitals, paperwork, and the many nonemergency calls they had to respond to. Senior firefighters avoided medical calls by assigning rookies to the ambulances.
To placate the firefighters and handle the increasing number of calls, the DC government decided to hire a civilian force of emergency medical technicians, or EMTs, to operate the ambulances. Although some officials thought the ambulance service would function better as an independent entity, the District kept it in the fire department to avoid establishing a separate bureaucracy. To save money, the city paid the civilian ambulance crews less than firefighters and gave them fewer benefits.
In 1976, the first civilian paramedic class graduated from a program run by Georgetown University; these EMTs staffed DC’s first “advanced life support” units, which didn’t just pick up patients and rush them to a hospital but could render care at the scene and en route.
In 1981, the ambulance service was reorganized as the Emergency Ambulance Division within the fire department. The name was later changed to Emergency Medical Services.
There are two components of DC’s emergency-medical-service system—firefighters with emergency medical training (firefighter EMTs) and civilian (nonfirefighter) EMTs. Both are under the control of the fire department.
Most of DC’s 1,700-plus firefighters are trained in basic life support, the lowest level of EMT training. Fire trucks with firefighter EMTs have been the city’s first responders on medical calls for nearly two decades. They were first on the scene in the Rosenbaum case.
In policy and practice, the umbrella Fire and Emergency Medical Services segregates the firefighter and civilian EMS branches. There currently are 25 basic-life-support ambulances staffed exclusively by firefighters and 14 advanced-life-support medic units nearly always staffed by civilian EMTs equipped to treat and transport patients with more serious conditions.
From the beginning, civilian EMTs and firefighters shared the same firehouses but little else. There were repeated red flags that the civilian EMS operation was beset with problems, that its marriage with the fire service wasn’t working.
Citizen complaints piled up in the 1980s, when DC’s emergency-response times were among the worst in the nation and citizens died when ambulances got lost. Ambulances were deployed by an outmoded dispatch system manned by undertrained dispatchers; the fire-service officers who ran EMS came and went in rapid succession. The District’s EMS was gaining a reputation as the nation’s worst municipal system.
When all 14 candidates in the spring 1987 EMT class failed the national intermediate paramedic exam and some EMTs were found to be functionally illiterate, committees and consultants were tapped to study the problem. The most thorough look was an internal EMS evaluation conducted by a consulting group in 1987. Its report, released in 1989, concluded that “the fire-department-based civilian EMS system is not working.”
More than 70 percent of the fire department’s budget is usually allotted to fire suppression, less than 30 percent for emergency medical services, and fire chiefs often have transferred EMS funds into firefighting. Some EMS personnel refer to their agency as “the red-headed stepchild of the fire department.”
“We’ve traditionally gotten anywhere from 15 to 20 percent of the fire budget even though 85 percent of the 911 calls are medical,” says Kenneth Lyons.
One veteran firefighter acknowledges: “If there’s a choice between the fire department getting a top-of-the-line ventilation fan or EMS getting a new IV pump, and there’s money for only one, the fire department will get the fan.”
This seems perverse because the number of emergency medical calls has gone up while the number of fire calls has gone down. In fiscal year 2007, EMS responded to 121,415 medical calls—about 330 a day—that led to 76,841 transports, almost all to hospital emergency rooms. The District has one of the busiest emergency medical systems in the country per capita.
It’s hard to follow fire trends in the District using data it has supplied to the National Fire Incident Reporting System. In 1999, the DC Fire Department reported more than 4,000 fire “incidents,” which can mean anything from a major fire to a smoking Dumpster. For the first ten months of 2006—the most recent NFIRS numbers—the department reported 954.
Between 1977 and 2006, the number of municipal fires in the United States fell 50 percent, according to the National Fire Protection Association. Factor in the growth of the US population during that time and the decline is even more dramatic—from 15 fires per 1,000 people in 1977 to 5.5 in 2006, a drop of 63 percent. It’s likely that DC experienced a similar reduction. Smoke alarms, sprinkler systems, and new flame-retardant building materials are all cited as reasons for the declining fire rate.
Firefighting and emergency medical services have two distinct cultures. Says an observer of both: “It takes a unique kind of person to do EMS, to constantly come to the aid of sick or injured people, just like it takes a unique kind of person to run into a burning building when the rest of us run away from it.”
Civilian EMS personnel have long been paid less and received fewer benefits than firefighters. “Our paramedic workforce continues to languish because of underpay, disrespect, promotional limitations, and an unrealistic retirement plan,” wrote EMS chief supervisor Jerome Stack in a December 2002 memo to Chief Thompson. “As a grade 12 Chief Supervisor with more than 25 years of service, my salary is less than that of a basic firefighter with longevity.”
“EMS personnel and cross-trained firefighters are two cultures at odds with each other,” said an October 1996 report to the DC government by Tri-Data Corporation. “Although they share facilities and work side by side, they have different work schedules, accountability practices, overtime arrangements, performance standards, dual chains of command, which leads to friction.”
Animosity and distrust are rife among the two agencies. Many firefighters ridicule EMS ambulances as “blood buckets,” “roach coaches,” and “pus buses.” They resent that their agency is now called Fire and Emergency Medical Services instead of the DC Fire Department; many wear shirts emblazoned DCFD.
A civilian EMS officer says that rookie firefighters who show him respect are quickly corrected. “They’re told by the senior firefighters that the respect isn’t deserved because I’m with the civilian EMS—only an ambulance man,” he says. “There is a caste system in FEMS, and we are considered untouchables.”
“EMS people were in the same firehouse with firefighters, but they were never a part of the family,” says Lieutenant Dan Dugan, a career firefighter and former president of Local 36 of the International Association of Fire Fighters. “They’ve always been separate.”
Dugan, who is with Tower Ladder 3 at 13th and K streets, Northwest, places most of the blame for the schism on the civilian EMS, which he says has “a huge problem of accountability” and an “absolutely terrible” record of attendance on the job. Firefighters, he says, often have to cover for absent EMS providers, and they resent it. Too often, he says, EMTs have been hired because the agency needed “warm bodies” to fill empty slots.
“When it came to hiring,” Dugan says, “the fire department got the cream of the crop of the applicants and EMS did not. Everyone knew EMS didn’t work. It’s been fouled up for ages.”
Just how bad is the District EMS?
There are no standard methods for comparing one city’s EMS performance with another, but indicators strongly suggest that DC’s bad reputation is deserved.
According to Robert Bass, a former EMS medical director in DC who now is executive director of the Maryland Institute for Emergency Medical Services Systems, which oversees Maryland’s emergency medical services, a key measure is “getting the right patient to the right hospital in the right time with the right care.”
On these critical factors, DC’s EMS is not performing well, according to a working paper published by the Rand Corporation in January 2008.
One example involves the handling of stroke victims. Washington Hospital Center is a designated stroke center with a rapid-response stroke team, yet it received just 26 percent of all EMS transports categorized as stroke. GW hospital, also a stroke center, received 15 percent of stroke calls. Providence Hospital is not a stroke center, but it received 20 percent of stroke patients.
Another example is heart attack. Washington Hospital Center, which has an emergency-catheterization laboratory and the city’s biggest heart-surgery program, received 22 percent of acute cardiac and chest-pain transports. GW hospital also has a cardiac program and received 17 percent of these patients. Yet United Medical Center, which has no cardiac-catheterization service, received nearly 16 percent of acute cardiac patients. The Rand report noted that, in general, District residents have a relatively poor rate of cardiac survival.
Another measure of EMS performance is how many people are revived after suffering sudden cardiac arrest—complete stoppage of the heart. Chances of resuscitation diminish 10 percent a minute; at ten minutes, death is virtually certain.
Most cardiac arrests occur when the heart goes into ventricular fibrillation—often called V-fib—a kind of short circuit that interrupts the heart’s normal rhythm. Shocking the heart with a defibrillator and administering drugs sometimes can restore a more normal rhythm.
A USA Today survey published in 2005 found that in Seattle and Boston, 40 percent or more of V-fib victims were revived by the time they got to the hospital. Milwaukee and San Francisco had revival rates of 27 and 22 percent. The District’s rate was 4 percent.
The data for this comparison were from 2001, and there’s some evidence that the District’s numbers have improved. In 2005, for example, DC reported that 12 percent of cardiac-arrest victims arrived at the hospital with a pulse. Kenneth Lyons is skeptical: “In DC, the percentage of cardiac-arrest patients who get to the hospital with a pulse has consistently run between 3 and 5 percent for the 23 years I’ve been with the agency.”
In urban areas, an EMS response time of eight minutes or less is desirable. According to District FEMS response statistics for 2007–08, advanced-life-support units arrived in 6½ minutes or less in about 90 percent of critical medical dispatches. Advanced life support means advanced EMTs, or paramedics, the most highly trained EMTs. FEMS officials consider this to be outstanding response time, and at first glance it is.
The best measure of response time starts when the 911 call is answered, and it ends when the EMS crew reaches the patient. But FEMS may be “scrubbing” its data to make its response times appear better than they are.
Response time can be broken into intervals. The first is when the 911 operator answers a call and asks a series of questions to determine the nature of the emergency. The second is when the dispatcher gets this information and locates and dispatches the nearest available responder. Another interval is the time it takes the emergency crew to reach the scene.
According to sources within FEMS, the District doesn’t start the clock on its response time until the unit is dispatched, and it ends it when the emergency crew parks its vehicle near the scene, thereby eliminating the call-processing and dispatch time. In addition, it takes time for an EMS crew to get from a parked vehicle to the patient.
“How the department defines its response time is how it manipulates those numbers,” says Lyons.
One evaluator who has studied DC’s EMS statistics called them “smoke and mirrors,” and an internal analysis of 126 cardiac deaths in the Sibley Hospital emergency department, published in 2006, seems to bear this out. William Suddath, an interventional cardiologist at Washington Hospital Center, performed the study at Sibley’s request.
Suddath found District emergency responses to be slow, with paramedics taking an average of 42.4 minutes from the time they reached the patient to the time they arrived at Sibley’s emergency department. This didn’t include the “down time” prior to the paramedics’ arrival at the scene, which, based on reports by families, nurses, and other witnesses, averaged 38 minutes.
Suddath reported that Sibley’s emergency department generally performed well, but he said “concerns abound” about EMS care. “The area of greatest concern,” he wrote, “and that which continues to evoke a great deal of anxiety and anger, is that of the ‘Pre Hospital Care.’ It is clear that the standards of care in terms of timing and expediency of field-care delivery remains substandard.”
First-rate EMS services usually have strong working relationships with local health departments and hospitals. Boston’s EMS is a separate service operated by the Boston Public Health Commission. Seattle has dual-trained firefighters and EMTs and a strong medical alliance with Harborview Memorial Medical Center; a fire/EMS station is located on its ground floor.
Maryland and Northern Virginia EMS systems have similar relationships with hospitals and other health-related institutions. The Fairfax County EMS works with the Inova Health System, the county health department, the school system, and family services.
The District EMS has no alliances with hospitals or health agencies other than the DC Department of Health, which certifies EMTs and reviews medical protocols but has little else to do with the service.
That hasn’t always been the case. A key link between EMS and the medical community was severed in March 2003 when the Mayor’s EMS Advisory Committee was disbanded at the apparent instigation of FEMS. The committee included physicians, citizens, Department of Health representatives, the fire chief, and EMS representatives. It had been involved in the development of emergency medical protocols, training, and other aspects of emergency care.
The disbanding of the committee effectively ended medical oversight of EMS. There currently is no medical watchdog to monitor how well or badly the District EMS is performing.
“The fire-department leadership wants a free hand to run EMS, and they pretty well have it now,” says an EMS officer who, like many interviewed for this article, didn’t want to be identified by name. Some fear being fired or retaliated against by the DC government; others simply want to avoid getting caught in the political crossfire.
Medical oversight is also weakened by the relative powerlessness and frequent replacement of EMS’s medical director.
James Augustine, the new EMS medical director, is an emergency physician, as is common in other cities, but only one previous medical director, Robert Bass, has been an emergency-medicine specialist. Like current DC fire chief Dennis Rubin, Augustine worked in Atlanta, where he directed the EMS system at the airports but not the city’s EMS operation, which is run by Grady Health System.
In DC, the fire chief has the ultimate say on things medical—one reason EMS medical directors have come and gone rapidly, leaving EMS in an almost perpetual state of turmoil.
In 2004, Chief Thompson fired medical director Fernando Daniels after Daniels pushed to take away a firefighter’s paramedic status when he’d made two serious medical errors.
In August, Michael Williams, a trauma surgeon who had headed EMS for two years, was forced out in an apparent power struggle. He was the sixth EMS medical director in ten years.
Says DC councilmember Phil Mendelson, chair of the Committee on Public Safety and the Judiciary: “Dr. Williams was not fired for incompetence. He was fired because he was asserting medical issues that got in the way of the convenience of the fire department’s operations.”
A Mendelson-drafted law to strengthen the office of the EMS medical director went into effect in April. One provision opposed by the administration of Mayor Adrian Fenty requires that future EMS medical directors be approved by the council. Mendelson says his efforts over the years to improve EMS have made him unpopular with some elements of the fire department and the Fenty administration.
“I’ve learned that the fire department was told to cooperate with me only to the bare minimum,” he says. “I don’t think this comes from Chief Rubin but from above.”
Once upon a time, EMS did have ties to the medical community. It had a good working relationship with DC General Hospital before the DC government closed that facility in 2001. The hospital served a large segment of DC’s lower-income population and did a good job of trauma care.
A consortium of hospitals—Georgetown, Washington Hospital Center, and Howard University—used to help train high-level EMTs and paramedics. Some of these hospital relationships lasted until budget considerations ended them in the 1990s.
“While it lasted, this training helped forge a strong relationship between EMS and the medical community that was of great benefit to us and the people we served,” Lyons says. “This really doesn’t exist anymore.”
The Rand report seems to agree: “Hospital and DC Fire and Emergency Medical Services leaders appear to know little of each other’s challenges.”
Becoming a paramedic takes time. Basic-life-support EMTs should undergo 110 hours of training, according to the National Registry of Emergency Medical Technicians. Becoming a paramedic—the most highly trained EMT—requires up to two years of emergency-medicine education.
But even if DC gets more paramedics, will it be able to keep them?
“Many of our most highly trained EMS providers, the best we have, stay on the job four or five years and then transfer to Maryland, Northern Virginia, or elsewhere and get higher pay and benefits,” Lyons says.
District EMTs also leave early because of burnout; some transfer to the fire department to become firefighters, a job in which they answer fewer calls and generally experience less day-to-day stress.
People knowledgeable about DC’s emergency-care system say little value is placed on EMS training. The department has a history of assigning people to training duty as punishment or because they didn’t perform well as EMTs on the street. One outside expert who visited the EMS training facilities, essentially housed in trailers at the Fire Training Academy in Southwest DC, called them “an embarrassment.”
Training deficiencies have been recognized for years—in a 1989 report called “Blueprint for Change” and the 2002 DC Office of Inspector General FEMS report, among others. The 2002 IG report cited EMTs’ complaints that “many instructors . . . do not have prior experience teaching paramedic and basic EMT courses. Additionally, they state that instructors arrive late to class, allow students to take long lunches, dismiss classes early, and sometimes are not prepared to teach.”
FEMS promised after the IG report that the training issue was “being addressed.” But a year later, in December 2003, all 19 EMTs in a training class signed a memo citing problems in the program that jeopardized their ability to provide advanced emergency care.
Some EMTs are so poorly trained that they have problems using electrocardiogram (ECG) machines to diagnose heart attacks. State-of-the-art ECG machines, used in Maryland, Northern Virginia, and many other communities, use 12 leads and render the most complete data available about a possible heart attack.
“Many District EMTs can’t read a 12-lead ECG because they have had no formal classes that train them how to interpret them,” says Lyons. Some EMTs can’t read a more basic three-lead ECG, either.
Says a firefighter who is a certified paramedic: “I can almost guarantee you that 5 to 10 percent of both fire and EMS basic-life-support providers cannot take a blood pressure. There are some people teaching paramedic programs and certifications who are not paramedics themselves.”
EMS training has gotten better, he says, “but it still is not anywhere near what a major metropolitan EMS should be.”
Says an emergency-department physician: “I know some EMTs who can save a life, and I know some who can’t put a Band-Aid on correctly.”
Dr. Joseph Wright, executive director of the Child Health Advocacy Institute, told the DC Council’s Committee on Public Safety and the Judiciary in May that his organization had offered pediatric continuing-education courses to DC fire and EMS personnel that went undersubscribed or completely unattended.
Wright noted that 10 of every 100 EMS patients are children. Under a federal grant, Children’s Hospital organized a training program for the District EMS to prevent what Wright calls “a pediatric Rosenbaum situation that I don’t want to see happen.”
Says Cynthiana Lightfoot, a member of Wright’s team at Children’s Hospital: “We asked FEMS to identify 60 emergency-medicine providers by name who worked in areas of the city with the highest number of pediatric calls.
“We condensed a ten-hour course for a pediatric emergency-training workshop for both civilian and firefighter EMTs. FEMS arranged the time and place three to four months in advance. We dropped off books for the ‘students’ two weeks before the workshop, and physicians from Children’s arranged to take time off to be instructors. After all this, no one showed up.”
Compounding the poor training, EMS providers work with old medical equipment and follow outdated patient-care protocols, the essential directions followed for the diagnosis and treatment of heart attacks, strokes, and other medical emergencies. Because of rapid changes in medicine, Maryland and Northern Virginia EMS systems update their protocols at least every year.
District EMS medic units do not carry two vital drugs—morphine to ease pain and Valium to control seizures—that have been the standard of care for years in virtually every EMS system in the country. Reasons given include concerns that the controlled substances could make EMS providers targets of robbery attempts.
“When a child seizes,” Lyons says, “it prevents oxygen from getting to the brain, but we can’t give that child Valium to control the seizures, so the only thing we can do is race to the hospital and hope the child’s brain isn’t fried by the time we get there.”
Breakdowns and malfunctions in the District EMS are common. Units have run out of oxygen, one of the basic components of emergency medicine. Many EMS crews use ambulances that are in poor condition—they’re referred to as “jalopies.” There have been shortages of such vital supplies as IV needles. EMS has run out of drugs such as albuterol to treat asthma. EMS officers say they often have had to ask hospitals for these items.
EMTs have been told by supervisors to use expired medications when fresh ones were unavailable. These have included epinephrine for severe allergic reactions and asthma and nitroglycerin for angina. The shortages anger many EMTs, especially when they see the fire department purchase costly fire apparatus.
EMS routinely runs short of ambulances. Far too often, say civilian EMTs, the EMS radio crackles with a voice saying “no ambulances available” while a fire-engine crew is at the scene.
In his testimony in May, Wright called the District “the hole in the doughnut”—an area where there is a reduced standard of care surrounded by areas with EMS systems that meet or exceed national standards. (See “When You Call 911 in the Suburbs,” page 68.)
Many who have looked at DC’s emergency medical system—which serves a working-hours population of more than a million—say it’s often ill prepared to deal with day-to-day emergencies, much less a major disaster.
“DC’s EMS system is 10 to 15 years behind the times,” says an outside expert who studied the system in depth. “And 10 to 15 years is being generous.”
Graydon Lord, a former fire-and-EMS chief in Georgia and now senior policy analyst at the Homeland Security Policy Institute at the GW School of Medicine, says DC’s EMS “has poor training, poor equipment, and a weak command-and-control system. The fact that DC has been unwilling to take its mission seriously shows a lack of respect for the citizens of the District of Columbia.”
If you’ve ever wondered why fire trucks respond to medical emergencies, you’re not alone. It’s one of the most wasteful procedures in emergency medical services in the District and elsewhere. The deployment of fire-engine companies on DC medical calls officially began in 1990, when fire chief Rayfield Alfred ordered fire companies with firefighters trained in emergency medicine to be first responders on medical calls.
Because this decision came at a time when urban fires were declining—between 1977 and 1990, they dropped by one-third—it raised suspicion that the real motive for sending fire trucks on medical calls was that it justified the maintenance of a large fleet of trucks, their staffing levels, and the department’s budget.
The decision was made with little consultation with the Mayor’s Advisory Committee on Emergency Medical Services, of which Howard Champion, then director of MedStar shock trauma and the emergency department at Washington Hospital Center, was a member.
Champion said at the time that “using a fire truck as a surrogate for an ambulance is stupid” and called it an “expensive waste of resources.” He hasn’t changed his mind.
Fire trucks cost more than half a million dollars each; some hook-and-ladder trucks cost up to a million. They get about three miles per gallon of diesel fuel. They’re a very expensive way to respond to a medical emergency. And fire trucks aren’t transport vehicles, so when transport is needed, an EMS ambulance has to be dispatched to the scene.
“Why are we running fire trucks on EMS calls?” one emergency-medicine expert asks. “You’re taking half-million-dollar-or-more machines out on the street with all that wear and tear and the not-insignificant danger to citizens, and you bring along firefighters who really don’t want to be at a medical scene anyway. It’s an absurdity, an attempt to protect the fire budget in an era of fire-resistant buildings.”
In the mid-1990s, a subcommittee of the Mayor’s Advisory Committee on Emergency Medicine advocated a new system that had the potential to replace fire engines as first responders. It began in August 1996 with two SUVs, called rapid-response units, equipped with emergency medical apparatus and manned by two civilian paramedics. It later expanded to four SUVs. The SUVs were able to maneuver through traffic more quickly than fire trucks and sharply cut the time needed to reach patients.
Because two civilian paramedics manned each rapid-response unit, they were able to provide emergency medical intervention at the scene and, if warranted, call an ambulance to transport the patient to a hospital.
“We often got to the scene within two minutes of dispatch, and we were beating the response times of the engine companies by a big margin,” says an EMT who rode on a rapid-response unit.
Besides being effective, the rapid-response concept was far less expensive than fire-engine-company first responders. A cost analysis revealed that the salaries of all the personnel needed for an engine company and the cost of unequipped fire apparatus totaled $936,104 a year, compared with $292,676 for an unequipped rapid-response vehicle and the paramedic teams to operate it. The per-unit cost saving for rapid response versus fire company came to $643,428.
“It was a great system,” says a paramedic member of the rapid-response team. “It worked so well that the people behind it wanted to expand the number of units in service, but the fire department saw us as a threat and killed rapid response after about three years.”
FEMS began its first transition to paramedic engine companies (PECs)—fire trucks with at least one paramedic on board—in 2000, and the rapid-response program slowly died. The so-called “modern” PEC program with firefighter paramedics began in May 2003. Today there are PEC units in 20 of the city’s 33 engine companies.
In a July 1998 article in Governing magazine, Garry Briese, then executive director of the International Association of Fire Chiefs, wrote: “As the number of fires declines, fire departments must find new ways to justify their funding and staffing levels. . . as well as maintain public support. . . . As a result, fire departments are faced with the challenge of reinventing themselves to protect their bottom line.”
According to Briese, the solution was to provide “emergency medical services, now a mainstay—and revenue source—for many fire departments.”
Many firefighters dislike responding to medical calls. They like to say they’re hired “to put the wet stuff on the red stuff.”
“Most firefighters think EMS is beneath them, and they see it as a punishment,” says a civilian EMT who feels he’s always gotten along with firefighters. “They’re being forced to do a job they don’t want to do, so how do you expect anyone who hates his job to do it well?”
An EMS officer says firefighters regard medical calls with less urgency than they do fires, perhaps in the hope that EMS vehicles will arrive at the scene first. “When firefighters get a fire call,” he says, “they drop everything and get on the fire truck as fast as they can. But when it’s a medical call, they may finish their meal or the newspaper article they’re reading and stroll over to the fire truck. I’ve seen it time and time again.”
In a May 2007 statement to the Task Force on Emergency Medical Services, George R. Clark, president of the DC Federation of Citizens Associations—which for years has argued for a separate EMS service—explained many firefighters’ apparent indifference to medical calls:
“Our heroic firefighters have not signed up to be the hundredth 911 call to transport a particular patient. They did not sign up to be the first responders for medical emergencies. They did not sign up to respond several hundred times a year to nursing homes and shelters that are poorly managed. . . . We can understand why firefighters might not accept medical responses as having the same importance as their critical firefighting missions. And the pay structure for civilian EMS personnel only strengthens that image.”
Clark said abuse of the 911 system also deters firefighters from EMS duty. He was referring to repeat offenders—“frequent flyers”—who call 911 whenever they want a nonemergency ride to the hospital or some attention. In 2006, 10 percent of all 911 District EMS calls went to just 20 addresses—a total of 8,400 responses and more than 2,500 transports.
Even when you know someone is abusing the system, EMS providers say, you have to respond—it might be the one call that’s an emergency.
Experts and observers alike have said since the 1980s that EMS must become a separate service if it ever hopes to be successful. A 1998 study by the DC Health Policy Council noted that “residents are clearly upset about a system that has fire engines responding to non-fire, medical emergencies” and recommended a freestanding EMS.
In 1990, incoming DC mayor Sharon Pratt Dixon’s health-issues transition team advised her to separate the city’s EMS from the fire department. She changed her mind in 1991.
When he campaigned for mayor in 2006, Adrian Fenty promised to separate EMS from the fire department and have it function as an independent agency. His position was supported overwhelmingly by civilian EMS employees, who wanted separation even more than better wages and benefits. The EMS union was the first in the city to support Fenty.
“In this city, having a fire department and having EMS under it just has left EMS out of the priority line,” Fenty told the Washington Times in the summer of 2006. “It’s just a nightmare—training and priorities and focus.” Separation would allow the city to have two well-run agencies, Fenty said, and “neither agency would have to suffer.”
The Fire and Emergency Medical Services subcommittee of Fenty’s healthcare committee noted in an October 2006 internal memo that the District FEMS “has the worst reputation in the nation” and “has been plagued by an inability to adequately meet even the most basic operational expectations of a well functioning system.”
Since taking office in January 2007, Fenty not only has reneged on his campaign promise, but he hired as fire chief Dennis Rubin, a DC native adamant about keeping EMS within the fire department. Rubin said at his confirmation hearing that if EMS were separated from fire, he would refuse the job and return to Atlanta, where he was fire chief.
Fenty has never explained his reversal. E-mail and telephone requests to his office asking why he broke his campaign promise to separate EMS from the fire department have gone unanswered. Some observers suggest that the firefighters union pressured him; others think he backed off because he realized it would be too politically difficult. He also might have realized that separating EMS from fire likely would mean closing firehouses, triggering fierce opposition from the firefighters union and its supporters in Congress. Civilian EMS personnel remain bitterly disappointed by Fenty’s broken promise.
“No one wants to touch the EMS-separation issue,” says one former city official. “It’s a hot potato with a lot of politics involved.”
Fenty announced in April that the fire service and EMS would be transformed into a fully integrated, all-hazards agency in which all personnel would be trained in both fire suppression and emergency medicine. The remaining civilian EMS members—there are about 230—would be cross-trained in fire suppression and become full-time members of the fire department. The fire department says it will allow employees to choose whether to become all-hazards firefighters or to specialize in EMS.
Fenty’s reversal gained support from the Task Force on Emergency Medical Services, formed through the help of David Rosenbaum’s family when it agreed to drop the District government from a $20-million lawsuit if it agreed to reform the EMS system. If reforms are not carried out, the Rosenbaum family reserves the right to reinstitute the lawsuit.
Often referred to as the Rosenbaum EMS task force, the 13-member panel included Rosenbaum’s son-in-law, Toby Halliday; Mayor Fenty; councilmembers Phil Mendelson, Mary Cheh, and Vincent Gray; then–EMS medical director Michael Williams; then–DC attorney general Linda Singer; city administrator Dan Tangherlini; and outside experts such as Boston EMS chief Richard Serino and Dr. Joseph Barbera, codirector of GW’s Institute for Crisis, Disaster & Risk Management.
Chief Rubin served as task-force chair—which meant that any consideration of separating EMS from the fire service was effectively torpedoed.
The DC Federation of Citizens Associations, which represents more than 40 citizens organizations from every ward in DC, attended every task-force meeting. Anne M. Renshaw, federation first vice president, wrote in the group’s September 2007 newsletter: “It soon became evident that with a predominantly fire department-oriented Task Force, the EMS train, albeit with some delivery improvements, was heading back to its station deep in the DC Fire Department.”
In many cities where EMS is part of the fire department, the system runs well. In others it doesn’t. In San Francisco, many of the same complaints and antagonisms seem to exist between EMS and the fire department as they do here. Last year, San Francisco decided to remove EMS from the authority of the fire department, and it’s exploring the idea of hiring private contractors.
One expert acquainted with the DC situation believes that the antipathy between fire and EMS has been so bad for so long that the agency will never function well even if it’s fully integrated into one department. The District EMS, he says, “needs to be hit with a wrecking ball and begun all over again as a separate agency.”
Rubin disagrees. He acknowledges there has been a “huge divide” between EMS and firefighters but contends that “we are getting very close to closing that gap.”
Says Rubin: “We should not be two agencies. One force, one standard, is what we believe in with clear direction from Mayor Fenty.”
Still, Rubin cautions, “I wouldn’t say when we become a fully integrated agency it will create camaraderie between fire and EMS workers.” He says that he’s seeking to “even out the current pay scale” and that the department is moving toward becoming one of dual-trained firefighter EMTs. He says he’s confident that pay raises for EMS providers will “start the healing process” by eliminating some of the wage and benefit disparities.
The disparities are substantial, and they increase with seniority and rank. The following salaries are the basis for retirement income: A fire sergeant with 30 years’ service makes about $92,150; an EMS sergeant with 30 years makes about $66,300. A fire captain with 30 years makes about $115,100 in base pay, while an EMS captain with the same tenure makes about $93,700. The firefighters’ figures include longevity pay but not overtime, which in fiscal 2008 accounted for $1 million in cost overruns above the FEMS budget of about $180 million. To cover overtime costs, Fenty has proposed redirecting $325,000 from the Office of Chief Medical Examiner and $600,000 from the School Modernization Fund.
Firefighters also get better retirement benefits. EMS personnel joke that their retirement benefits consist of being taken out back of the fire station and shot. In more than 30 years of DC’s civilian EMS, fewer than a dozen members have actually retired from the service.
“We’re not seeing anything being done to bring parity between the fire and medical sides,” an EMS officer says. “The only aggressive behavior we’re seeing right now is attempts to push experienced civilian EMS personnel out and bring in much less experienced firefighters who are earning more than we are.”
No civilian EMS candidate has been hired in two years, and the current 230-member force is down from a high of about 350.
In December, the DC Council passed a bill, supported by fire chief Rubin, to equalize the salary and benefits of EMS and fire-service personnel. Sponsored by councilmember Mendelson, the bill follows the recommendations of the Rosenbaum task force. Mendelson called the bill “a significant step forward in addressing the cultural divide within Fire and Emergency Medical Services.”
The cultural divide remains, however: Negotiations among EMS, the fire department, and the administration over pay and benefits issues have broken down.
“It is apparent to us that the city really isn’t interested in giving us pay parity, nor is it interested in bargaining in good faith,” says Steven B. Chasin, chief shop steward for the local EMS union. The city and the fire department contend that firefighters perform dual roles—firefighting and emergency medical services—and are therefore entitled to higher pay and benefits.
The issue remains the major obstacle to the bill’s implementation, and there’s still no resolution in sight. The EMS union is seeking the appointment of a mediator.
Graydon Lord of GW’s Homeland Security Policy Institute points out a fundamental problem in integrating fire and EMS: “EMS is fundamentally the practice of medicine in the prehospital environment. You don’t expect your cardiologist to deliver a baby, so why are we expecting our public-safety officials to be double- and triple-hatted? That’s an unreasonable expectation.”
Rubin admits that integrating EMS into the fire department isn’t easy: “We are going through some growing pains right now. If you have absolutely no discipline or controls in a system, and all of a sudden you have all of these disciplines and controls, there’s a recoil. But there need to be strict standards of accountability. Some people in our force who have looked for this day are elated, and some people who wanted no accountability are fighting me to their last breath.”
David Rosenbaum’s son-in-law, Toby Halliday, supports Rubin’s idea of a single service and wants EMS medical providers to no longer be “second-class citizens.” But he, too, has reservations about a single, integrated service.
“One of my greatest concerns,” he says, “is that leaving it as one system means there will always be tension between priorities and resources for fire suppression and medical responses.”
Several EMS providers say that attempts to integrate the two agencies have worsened matters. “They’ve now created such a hostile working environment that no one wants to come to work,” says a senior EMS provider, “and this goes for firefighters, too, because they don’t want to ride EMS.”
Last summer, two EMS ambulances staffed by firefighters were found “hiding” in upper Northwest DC in an apparent attempt to avoid EMS calls. One of them was an ambulance normally stationed in a part of Northeast DC known to be one of the busiest for EMS calls. The ambulance reportedly parked for more than seven hours at locations in upper Northwest DC, where EMS calls are usually relatively light. According to FEMS, the firefighters involved in both incidents are currently in “nonpublic-contact status” and “disciplinary action is pending.”
One reason that EMS calls in upper Northwest DC are light is because of a long-standing agreement between the District and the Bethesda–Chevy Chase (B-CC) Fire and Rescue Squad. Instead of calling 911, residents and some institutions in upper Northwest DC often dial the ten-digit number for B-CC Fire and Rescue. According to Chief Ned Sherburne, B-CC makes 500 or more runs into Northwest DC every year.
As he integrates FEMS, Chief Rubin is trying to put in place a new “culture of error identification.” He says FEMS is aggressively investigating outside complaints. He promises greater accountability as EMS “migrates toward a totally paperless electronic patient-reporting system that will give us a clearer picture of everything and allow hospital information to be put into the findings.” EMS personnel are now entering patient information into hand-held computers, but the system is not yet complete, in part because some EMS personnel haven’t been adequately trained to use the computers.
Outside the fire-department command structure, there’s skepticism that these changes will significantly improve the city’s emergency medical services. The Rand paper in June noted that “we did not find a single, comprehensive quality plan with timelines for DC FEMS that outlined the current state of quality of care with established measures and benchmarks.”
“To determine what is a good EMS system,” says Lord, “you don’t just look at a series of specific data points that tell you response times or cardiac-arrest survival rates. You also have to look at the longevity of the personnel in the agency and how they are treated, because to build a truly good EMS system you need respect and longevity.”
Chief Rubin—who enjoys a national reputation as a firefighter and recently ordered that all FEMS recruits be instructed that their EMS training is as important as their fire-suppression training—believes the transition will be complete in five years. Many observers think that goal is unrealistic.
Councilmember Mendelson, who has often criticized FEMS, supports integration and thinks it will work in time. Others don’t believe the two cultures will ever be unified. They fear that EMS will remain subordinate to the fire side, and they see separating the two functions as the best hope of getting the city the emergency medical service it needs. But given the politics of the issue, it seems unlikely that a move to separate the services will be resurrected anytime soon.
For now, people with medical emergencies in DC might just hope for a little luck if they dial 911. Or heed the words of a DC ER physician: “If you can, you might be better off driving yourself to the hospital.”