"What Was She Thinking: Do You Realize That Everything You Say Over The Radio is Retrievable and Come Back to Haunt (Discipline) You?"
On Tuesday, March 23, Pittsburgh Public Safety Director Mike Huss and Mayor Luke Ravenstahl held a press conference to discuss the discipline of EMS employees following the death of Curtis Mitchell. During the conference, a 911 tape of the incident was presented.
OK - so we know something went wrong. I too have worked in bad snowstorms and have had to walk to patients. So some thing(s) went wrong, and without knowing all the facts it's easy to point fingers. So (since we all seem to grasp that there was a problem), here's the question: How do you fix it?
Assumptions (based on my knowledge of Pittsburgh):
A city that is in dire financial straits (under state financial supervision), so you can't throw money at it. It's probably safe to assume that EMS is pretty busy and that lots of residents use EMS for non-emergent transport.
An EMS system that has been battling "takeover" threats for a long time (fire service), which has taken a toll on morale.
A culture that apparently assumes patients are not needing of "emergent" care until proven otherwise.
A city where labor unions have great political power, and where they have historically spent great efforts (EMS and otherwise) opposing any form of change (including the culture and ridding the service of medics who don't seem to want to care for patients).
A city where "upper" support for EMS appears minimal - a public safety director whose loyalties appear to be to the fire service, and mayor and council appear to support the union more than their own management.
OK, those of us with all the answers. Where do you start? How do you change the EMS in this environment to one of (sorry to use our motto) prompt, compassionate, clinically excellent patient care, whenever and wherever needed?
I'll openly admit that I don't hold all the answers, and I'm mainly doing this on a day off to procrastinate (attempting a 2nd draft of my masters dissertation, the first draft came back with a lot of feedback lol)
So I agree something went wrong and from your thoughts Skip, I wonder if this has been going on for many years. I love the internet and how quickly google can bring you any information from 1 or 2 keywords.
Not being on the managerial side, and the UK having a different funding arrangement than the US but the operating budget for Pittsburgh EMS openly available on their website doesn't seem to make sense to me.
2010 is a proposed budget of $12million. 94.3% (close to $11.3million) of it is salary. So that leaves 5.7% (close to $700,000) to operate a service 13 vehicles and handle a proposed 55,000 calls.
I guess looking at this insurance/medicare claims for the 55,000 calls gets added on top of the $700,000?
If I've calculated right the projected UHU is 0.48. Seems optimal to me. There are no fly cars in operation and it appears to be an all ALS, all Paramedic service.
This probably where the culture of non emergent till proven otherwise comes from. The getting the patient to walk seems to be ingrained into the woodwork. 1 crew requests it and you can say bad apple but 3 and you need to change supermarket.
In the internal report, it appeared that there was a clinical triage scheme in operation at the dispatch centre, but they found that doc's doing the triage didn't have access to the CAD there weren't enough phone lines. Consultation Documentation on paper, which none of the other dispatchers or the responding crews could see.
The merger appears to be on the cards since early 2000, so its understandable why morale is low. I guess you face problems when you have 1 person responsible for all 3 public safety divisions. He's going to choose his alignment. Political support to unions is nothing new for me here in the UK, just look at the British Airways Strike for an example of that.
The answer then?
We always say in the UK that in order for EMS to progress we need to be removed from the National Health Service and become a division of the Home Office like Fire and Police. Because the funding is wildly different. You look at the difference in response to incidents....the fire service rolls up and raises its command shutter with computer and 42" plasma screen, pulls google map images of the response (thats the regular truck not an MCI special) the EMS crew join in with the bit of blue roll ripped off the tissue dispenser to implement their side of the plan...
That being said when you have an enjoined division of public safety, you end up getting the wrong fit, you don't get EMS specialists at the top, you get a police officer or government official who doesn't see a patient at the end of the emergency response.
When the Department of Health took our services from 32 and merged to create 11, it became less of a merger and more of a hostile take over. It our case a large deemed poor quality service took over 2 smaller high quality service. Did the managers and experience of the better services carry across, no the management structure remained the same and the poor quality was forced upon the smaller services staff rapidly reducing morale.
I can understand why front line staff are anxious and perhaps being in an underfunded, neglected organisation, negativity breads negativity and the patient suffers.
The real issue lies with the response model. Like us in a large scale city model, the amount of non emergent work far out weighs the emergent work. So you have to wonder in an all Paramedic service what skill retention is like. I appreciate its not the attitude but when all you do as an ALS crew is shuttle-bus patients with low acuity medical conditions, offering a ride to hospital only it can drain on your will to live.
One wonders whether there can be a need in the US model for a BLS response. Yes our double ECA crews have attracted attention when they are not deployed correctly, but when they are doing the low acuity omega calls and doctors transports. Allowing ALS resources to concentrate on ALS emergencies keeps tempers low, skills and knowledge high.
We have had a nurse triage system in dispatch for some time, It works well but when an ambulance is required the entire consultation is passed to the crew, which I can say on a 4.3" MDT can prove an interesting read. So the excuse of not knowing what happened previously tends to not be a problem...If this incident happened here, the 2nd and 3rd crew would have known the history and really not reaching the patient on the 3rd attempt would not really take place...
We also need to consider the system status management plan, are we keeping crews unnecessarily at street postings, are we getting them regular comfort breaks. Here there is a clear link between overworked medics and clinical/adverse incidents.
As EMS as a whole and we've said this countless of times, we need to move with the times. We need to recognise that the days of EMS is for emergent health needs only are over. Many services like us here are seeing positive results with specialist practitioner roles both primary care and critical care, yes we have our problems but we are meeting patient needs.
The start to reach your motto is to not reinvent the wheel but better use the ones we've got. Respond to and adapt to the patients needs not refuse to when the needs get tough...
Assumptions (based on my knowledge of Pittsburgh):
For those of you who want to work on the how-to-fix-it question, Skip's assumptions are mostly spot on.
Biggest exception: at least since I've been here, there has never really been a serious takeover threat from the fire service (they already have a pretty sweet deal and aren't going to take on all that extra work unless they feel that deal is threatened), but there was a lot of talk one or two mayors ago about ditching EMS as a municipal entity and turning its provision over to the hospitals. Add to that the strain of working the same conditions as the PPD and PBF (Fire is a Bureau here, not a Department) without having pay parity or even the same negotiating footing, and you're right about morale--though for slightly different reasons.
Then you have to add in that SW PA is a place where you can go to paramedic school for $850, so there is always a plentiful supply of newly-minted medics to draw from, and wages don't have to be very high. I don't know too many people with a good work ethic who are left in the profession, or aren't at least on their way out.
So add this into a system where, yes, there are plenty of non-urgent calls (particularly in poor neighborhoods like the one where this guy died), and you get the local joke about the ABC's of Pittsburgh EMS: Are you alive?
Do you have Blue Cross? Can you walk to the truck?
I never saw it, but from what I hear, the Pittsburgh episode of TLC's "Paramedics" a few years back was pretty representative of the time: the pt who made it to the ambulance before the medic noticed that the pt was in V-tach (despite it being clearly obvious on TV in the house--and incidentally the only pt carried during the entire episode), the medic shouting at her kid via cell phone while driving to a call, etc.
Where to start? As a taxpayer here, I would like to start by breaking the back of every union in town, make every last gov't employee here as afraid of losing their job as everybody in the private sector is. Only when you have a reason to do more than the absolute minimum is there any chance for improvement.
Then hold people accountable. As it stands, the people being disciplined are 2 district supervisors, one person running a call-back line from the dispatch center, and the idiot who made the vulgar remarks on a recorded radio channel. I would add more: from reading the report, it sounds like at least one of the dispatchers suggested the call cancellation to the caller, which should never happen. The crews involved may or may not need formal discipline but at the very least need a "come-to-God" meeting with the boss, clearly explaining what is expected from them at all times. I would also add the crew that left a woman and her kid having an asthma attack to get to the hospital on their own because they wouldn't walk down to the house (in that case, it sounds like mom was willing to walk to the ambulance but she couldn't carry both her infants and a diaper bag up the steps in 2 feet of snow).
I would also quit wasting PBF's time (and my tax dollars) responding to low-priority calls. That was one of the "solutions" started in the wake of this: to send FRs to lower-priority calls than they normally go to, which isn't going to change a danged thing.
Hopefully, my remarks don't turn this into a debate on whether EMS should be a "hobby." I'm going to say it anyway. WOW! WHAT A LACKING WORK ETHIC! I've been a volunteer for 21 years. Never had anything like this happen, never heard anything like that said. I've seen patients reached by snowmobile (privately owned by a fireman), fourwheeler (privately owned by a neighbor)and carried out on a Stokes basket strapped to the back of a brush truck. I have seen a quadriplegic with a fever dragged out on a Stokes basket pulled by a snowmobile with 4 EMS providers running alongside holding onto straps tied to the basket so the patient did not tip over. The snow on that one was so deep that one of the providers tripped over a mailbox that had been completely covered with drifting snow. The patient was transported that way for over a mile till they got to where the ambulance could be driven. All I can say is, when you are dealing with volunteers, the work ethic is so different, probably because you know they truly have a desire to help their fellow man. They are not collecting a paycheck, so there's not any possibility that that's the only reason they're there.
PEMS, not PGH Fire operates the city's two heavy rescue companies. If there is a potential problem with a two-person medic crew not being able to carry a patient four blocks on a hill in two feet of snow, the medics had the opportunity to a) walk to the patient's house, b) assess the patient as needing transport, c) calling for an EMS Rescue company and an Engine company for manpower and the stokes baskets or SKEDs that the rescues carry. Those litters can be either carried by hand or used as sleds in snow.
As for PEMS fixes, the money limitations and strong unions are a bad combination for real fixes.
One possibility might be to a franchises load-shedding program like Greenville County, SC and Skip's neighbors in Guilford County, NC use. Guilford County runs a county 3rd service EMS system. The county also has a rescue squad that morphed into an ILS EMS service. That service handles all of the Alpha-priority calls unless they are not available within 30 minutes of the call location. My understanding is that they also pay the county a franchise fee for the right to run the Alpha calls. This is a pretty good solution - run fewer calls and generate at least a little more revenue by doing less.
Greenville County does the same thing on a more limited basis for DOAs only.
In both cases, the franchisee bills for the patients/DOAs they transport, but the revenue to call volume ratio seems to work out in favor of the EMS workload, particularly in Guilford County's case.
I'll admit that my information on Guilford County is 8 years or so old, but I haven't heard anything about them changing their load-shedding system.
It sounds as if this would work for PEMS as well. Maybe a more reasonable workload and running fewer low-acuity calls would help improve paramedic morale.
It looks as if Pittsburgh might be headed the way of a lot of other cities with strong union representation - more calls and fewer units to run those calls as has occurred in Detroit, Cleveland, and elsewhere throughout the Rust Belt.
The bottom line is that if we're going to blame the system model when medics make a mistake with fatal consequences, we can't use a double standard and defend the system model and claim that the medics were scapegoated when the system model that we like makes a similar fatal mistake. Yes, TOTWTYTR and Rogue Medic, I'm talking to you.
Pittsburgh is already a 3rd service model, so changing it to the model you guys tout as the "best" isn't an option. Apparently, the system model is to blame ony if it's one that you guys don't like. If your chosen system model has people that make a mistake, then it's time for your excuses, your claims of scapegoating, and the double standards to be quickly floated into the blogosphere.
At least, in the DC case, the crew actually made patient contact before they made a bad decision.
I don't know how model can have anything to do with it. 3rd service, private for profit, non-profit, fire based, hospital based, whatever.....you can put a highly motivated, caring provider in ANY model and they will deliver good patient care and work ethic. You can put a lazy, gimme gimme, slug in ANY model and you will get what you pay for.
Here's my unqualified, unresearched, opinion on one of the biggest problems. Unions.
I worked for a service a few years back that was, in 5 years time, a 2-time winner of the Pennsylvania Rural EMS service of the year. That place trained every month, closely reviewed calls, took HIPPA VERY serviously, took unit checks, equipment, procedures, technology, attitudes, and appearance VERY seriously. Here's the kicker where the unions come in...THEY WEREN'T UNION. If you were a lazy, miserable, un-caring slacker.....YOU WERE GONE!!!! END OF STORY.
I've also worked for union shops. Guess what....the guy that comes in, thoroghly checks his truck, cleans it in and out, takes care of the station, shines his boots, takes his calls, treats his patients correctly and compassionately.......versus the guy that comes in looking like a slob, hungover, doesn't even look at the truck, kicks his dirty boots up on the couch a 2 minutes after shift change, and treats patients like a burden and a problem. What is the difference between these two employees in a union run EMS service...NOTHING. THEY ARE EXACTLY THE SAME. And just go ahead and try to fire them....they better have raped a nun in front of a crowd.
Unions protected hard workers from unfair money mongers 70 years ago. Now, they protect the lazy, apathetic "workers" that think they should get scheduled raises every year while doing the bare minimum.
Bottom line......union shops provide a safe haven for slackers who wouldn't be tolerated at other places to flock together like magnets to a refrigerator. Next thing you know, you have a service with a minority that just happens to hold a higher standard for themselves....and a majority of people you wouldn't want showing up to treat your neighbors dog.
Hey Ben -- how about leaving the type of system out of what has been a pretty good discussion. If you don't like what people have written on other forums, fight it out in those forums. Nobody here talked about system model, 'cause it's not an issue in this case. Lately, there's been sufficient badness to go around such that everybody can see that it's irrelevant.
Skip, when you start telling those who use any excuse to bash the Fire/EMS model here the same thing, then maybe I'll consider it.
"Nobody here talked about system model, 'cause it's not an issue in this case." Just not this time, and that's my point.
Here are a few examples of posts on JEMS.Connect and sister site JEMS.com that contained Fire/EMS system model bashing by others and upon which 3rd Service proponents were either eager to bash a Fire/EMS model or whom remained silent when unproven and unprovable perjoratives were used to bash said Fire/EMS models:
The absence of system-model bashing for the Pgh EMS 3rd service problem compared to the wide-open system model-bashing that DCFEMS is catching is a glaring double standard. Either the system model is a problem in both, or it is a problem in neither when the results and provider attitudes are the same.
If you're going to complain about system model comparisons, how about being fair and doing it for all models instead of the silence when the system that let a patient die has a similar model to the one in which you work?
Can I now expect to see you call out those who post perjoratives about any and all EMS system models? If not, then I'll continue to point out the double standards of anyone who applies a different standard to Fire/EMS than to the other system models. However, I'm not surprised that the long silence was broken by a wish that the system model hadn't been brought up because seemingly, it's the pet system model of a lot of the folks who post here.
In any case, it appears that Pgh EMS's dediction to research, heavy physician interaction, high clinical standards, and some of the extras they do like the heavy rescue companies and the river rescue program didn't do much to help the patient who died. When the patient's family calls 911 nine times in a 30-hour period and the patient dies without EMS ever making patient contact, that is indeed a "system" problem.
If the system model doesn't have anything to do with it, as Blair states, then it doesn't have anything to do with the DCFEMS incident that resulted in a dead patient, either. You simply can't have it both ways based on personal biases when the outcomes are the same - a needlessly dead patient.
First of all, you have no knowledge of what I have said or not said to anybody - and I have no obligation to do my "calling out" in a forum of your choosing. I have, in many ways in many places, asked people to tone it down. Usually it takes only one request - you are apparently determined to be the exception. (Please - contact Chief Gary Ludwig at the IAFC-EMS Section or the Memphis Fire Department who will be happy to verify this for you.)
Some of the fire-bashing is, in a word, asked-for. Nobody has started a national organization called "Advocates for Third Service EMS" or "Advocates for Private EMS" or "Advocates for Hospital-Based EMS." Is it any wonder that folks in those other sectors feel threatened and inclined to strike out? You're part of a group that, intentionally or not, is seen as being on the offensive. The volume of the rhetoric has risen remarkably since that happened.
Many of us are simply tired of the endless (and yes, it seems to often start with you) conversion of every discussion in this forum to a model-bashing discussion. Let somebody mention the word "fire" with anything but glowing praise and off you go. Let somebody mention any other model, and off you go.
Did you ever notice that once you head down that road, the thread quickly peters out? And any useful discussion that might follow is lost. You'd do the rest of us a big favor to start a thread about model-superiority and let those who are interested argue there. At least the other threads, those that might be of interest and use to others, would not be lost to conversion.
To put in my 2 cents to the discussion... I'm not going to point fingers or say who went wrong where, but I think we would all be saying DRASTICALLY different things if one (just ONE) of those paramedics was enterprising enough to pick up a shovel.