I'm sitting here tonight, thinking about the last 30 years and wonder what happened in all that time to get us where we are today. Back when I was going to paramedic school, California EMS was a "punchline" - a national joke that went something like “the only thing that California ever did for EMS was coin-the-phrase 'paramedic'”.
Almost from the beginning, the system was broken and everybody who was in charge didn't want to fix it. As paramedics, our power is limited in California. I some states, paramedics have greater autonomy. They work off of standing orders and rarely have to call a base hospital for orders because there rules are so finely honed. In California, we fought and fought to be able to elevate prehospital care, but the darker power has stood in the way.
Years ago, while paramedics were fighting to be able to intubate patients instead of using the Esophageal Airways. I recall a nurse from San Bernardino County, standing up in the middle of a debate on the topic, and stated rather frankly, “why should paramedics be allowed to do something that I am not allowed to do”. Many of us could not fathom that logic, the nurses were supposed to be on our side, or so we thought.
Being a tender young age at the time, I was ignorant and naive. But at that moment, I knew that the emergency room nurses in San Diego had been watching the progression of the prehospital system, and were afraid. It was a moment that stayed with me throughout the years. The very nurses we worked with, viewed "paramedics" as potential threats to nursing positions in the ER, and possibly the hospital. While national momentum was heading in the direction of a prehospital delivery system, San Diego nurses knew they had to develop a way to control the juggernaut that was heading this way and reign-it-in, before it was too late.
Ten years ago, my former wife and I were talking about this very topic, and she told me of a conversation she had years before with a co-worker. She told me that the co-worker (herself a nurse) would lay awake at night, worrying about what she was going to do if a less expensive paramedic, were to replaced her in the emergency department, in the face of harder economic times.
I'm not exactly sure when it occurred, but about the time the paramedic service in San Diego was getting on its feet, San Diego county registered nurses were put in charge of the new prehospital system and the Division of Emergency Medical Services. Although doctors were the ones that oversaw this new prehospital system, it was evident that the nurses in the County were clearly running it. Additionally, they also were the same ones that were training the paramedics as well.
Seeing the opportunity to control all aspects of the prehospital system, and minimize any chance county certified paramedics would take nursing jobs, those at the helm of the County Division of EMS began to write the rules and regulations under which we were allowed to practice. The most significant was the rule that stated that in order for an ambulance to operate in an ALS capacity, there must be 2 paramedics on board at all times. A temporary exception would be granted to the ambulance provider, on a case by case basis dependent on need and reason.
In essence, the rule was designed to keep paramedics from operating outside of the ambulance, in a hospital setting.
What made me laugh was when they tried to tell me that they made that rule to go above the national standard which was characteristically one paramedic and one EMT as a team on the ambulance. We have to remember, the San Diego was selected as a “model” EMS delivery system by the Federal Government. This was their argument, and also their justification for creating the rule.
Now, as I stated previously, several of the fire departments around the County had jumped onto the bandwagon early and had fully funded and sent personnel off to the EMS Training Office–UCSD Medical Center, in San Diego. It is an unwritten law of physical science that firemen go together with nurses, like bees to honey. Fortunately for the firemen, many of the nurses in the County would walk through the halls of the hospital emergency departments, with her eyes glazed, and their tongues wagging every time a fire department paramedic walked through their emergency room door. To this day, I can still remember a conversation I had with the nurse who told me that the reason she became a nurse was to marry a fireman. So firemen had an “in” with the nursing staff that was running the county division of EMS. The result of that cozy little alliance was the rule that an ambulance provider could only provide advanced life support service and staff paramedics if they had a 911 response area.
Since those rules were written, the County has relaxed its policy to some degree on the need for 2 paramedics on board the ambulance to operate in an ALS capacity. They still want to paramedics on the scene, but because of the City's deal with Rural Metro, one paramedic comes on the ambulance and the other paramedic comes on the fire truck. The belief being that the fire department gets there faster and can then initiate treatment sooner.
There have been several providers that have held the contract for paramedics services in the city of San Diego; Medevac, Hartson, American, etc. Today, Rural Metro holds the contract. If the city's lucky Rural Metro will be sent packing also. For the past 30 years every provider that is held the contract to provide paramedic services for the city of San Diego, has walked into the City Council chambers and promised the moon, the stars, and the heavens above if the city were to award them the contract, and of course because they are a large provider of ambulance services the city awards from the contract. Every time that contractors been awarded the provider that it has been awarded to, fails miserably and leaves the taxpayers holding the bag.
To fix this failed system we need proactive leadership on the part of both the city and county governments of San Diego. Many years ago, I can remember when there were only a handful of ambulance providers in the county. These providers were all local hard-working entrepreneurs, who want a chance decided they wanted to make a difference and started their own ambulance services. And, for 30 years every provider that didn't have prior experience as a 911–ALS ambulance provider was not allowed to improve or to better their ability to serve the public. These entrepreneurs, these local businesses, who paid their taxes, paid their fees and supported our local government. Not one of these aforementioned ambulance providers has asked the city or the County for one dime back in a subsidy or a payment of any kind.
Today the County Division of EMS, largely ignores these non-–ALS ambulance providers, with the exception of a single representative from the San Diego County Ambulance Association. That delegate attends committees to listen and observe, but never are they allowed to vote or have a say in any of the decisions or rules they have enacted for us to operate under. So, how is this fair?
It was our founding fathers of this country who cried out before the King of England, “no taxation, without representation”.
My resolve in this instance is clear. There is only ONE solution that is equitable for everyone except one (and you know who you are!). The rules for ALS, must be changed. Set up a system where the existing services are allowed to participate and elevate the level of service delivery to the constituents of San Diego city and county.
A change to the ordinances that preclude a provider the ability to elevate their level of services would actually benefit the county's population. By creating a system of EMS delivery in the City of San Diego for instance, where instead of a single provider with a monopoly, there were say 5 or 6 that had to meet of exceed an obtainable set of standards that were defined by the County or independent EMS Board, it would provide greater control for the city. Should a provider not measure up to the standard established by the city, it would be easier to replace them without having a disruption. Today, if the city wants to admonish Rural Metro for their behavior, Rural Metro has the council over a barrel.
Currently, the City has had to renew the Rural Metro contract for another 2 years because they are not ready to release and RFP. I say that we use this time to open a dialogue with the county and the providers in the area. They have invested in San Diego, isn't it time that San Diego invest in them?
Given the state of our economy both locally and nationally, it would seem to make sense to have a plan, instead of trying to determine how we are going to cut funding for necessary services? Maybe then, more cities in San Diego County will be able to design a delivery model that doesn't cost the citizens a tax subsidy.
I believe that if you research this topic, you'll find that there is a system of EMS delivery that includes public and private participation. A google search will likely reveal this.Try the terms “EMS delivery system examples”, or better yet “EMS Structured for Quality; Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service”, it's published by the American Ambulance Association. I'm sure most of you will find it very informative.
I don't have all the answers, but maybe my well of experience can help me deliver one or at least help in the search.
I spent many years being silent, fearing retribution or retaliation. However today I'm winding down in my career, and I'd like to give something back while I can.
With the introduction of social media; Twitter, Facebook, instant messaging, e-mails, etc., I'm afforded the chance to talk to you candidly, and not worry about those in power that pull the strings and make us dance like puppets. I cannot speak for you, but I can speak to you. My days as “Pinocchio” are over. This is my last dance, and I truly hope that those who can make a difference will put this county first before politics, and keep the special interests and the crooks from continuing to assert their own agenda.
