A Pissing Match Long Overdue

The plight of urban emergency medical service is a study in dire, vague statistics, but it is best illustrated in absolutes: There are never enough medics; there are never enough ambulances; there is never enough time.

That’s not 100­­-percent accurate, but across the nation, city EMS divisions have been stretched so thin that it’s beginning to look like an epidemic. Philadelphia, for instance, employs 248 paramedics compared to 1,912 firefighters, even though 84 percent of 911 calls are medical in nature. In Washington D.C., there has been a mass exodus of emergency medical personnel because of overwork and stress, leaving the already understaffed department with an even more critical shortage.

In Cleveland, the situation is similar. Mayor Jackson and the ever-elusive fire chief Daryl McGinnis cooked up a Fire/EMS integration plan in large part to address the changing landscape of emergency response.

Scene published a story two weeks ago castigating Jackson for fast-tracking the integration’s first phase without proper vetting by city council and the support of the firefighters union.

What’s clear now is this: Though Jackson was still imprudent to orchestrate this substantial restructuring of public safety with what appeared to be a lack of transparency – city council, firefighters and some EMS workers all maintain that they first learned about the integration’s schedule (to the extent that there was one) in the pages of the Plain Dealer – the plan is actually necessary for a more balanced approach to public safety.

In real-world terms, the Fire/EMS integration means citizens will get a better, more efficient response to emergencies. After the final phase, (whenever that is), all emergency employees will be dual-role providers – in effect, firefighters/paramedics – so they’ll be a more versatile, flexible corps.

That’s theoretically a great deal for citizens, but Fire and EMS personnel are apprehensive about what it means for them individually as the integration continues to move forward. Both divisions acknowledge that the integration makes a certain amount of macro-level sense, but there are still many unanswered questions on the micro level.

“The uncertainty is stressful for the field people of both fire and EMS, most of whom have families to support,” said one EMS employee. “You have an already thankless job at a very busy department, where employees routinely become injured, are bled and vomited upon, and are cussed at and and sometimes even assaulted. And yet you go to work every day not knowing if your job, healthcare, and pension, as you know it, will still be there tomorrow.”

IMBALANCE, STRIFE

Cleveland’s personnel dilemma isn’t as lopsided as Philadelphia’s, but the roughly 260 EMS workers the city employs compared to the roughly 800 firefighters makes one seriously question the department’s current makeup, especially when 70 percent of emergency calls are medical in nature, according to the city.

Make no mistake: EMS employees are generally very laudatory toward the fire department. Assistant Public Safety Director Ed Eckart said that though the relationship between Fire and EMS has been bumpy over the past 20 years, it’s “gotten much better” recently. He added, in good faith, “I wouldn’t do [a firefighter’s] job for a million dollars.”

But despite firefighters’ crucial service to the city in the areas of suppression – literally putting out fires – and rescue, Eckart said what’s most needed today in Cleveland’s poor, aging communities is simple medical help – a faster response for older folks who go into cardiac arrest, for gun-shot victims, for the perennial terror of heat stroke, etc.

Therein lies the integration’s practical hinge: The city has firefighters sitting around in stations more or less twiddling their thumbs. The stations may be decrepit and outdated – as Fire Union President Frank Szabo is fair to point out – but they’re certainly outfitted with beds and TVs and computers.

Meanwhile, EMS squads routinely spend the entirety of their 12-hour-shifts in an ambulance, on emergency calls. They don’t even have stations, per se. They’re relegated to the basements and closets of nursing homes and police stations. They technically aren’t even allowed to sleep on overnight shifts or during overtime hours.

JUST TO MAKE THINGS CRYSTAL CLEAR

Frank Szabo said that last year, with 38 companies, the fire department responded to 65,000 calls. On average, that’s 178 calls per day. Divided among the division, that’s an average of just fewer than 4.7 calls per company.

And bear in mind that that doesn’t mean 4.7 fires. That’s 4.7 calls. And that’s through a full 24-hour day (emergency response obviously isn’t just a 9-5 job), so that’s a call every five hours or so, on average.

EMS responds to about 90,000 calls per year – city officials hate nothing more than exactitude – and from 2009-2012, there were only 15 active ambulances. Simple math here: (90,000 / 365) / 15 = 16.4.

Paramedics estimate that an average call can take anywhere from 40 minutes to an hour – 10 minutes to arrive, 20 minutes to stabilize the patient, 10-15 to transport to the hospital – so it’s not like there’s much downtime.

In fact, there were days during the 15-ambulance period when there was no downtime at all. Both Eckart, who was EMS commissioner at the time, and EMS Union President Orlando Wheeler confirm that on many occasions, every single ambulance was actively on a call and people with medical emergencies were forced to wait.

Eckart didn’t know the precise wait times, but stressed the importance of EMS’ system that prioritizes the most serious, time-sensitive emergencies. Wheeler said that right now, EMS is operating 18-20 ambulances every day, so the backlog situation has definitely improved.

Increases in personnel would also improve the efficiency and capacity of medical response, and Wheeler said that in the early stages of the integration discussions, the EMS Union voted on a memorandum of understanding with the city that would permit a limited number of firefighters to work on ambulances to help with their workload.

EMS employees say that agreement never came to pass because of disputes from the fire union, but that 45 new EMS hires have shouldered some of the burden. Szabo said that there have been dual-role firefighters who have already been working on ambulances for the past two decades with no additional pay.

Both sides are very sensitive to change, regardless of context. The Fire Union was incensed about losing two rescue squads in the first phase of the integration – these aren’t trucks with ladders or hoses, mind you; they’re more like the fire department’s version of ambulances. At any rate, a union press release lamented that Cleveland fire has now been reduced to 34 companies, its lowest capacity since 1899.

That may be true, but Cleveland’s population is also the lowest it’s been in 100 years – 397,000, as of the 2010 census. Back in 1900, the population hovered at 381,000.

Depending on the changes, and how they’re handled, it’ll be a lot more than “sensitivity” the city will have to deal with.

A DUAL-ROLE DUEL

“The only apprehension I have is that in the [integration] process, both parties might not fare out equally,” Orlando Wheeler said. “If one fares better than the other, that would create animosity among the ranks.”

“We don’t want to be overshadowed by a suppression-happy fire department,” said another EMS worker.

It’s not that animosity already exists, said Eckart in a phone interview. It’s just that currently, the cultures of the two divisions are extremely different, and that makes a seamless integration challenging (over and above the challenges of logistics.)

“These are two divisions that are steeped in their own traditions and in their own types of operations,” said Eckart. “Firefighters are very ‘Chain of Command.’ and they’re very structured in the way they attack a fire, whereas EMS personnel are trained to be more critical, independent thinkers. They need to be problem solvers without having direct supervision.”

That’s why the word ‘integration’ isn’t just semantics, said Eckart.

“We’re not calling it a ‘merger’ because one division isn’t swallowing up the other one. We’re really integrating the strengths of the two existing divisions – the whole goal is to capitalize on their specific strengths.”

That’s a lovely philosophical ideal, but it doesn’t necessarily solve the culture-clash problem. Nor, as EMS personnel have pointed out, does it resolve the thorny questions that remain about their pensions and their seniority.

EMS workers are worried that even top-level paramedics will enter the new system at the bottom of the barrel. They’re also scared that their fire training won’t be fully funded and that all the funds they’ve personally contributed to their pensions won’t be matched by the new pension system.

“That’s one of the things we’re still going to have to figure out,” said Eckart, when asked about pensions. “But it might have to be figured out on an individual basis.”

When asked about EMS’ fire training: “That another thing that we’re still going to have to figure out. You know, sometimes these things change.”

TRANSPAREN-What?

The lack of answers and planning has EMS employees extremely frustrated. A meeting scheduled for February 26 to explain the integration to the EMS rank and file was indefinitely postponed. Eckart said there was a scheduling conflict due to union negotiations.

“There’s still a lot more that needs to be done,” said Orlando Wheeler, tactfully. “Still a lot more information that needs to be disseminated. But remember, we’re still – in terms of basketball or football – this is still the second quarter.”

Many employees contend that these are questions that should have been answered before the tip-off.

Eckart said that the city was transparent in their planning – “communication is the key,” he said – that they “engaged everyone,” that they had over “100 hours of meetings” and commissioned “working groups” to explore specific subject areas.

Frank Szabo didn’t feel like he was thoroughly engaged.

“Those little focus groups were hand-selected by the city,” he said. “And they only made recommendations. There’s no way of verifying whether or not those became part of the actual integration.”

Szabo said the city even brought in an International Association of Fire Fighters (IAFF) integration expert, Lori Moore-Merrell, and that her input was poorly received.

By phone in Washington D.C., Moore-Merrell said that her expertise was in system design. Her team at IAFF uses geography and population demographics to approach improvements in city emergency response.

“They should’ve switched to an all-hazards infrastructure years ago,” Moore-Merrell said.

She means the dual-role system where every emergency employee can respond to anything other than a criminal event.

“I’m not certain if they took my input,” Moore-Merrell said, “but a lot of decision makers who haven’t had experience in emergency response don’t know that you can’t equate call volume with number of vehicles. Response time is more important than transport.” (Translation: Fire trucks are more important tham ambulances.)

Eckart said that in the next few days, four more fire engines will be equipped with advanced life support equipment so that they can be “first responders” to medical emergencies. But no word on which “phase” that upgrade falls under.

“The union would be okay with the phases, as the city calls them,” said Szabo, “but we’re just not sure what they look like. “We don’t really know where they wanna take this.” In his gut, Szabo still feels that this looks more like a downsizing of the fire division than an actual integration.

The EMS rank-and-file is on board too, but again, just wants answers to their questions.

“It’s true that they distributed survey and had talks with the unions,” said an EMS worker, “but I haven’t seen or heard of a complete plan on paper that addresses structure, costs, timetables and rules. If this was so transparent, why didn’t Eckart just pull out the plan and share it? Is it even written down?”

The Mayor’s chief of communication Maureen Harper says an “operational document” exists and has been shared with union leadership but not the rank and file. However, within the document, there’s no timeline set in stone.

Nevertheless, Ed Eckart is convinced that the integration will go smoothly.

“This isn’t just political bluster: I truly believe that every one of these individuals raised their right hand on the day they were sworn in to serve the community. And at the end of the day, regardless of what their position is on what we’re doing, they’re going to answer the call.”

This article appears in Mar 6-12, 2013.