Controversial Plan to Sideline D.C. Medics at Night Gets Mixed Reaction
A controversial redeployment plan that would leave D.C. ambulances staffed with no paramedics during the overnight hours will not take effect until next year at the soonest, as stakeholders consider the benefits of a proposal that national authorities are calling everything from "innovative" to "unconscionable."
The plan, introduced last month by D.C. Fire Chief Kenneth Ellerbe, would pull paramedics from 14 ambulances between 1 and 7 a.m. and instead have them available for calls during busier hours from 7 a.m. to 11 p.m. Paramedics' shifts would be staggered, increasing the number of ambulances able to provide advanced life support during the afternoon hours, when fire officials say call volume is highest.
Ambulances staffed by lesser-trained emergency medical technicians would be used overnight to provide basic life support, and cross trained firefighter-paramedics and paramedic supervisors could administer more advanced aid as needed.
The plan, which Chief Ellerbe initially hoped to implement Nov. 5, requires approval from the D.C. Council. And council Chairman Phil Mendelson, a Democrat, said that a vote would not come until next year's council session after a hearing later this month.
In the meantime, the proposal is drawing attention nationally among emergency medical directors and specialists always looking to maximize resources.
"In the [emergency medical services] world, it is not uncommon that deployment patterns shift depending on the time of day and call volume," said Arthur Romano, deputy director of EMS for Greenwich, Conn., explaining that shifts and downgrades are most often done to save money. "But they are shifting levels of care at the nighttime hours, which is somewhat unusual."
The proposed plan essentially offers two different levels of service to the city, said Paul Werfel, paramedic program director for the University Medical Center at State University of New York, Stony Brook. The increased staffing during the day lopsidedly benefits commuters who come to the District to work and leaves residents lacking sufficient care at night, he said.
"If I live in Crystal City, my level of EMS resources is higher than for a person who lives in the District," he said. "I think that stuff is unconscionable."
The District has long struggled with EMS delivery, most notably reflected in the 2006 death of New York Times journalist David E. Rosenbaum, who was fatally beaten during a robbery as he walked near his Northwest home. An inspector general's investigation resulted in findings of an "unacceptable chain of failure" in the response to the medical call and "alarming levels of complacency and indifference" on the part of the first responders. The incident prompted the creation of a task force to reform the city's EMS service.
The District's current model calls for EMS delivery throughout the day with 25 ambulances staffed by EMTs and 14 ambulances staffed with one paramedic and one EMT.
Delivery models vary across the country. Among the premier EMS providers, Miami staffs its paramedic ambulances with a firefighter EMT and two paramedics. Miami, like the District, provides medical services through its fire department. Boston, also highly regarded, administers prehospital care through a department separate from the fire department. The city staffs just five paramedic ambulances, which are selectively dispatched to only the most serious emergency calls. San Diego, which provides medical services through a fire-based public-private partnership, staffs its fire engines with a paramedic and puts one paramedic on ambulances. Department policy calls for two paramedics to respond to life-threatening emergency calls.
The three cities all provide 24-hour coverage with paramedic-staffed ambulances.
Chief Ellerbe has touted the change in the District as a way to provide better service to the community after the department studied a year's worth of statistics on call volume. While paramedic shortages are fairly common in smaller departments across the country and dollars are tight among most local governments, the chief repeatedly has denied he is pushing his proposal for staffing or budgetary reasons.
But even among new and cutting-edge ideas, the District's plan comes off as an anomaly, said medical professionalswho were unable to point out any other departments in the country that use the model. Likewise, D.C. officials did not identify any similar plans in use.
"We are certain that there are probably comparable plans around the nation, but we designed a plan to meet the specific needs of the District of Columbia, which is growing at a record pace, unlike few other cities in the nation," fire department spokesman Lon Walls said.
While data provided by the D.C. Fire and Emergency Medical Service Department show the volume of medical calls doubles during the day - from an average of 10 per hour overnight to about 20 per hour between 1 and 7 p.m. - Mr. Werfel said the ebb and flow of the severity of the medical calls received should also weigh into a redeployment plan.
"The call index of severity is much higher at night than it is during the day," Mr. Werfel said. "At night, when someone gets woken up in the middle of the night with chest pain, that's a real [advanced life-support] call. What he should be looking at is not how many calls, it's about the nature and severity of those calls."
Calls requiring advanced life support usually involve severe and life-threatening situations, such as heart attacks or trauma. Paramedics are trained to perform more complicated medical procedures and to administer drugs, as opposed to EMTs, who respond to calls involving more common injuries and illnesses. Medical calls that come in during overnight hours tend to be more acute in nature and patients can better benefit from the help of a paramedic over an EMT, both Mr. Werfel and Mr. Romano said.
"A lot of the daytime calls, which may come through 911 as being cardiac, they often turn out to be less than acute emergencies," Mr. Romano said. "They are not of the moment-by-moment criticality where a paramedic means a difference."
In response to questions about whether the D.C. fire department also reviewed data on the nature and severity of medical calls, Mr. Walls said the department considers all advanced and basic life-support calls important.
Don Lundy, president-elect of the National Association of Emergency Medical Technicians, said that with fire and EMS departments across the country currently grappling with paramedic shortages or smaller budgets due to the economic downturn, it's important for agencies to think outside the box for a solution.
"I applaud Washington for trying new, innovative stuff," Mr. Lundy said. "We all need to take a deep breath and realize that EMS might not look like what it did 20 years ago."
South Carolina's Charleston County, where Mr. Lundy works as EMS director, restructured its own response strategy in 2009. After tracking three years worth of data on call volume, location, time and type, the county removed ambulances from rural areas replacing them instead with rapid-response vehicles equipped with many of the same medical tools as an ambulance. The vehicles, which do not transport patients, allow paramedics to respond faster and treat patients while ambulances are en route. Once transported, the rapid-response paramedic would stay in the coverage area rather than accompany the patient to the hospital a move that allows the paramedic to go right back into service.
The strategy immediately shaved an average of two minutes off county EMS response times.
Comparing Charleston's plan to the plan in the District, Mr. Lundy was skeptical of the reliance on firetrucks to transport the cross-trained firefighter-paramedics.
"To roll a firetruck, that's a $400,000 vehicle. That's an awful expensive resource to go out on a single-source call," he said. "A paramedic on a single-source vehicle, they would probably see as more cost-efficient."
Mr. Werfel lamented that more information is needed about the District's plan, especially about the data on call severity, before they would be able to give a stamp of approval.
"I would be willing to support it if you can show it's not just less calls but also lesser call severity, but right now there is not enough information to support it," Mr. Werfel said. "Right now it just seems like this is a whim."
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