Sunday, April 09, 2006

The Great Ambulance Debate...

This is a bit outside my purview, but here's my two cents on who gets to provide emergency ambulance service to the LACoFD. For the last few years, American Medical Response has provided a majority of the 911 ambulance service for the County fire department.

Unlike LA City and (a few smaller municipalities) that use their own ALS and BLS ambulances to transport medical patients, the County sends two-man paramedic squads--just like in the 1970s show "Emergency!". Private ambulances respond to 911 calls but they're staffed with two EMTs who assist the fire medics with patient care. The fire-medic then hops onto the private ambulance and transports to the hospital with the EMTs.

This is a particularly stupid system for a variety of reasons. First, the fire department has to separately alert the ambulance dispatchers on any medical call. This causes a delay right from the start of the 911 process.

Second, the delay is compounded by the private companies finding the closest ambulance that's sitting on some street corner and then sending the ambulance to the call. Invariably, the fire station that is sending the engine and squad is closer to the call, often by miles. Once the ambulance has been dispatched from its street corner, then another ambulance is either dispatched to the original street corner, or will sit at its assigned location and wait for the next call, which could be any distance away.

In the ambulance industry, this is known as "system-status mangement." Not only is it a complicated system developed by mostly moronic people that work at big companies like AMR (and even more moronic people who work at smaller companies), but it makes for grumpy EMT's who are stuffed into the front of ambulances driving around aimlessly or sitting in the parking lots of 7-Eleven's.

Even the casual scanner listener will often hear LA County fire captains and medics requesting "AMR's ETA" over the radio. Partly, the Fire guys are pissed that they're on a medical call, but they're also pissed that sick people have to wait for an ambulance while they've been on scene for many minutes providing care.

While AMR and others take response times very seriously because they're financially and contractually obligated to respond to calls in a certain amount of time, individual EMTs have less incentive. Mostly because they're going to get on scene and likely be treated like total shit by both the medics and the firefighters. Also, they're EMT's, so medically, they can't do shit. Often, they're also pissed because 95% of them are trying to/have tried to get hired by a fire department and are either in the middle of the long, long, long process, or have already been rejected.

Then, they're gonna carry the patient around on the stretcher while the (extremely strong and fit) fire guys sit around or scurry back to the engine. Granted, LA City's system isn't flawless. Often, busy periods leave ambulances scrambling across town (especially in South LA and the Valley), but non-ambulance ALS resources can often be paired with a BLS transport unit and that solves the issue. LAFD has done a great job of flooding the districts with FIRE STATION-BASED ambulances and paramedics on engines allowing for great flexibility.

The LA County Board of Supervisors a few weeks ago broke AMR's monopoly on ambulance transport in the county. This is both good and bad:

Good = AMR is shitty company. Period. In LA County where they primarily do non-emergency transport work and BLS 911 operations, they suffer from the complacency as the industry leader. In other parts of the country--and even California--AMR paramedics are the primary 911 responders. There are highly competent and experienced paramedics within those operations that provide first rate care. The company, however at the managerial level, totally sucks. And the last thing I want to hear is a defense of AMR from anyone. They're a unit of a large and poorly performing public company. The bottom line is stock price and return on investment to the shareholder. That is their motivation. They treat their employees like shit, and are lucky to have exclusive 911 contracts in many markets that provide employment for some excellent EMS providers. Paramedics and EMTs in a number of locations are even LUCKIER to have strong unions that deal extremely well with AMR.

In LA County, however, since top-line care is mostly provided by the fire departments, AMR cannot hide behind the good medicine and competence of its paramedics. It's all about the dollars in LA County. As for the smaller companies like Schaefer, Care and Westmed, it's a mixed bag. They now get wider leeway to play with the big boys, but suffer the same evils from barely competent EMTs, greedy executives and the system status issue.

The County should either begin staffing its own transporting ambulances or make their squads truly first assestment and treatment units and allow the private ambulances to use medics for 911 responses and transports. Holding the monopoly on ALS care while depending on the privates for response and transport via BLS units is stupid beyond the pale.

Thank God no one reads the site, or I'd have a hundred idiot EMTs and even more idiot firefighters bitching at me in ungrammatical sentences with dozens of misspellings.

4 comments:

LAFD Media and Public Relations said...

...more people read your site than you might imagine!

Thanks for sharing your opinion. As a stakeholder, you most certainly have a right to do so.

Stay Safe and Be Well,

Brian Humphrey
Firefighter/Paramedic
Public Service Officer
Los Angeles Fire Department

LAFD News Blog: www.lafd.org/blog.htm

Anonymous said...

"Thank God no one reads the site, or I'd have a hundred idiot EMTs and even more idiot firefighters bitching at me in ungrammatical sentences with dozens of misspellings."

It wouldn't be so funny if it weren't true. I'm bookmarking!

Anonymous said...

I hope nobody reads this site, because it is full of errors and disrespect.

Not all of LACoFD's 911 transport companies utilize system status. Schaefer and Westmed/McCormick utilize many centrally located stations and post only when there is a lack of coverage between two stations.

As an EMT I take offense to your blatant disrespect to our job. Some of us take pride in the job we do and in fact participate more in patient care than the average paramedic does.

The title of this article leads the reader to believe that you are going to write about some "great ambulance debate" when you never debate anything at all.

The squad system works well, because the majority of 911 calls tend to be BLS and the ALS resource (the squad) doesn't then become tied up with transporting non-emergent patients, thereby allowing the paramedic resource to go back in service. There is very little delay in the dispatching process. The call is transmitted from LACoFD dispatch to the private ambulance company dispatch via MDT. They receive the call at the same time the fire station does. Most times we arrive on scene at the same time or even before fire does. This fact alone shows how little you actually do know about the process or the system.

" Also, they're EMT's, so medically, they can't do shit. "

Are you just bitter at life for some reason? Most patients require an EMT level of care, not a paramedic level anyways. Basic skills such as airway management and ventilation are the absolute most important in patient care -- a skill EMT's are well trained in.

"Then, they're gonna carry the patient around on the stretcher while the (extremely strong and fit) fire guys sit around or scurry back to the engine."

The FD is very helpful on scene when we need extra hands to safely move a patient. Extremely strong and fit? Have you seen most LACo firefighters? One was telling me the other day that proper fitness is now req. to earn your bonus...something like half the dept. isn't qualifying for their bonuses!

"LAFD has done a great job of flooding the districts with FIRE STATION-BASED ambulances and paramedics on engines allowing for great flexibility."

Have you read the LA Times in the past few years? Front page articles dedicated to the over-worked and ran LAFD RA's. Their system is so inundated with medical calls and a lack of ambulance resources that they are bursting at the seems! You're talking about a city that regularly moves up companies code 3 simply to get coverage in certain areas!

I take this blog with a grain of salt, because you obviously are writing for the entertainment value since the knowledge level just isn't their to hold an intelligent debate over ambulance coverage in LA County.

Dutch said...

This is a good start. Not for debate but for grievance. Maybe you could consider another title and leave the subject open. I'm sure this is a good way to bring some of our troubles to a forum at a national level and hopefully we can begin to resolve some the EMS/Fire woes.

Leave out the insults.

Best Regards,

DTS