In the video, the man is flat on his back on the side of the road. He is unconscious and his heart is not beating.
Seconds before, the 68-year-old was riding his bicycle – and was, at the time he went into cardiac arrest, a few miles from the finish line of the annual MS-150 Houston-to-Austin fundraising ride. Fortunately, there are plenty of public safety personnel nearby. Two police officers on traffic duty react instantly and begin the deep, fast, and rhythmic compressions of modern CPR until the first paramedic appears on a motorcycle, followed in short order by an ambulance and crew.
While passing riders stare and traffic moves around them, the Austin-Travis County Emergency Medical Services crew tends to the man; they are calm and collected under pressure. On the Austin Police camera video, time seems to slow as they move through their protocols for handling cardiac arrest patients. Within minutes, they've restored the man's heartbeat – quite literally, brought him back to life. They install him in the back of an ambulance, hit the lights and siren, and race off to the hospital.
Within days the man was discharged, sent home to Houston with his family. Although cardiac arrest accounts for just 0.5% of all calls for EMS service in Austin, according to the department – perhaps 600 of roughly 120,000 calls for ATCEMS service each year, notes ATCEMS Medical Director Paul Hinchey – such calls are among the most serious, time- and skill-critical emergencies that first responders and paramedics handle. Unless someone intervenes, death is virtually certain.
Responding to cardiac arrest is something that ATCEMS – in conjunction with "first responders," typically firefighters, all trained as emergency medical technicians – does well. ATCEMS has a higher than national average rate of survival for cardiac arrest patients. Since 2008, roughly 40% of all cardiac arrest victims whose collapse was witnessed (as with the MS-150 rider), and who are attended by ATCEMS and taken to the hospital, survive and are discharged (compared to roughly 30% of patients nationally). When it comes to patients whose cardiac arrests aren't witnessed and immediately tended to, ATCEMS still posts an average survivorship of 12%, above the national average of roughly 10%.
ATCEMS boasts a large number of highly trained paramedics, and both Austin and Travis County are rich in skilled first responders (trained, mostly, as basic emergency medical technicians). Both Hinchey and Ernie Rodriguez, director of ATCEMS, have been lauded for their interest in researching and implementing best practices to foster better patient outcomes. That's how the so-called "pit crew model" of dealing with cardiac arrest was born, says Hinchey – literally built on the approach a pit crew takes to assessing and servicing a race car: Everyone has a particular job, and the crew works in synergy.
While the best of the city-county collaboration that is EMS is on display in incidents such as the April MS-150 rescue, that cohesion and focused sense of purpose belies a friction and seeming instability just beneath the surface. As much as the agency is succeeding on the ground, it is also an agency – a system – in transition. On occasion, glimpses of conflict bubble to the surface and into public eyes: In February, a volley of email-sniping between Austin Public Safety Commissioner Mike Levy and ATCEMS Employee Association President Tony Marquardt made headlines; there have been unflattering city audits of ATCEMS that questioned its approach to employee health and safety and its ability to manage bill collections; and as the spring progressed, there were accusations from Marquardt that county Emergency Services Executive Danny Hobby was endangering lives by withholding funding for a much-needed ambulance in eastern Travis County – among other notable scuffles.
In isolation, as they're invariably reported, these conflicts are difficult to decipher. Taken together, and in the context of an agency approaching it's 40th birthday (the ATCEMS system was chartered in 1978) and that must now determine how it will grow into its next 40 years amid a vastly different landscape – both in terms of local demographics and national changes to health care delivery – it's little wonder there are random flares of temper at meetings of the Commissioners Court, or furrowed brows during city PSC meetings.
Beneath the daily attending to patients and beyond the occasional alarmist headlines is an agency caught among various visions of how it should move into the future. There are those who believe ATCEMS should be consolidated with the Austin Fire Department; and those who believe the county should create its very own, countywide fire department using the 14 independent Emergency Service Districts that each currently provide fire suppression services for their own geographic areas, while retaining the stand-alone paramedic services of ATCEMS. There are also those who believe the county should create its own fire department-based EMS services; and there are those who believe the EMS system is fine just the way it is – as a stand-alone third service for emergency medical services across the city and county.
"We have incredibly fine EMS service. When the advanced-level service paramedics show up in an [ambulance], you are in extremely good hands," says Sarah Eckhardt, former Travis County Commissioner and current candidate for County Judge. But, she continues, the county and city have grown so much, and health care reform is reshaping how public health institutions will function – she believes it's time to look at how to continue to deliver high-level care, while being smart about how we deploy resources. "All of this hand-wringing and fear and anxiety, it's all a harbinger of a good thing: We're finally talking ... about what we have and what we need. And that's causing a whole lot of [discomfort] because it means some things will probably change. In this case, we need some change."
ATCEMS is run by an "inter-local agreement." Paramedics are city employees, and the city-hired director, Rodriguez, oversees daily operations of the busy agency, including staffing and deployment of the various resources – including some four dozen ambulances, the majority of which are stationed inside the city limits. For years, the agreement between the city and county has essentially worked like this: The city funds the agency at roughly 75%, says Austin's Deputy City Manager Mike McDonald, and the county kicks in about 25%, without any additional breakdown of what, specifically, the funds are paying for. For a time that worked relatively well, stakeholders say, because most of the growth was happening in the city, and everyone agreed that it was worth it for the two governmental entities to collaborate in order to ensure continuity of care.
"I tell people all the time, even though you're living in the city, when you're facing a crisis you don't know where that crisis is going to occur," said McDonald. "You may not be at home." Eckhardt agrees: "If I have a car accident ... coming back from my son's soccer game at Northeast Metro Park, I want the same level of paramedic response" as someone would get in the middle of Downtown, she said.
But because of geography and the distances between county population centers, the response levels haven't been equal. The quality of the care has always been there, stakeholders note, but it hasn't necessarily been equally accessible. The "weakness" of the system, says Eckhardt, "is that our ability to serve the entire county – with its different terrain, its different population concentrations and the different types of calls from moment to moment – makes for really unequal service levels."[page]
Despite that simmering issue, the agreement between the city and county has for years remained relatively unchanged. Although the majority of calls for service still come from inside the city, explosive growth in the county over the last decade is now causing county officials to reconsider how EMS services are delivered. And there is now more at stake than simply the provision of paramedic care and ambulance service that ATCEMS provides, county officials say. Consider, for example, the issue of the county's Emergency Service Districts and the power of Austin's extraterritorial jurisdiction (ETJ).
Among the various taxing entities in the county are the 14 ESDs, which respond to fire calls and provide first response for medical emergencies outside the city of Austin – just as the Austin Fire Department does within city limits. As the county's population has grown, the demands on the ESDs have increased, in many places stretching thin their ability to provide services – an issue compounded by the city's annexation of tax-rich properties in its ETJ. That happened recently to ESD 11, which is responsible for 114 square miles of Southeast Travis County. It's a modest district, without the property-rich tax base of, for example, Lakeway or Bee Cave. The district would have gotten a nice bump in revenue – to the tune of at least $1 million per year, says ESD 11 Chief Ken Bailey – with the development of the Circuit of the Americas Formula 1 track in Elroy, in the heart of ESD 11. Then the city of Austin carved a little path eastward from the previous city limit to encircle the track. That leaves Bailey with roughly $2.8 million in 2014 to fund personnel and operations at three fire stations that serve some 30,000 people.
While the annexation issues may be equally vexing on the county's west side – 65% of the revenue in West Lake Hills is in Austin's ETJ, says Bailey – the tax base there is more affluent, allowing for larger budgets for the ESDs. In other words, the 10-cents-per-$100 taxing power of the ESDs is the same but certainly not equal, though their responsibilities are. All together, the county's ESDs have roughly $44 million a year to spend, says Bailey, money that now is unevenly parceled out and that will be increasingly crippled as Austin continues to grow.
"Potentially, if the city of Austin grew to its farthest borders and butted up against everything else, the ESDs have one-third of the current budget ... to operate on," said Bailey. "How do you sustain that?" And as it stands, the majority of calls for service in the ESDs come from the less affluent areas and are, as with AFD in the city, medical-related calls. If the city swallows up the ESD budgets, how will they be able to continue to serve higher-need, lower-income, and other rural county residents?
Perhaps no one better understands the pressures facing the ESDs – and, by extension, the county as a whole – than Danny Hobby, the county's executive manager of emergency services. Hobby is tasked with overseeing the contract between the city and county for ATCEMS services and is also the go-to guy for ESDs seeking county help to fund their operations. The question now facing Hobby and the county is how to address competing needs while ensuring all residents have access to high quality fire and EMS services.
With the support of Commissioners Court, Hobby is taking a broad approach, meeting with various stakeholders – including ESD commissioners and chiefs, representatives of the county's smaller cities, and ATCEMS and Austin officials – to try to determine how the county will address its growth issues. In May, Hobby got the nod from Commissioners to begin looking into a variety of models for providing countywide fire and EMS services. In addition to staying the course with ATCEMS as it is currently configured, the county is also exploring other service models, including whether it would be feasible to create a countywide fire department that would essentially consolidate the ESDs, and whether there might be other methods of providing EMS paramedic services to county residents – perhaps by further consolidating into a countywide fire-based EMS service. "Our residents deserve the most appropriate resources and response we can provide them, and our taxpayers deserve the due diligence necessary to make sure the cost of service is balanced and reasonable," Hobby wrote in a memo to Commissioners.
The suggestion that the county should look at other ways of delivering emergency services is not new. In 1998, county officials circulated a planning document that proposed just that: a countywide fire-based EMS service. For whatever reason, says Hobby, the idea never went anywhere. Now, he says, in light of the increased county service calls and the shrinking ESD budgets, the county must focus on its future: "here's the thing with the [ESDs], you're seeing that they're having fewer fires and more medical [calls] ... some of them are 75-80% medical" calls, he said. "You've got to now start paying attention to that and [ensure] that you're addressing that as the demand ... increases. But when you have lower funding [for the ESDs] and when you have resources that are limited ... there's got to be a give here. We've got to figure it out."
Not surprisingly, the fact that the county has renewed its interest in talking about alternate service-delivery models for EMS has caused consternation, most notably within the ATCEMS Employee Association. To union President Tony Marquardt, the notion of breaking apart the agency as currently configured is a bad idea, one that would lessen the quality of care for county residents.
Currently, ATCEMS is the region's largest agency employing paramedics – professionals with the training and certification to deliver advanced care, including the ability to administer cardiac drugs, for example, or to intubate a patient. (The county-run air ambulance, STAR Flight, which also answers EMS calls, employs nurses and a small number of paramedics.) Employees of the ESDs, and of AFD in the city, are trained not only as firefighters, but also as basic- or intermediate-level medical technicians. Because of their numbers, the ESD or AFD employees are more likely to get to a call first and are able to offer basic care until more advanced paramedic providers arrive. Because all of these providers – roughly 2,000 in total around the county – operate under protocols designed by Medical Director Hinchey and his team at the medical director's office (and every first responder and paramedic in Travis County works under Hinchey's medical license), residents of both county and city are offered the same quality of care regardless whether they're living in the Austonian or in Webberville. "[T]he reason [the current system] still works better than some of the alternatives ... is that we have a unified system," says Marquardt. "We have protocols and resources going to the same place."
Nevertheless, Hobby's determination to put all the pieces on the table and to figure out what will work best to build a complete picture of service for county residents has many people inside the ATCEMS universe nervous about its future. Does this mean the county wants to secede from the partnership? Hire its own paramedics? Contract for ambulance transport with a private company? Does it not appreciate the level of care the paramedics offer? Will jobs be lost?
Ultimately, Marquardt says that he's concerned that the county – perhaps under pressure from some of the ESDs – will pull away from ATCEMS in an attempt to save money in the short-term, while in the long-term crippling the possibility that patients in need of care will have effective access to those services. A fractured service, or two separate services, is not a good idea, he says: What's actually needed is to add more resources – additional ambulances and advanced medical care on top of the eight ambulances the county currently houses at various ESD fire stations.[page]
County officials have said repeatedly that they have no intention of fracturing the service. "I don't see the county wanting to do that," says retiring County Judge Sam Biscoe. At issue in large part, however, is how the system is paid for – and how Austin's EMS officials have previously responded to county concerns about service. For example, he says, at present the county still pays the EMS tab for residents of cities in the county that used to be small – like Lakeway and Pflugerville – but that have grown significantly, and should be paying for at least some of the services they receive. And since the vast majority of Travis County residents are also residents of the city of Austin, the county has the duty to look at ways to offset the burden of double taxation, he said.
Eckhardt, who sat on the Court's emergency services committee, said she believes that exploring the possibility of consolidating the 14 ESDs is an important step to strengthening a countywide approach to providing emergency services. Although they're independent taxing agencies that can't be compelled to surrender autonomy to the county for consolidation, Eckhardt says county and ESD officials have been working together for years to build a level of trust that might allow some level of consolidation to happen. Consolidation would also ensure that emergencies countywide are tended to by the very first responders available, regardless what slice of the county they're "assigned" to. That in turn could be enhanced by the advanced life-support care provided both by ATCEMS and STAR Flight.
At the time of this writing, only ESD 11 Chief Bailey has come out publicly in favor not only of consolidating the ESDs, but also of pulling out of ATCEMS and instead creating a countywide fire-based EMS service, which he says will save the county money. The county wouldn't have to hire inexperienced paramedics or even train firefighters as medics, he said, to offer the advanced-level EMS service. Instead, he says, the county could offer county jobs to current city employees. "My guess is that if I can pay you the same amount and you're not going to get your teeth kicked in [on a busy and tiring shift] Downtown, I'm thinking there'll be people who are interested," says Bailey. "So why wouldn't we go in that direction?"
There may be at least one reason that this isn't doable at present: To date, Hinchey has declined to allow under his license paramedics who would work exclusively out of the county stations. Clinically, the thinking is that advanced-level paramedic skills must be regularly honed to keep them sharp. As it stands, there are not enough advanced-level calls in small villages, cities, and unincorporated areas of the county to do that, Hinchey and others say.
To Eckhardt, that makes sense. "It's better to have a consolidated system in a high-volume area," as ATCEMS essentially operates its paramedics, concentrated in the city of Austin, she said. "That makes a lot of clinical sense." But the "downside of that, from a countywide fire perspective, is that if your [paramedic] system is designed specifically for an urbanized setting, and then you try to scale that countywide" – as Marquardt and others would like to see happen – "it's going to be extremely expensive."
That raises the question of whether city EMS officials have really been listening to what the county says it needs: the ability to respond quickly to emergencies with high-quality paramedic service. Bailey says those dual needs haven't always been heard; for example, there is just one ambulance stationed in his large district and it's right on the city-county line, and thus spends a good amount of time running calls in the city. That means that even when his crews are quick to a scene, patients in need of transport to a hospital are going to be waiting around a while – and that is a dicey situation, considering that the nature of an emergency is impossible to predict. He charges that ATCEMS has been more concerned about stationing ambulances where they can easily move into the city to cover calls – often leaving his ESD without coverage. If there were a countywide, fire-based EMS system, employees could be cross-trained and, importantly, there'd be no waiting for transport service in critical, time-sensitive emergencies. Marquardt agrees that the county for years has been asking ATCEMS to do more with fewer resources than it needs, indirectly putting patients at risk. "That's a pattern we've had with Travis County," he says. "Then we get increased response times and we have to run more and more, including from the city, to make up for the lack of resources in the county."
County officials, including Biscoe and Hobby, say these are valid concerns, and are among the reasons the county needs to determine exactly how many ambulances and paramedics it needs, how to best use STAR Flight, and exactly where its resources should be located. And after years when city and county essentially didn't communicate at all on these issues, this year the two governments are finally coming together in the EMS system's best example of intergovernmental cooperation to date.
The outcome, however, remains in doubt.
In order to best determine where resources are needed, not only in the county but throughout the ATCEMS system, Hobby and Rodriguez, along with ATCEMS Chief of Staff James Shamard, early this year formed a "Zone Group," which amassed statistics for every ambulance in every "zone" of the city and county and determined, to the granular level – down to every hour of every day of the week – where calls are happening, where resources are stationed, and how resources shift when a call comes in, all in an effort to figure out how response times and resource redundancy can work together to promote an optimal system. The project has resulted in reams of data – charts and maps and lists designed to reveal not only where resources are used, but where they may be needed in the future.
Both county and city officials are pleased with the group's accomplishments. "I've been with the city and EMS for about 17 years and I think ... the relationship and how we're working together and ... the product that we're creating is like nothing we've ever done before," Shamard told Commissioners in May. "I think we're really tackling the real issues, which is how we get the most appropriate service to the sickest patients [in] the appropriate time based on the financial constraints we have to work with."
The new cooperation between entities has also prompted officials to reconsider how the EMS budget is apportioned, and for the first time, in fiscal year 2014, the county will be paying into the system based on "a cost determination model," says Hobby – in other words, paying only for what it uses and not a simple percentage of the agency's entire budget, which last year was $55.6 million, with $12.5 million of that billed to the county.
The changes, Hobby said, have been a long time coming. Back when the county agreed to fund a percentage of the service, the thinking was that doing it that way would make the county "part of the budget, thinking that if we were part of the budget then we would be treated as part of a system. We never felt like that happened," he said. But with the work he and Rodriguez have been doing, "you're seeing the city and county working more closely together," he said. "For the first time – and I think they're delighted, as we're delighted – that we ... both know what the cost is on both sides."
While Rodriguez, Hobby, and Shamard seem pleased about the work at hand, Marquardt has remained skeptical. All spring – seemingly, at every public meeting where EMS issues are discussed – the union president expressed concerned about the county's motives, and warned that Hobby was endangering county residents by withholding promised funds that would immediately add paramedic resources to the county – including a new ambulance stationed in East Travis County.
The roughly $1.5 million to provide the ambulance (located within ESD 4, which has been broken by Austin's annexation into disconnected islands that ring the city from east to west along its northern border) were included in the county's FY 13 budget, but were never actually allocated until this summer. (The new ambulance finally came into service July 1.) Throughout the spring, Marquardt charged that Hobby was purposely withholding the funds, undermining ATCEMS cohesion – and offering another sign that the county perhaps wants to secede. "They're rebelling against putting any more ATCEMS units" in the county, he said.
Hobby has maintained that the decision to delay the ambulance was related directly to the ongoing zone work; Marquardt says Hobby is simply using that as a front for another agenda. (Frustrated with Marquardt's dogged, public harping on the issue, Hobby momentarily lost his cool during the May Commissioners meeting: "Tony, I can explain it to you, but I can't understand it for you," he said.)
The uneasiness about the future of the ATCEMS system is not surprising. How the city and county are cooperating – and whether they'll continue to do so going forward, into the next four decades of local EMS service – is an overarching issue that in many ways overshadows a world of small hurts and worries below. Does ATCEMS have a good recruiting system? Does it take too long to clear paramedics for duty, leaving a string of ever-growing vacancies? (As of June 1, the department reported 40 total vacancies out of a total staff of 457.) Does focusing on the relatively small proportion of cardiac arrests, no matter how critical, really provide meaningful data about the health of the system? Does the switch to staffing ambulances with one paramedic and one intermediate or basic EMT (from two paramedic staffing) place patients in danger? Is Rodriguez a strong enough leader to get the agency through this protracted rough patch?
On this last point, city Public Safety Commissioner Mike Levy, who has long been passionate about local EMS, does not mince words: "Culture, vision, and values start at the top, and trickle down," he wrote in an email. "Rodriguez is rarely seen outside his office. ... Just a lump. Which would be OK, but we're talking about the degree to which the program can make a difference in people's lives." In particular, Levy has been vocally opposed to the switch to paramedic/EMT staffing, which he believes puts patients in jeopardy and is designed to hide the agency's inability to recruit trained paramedics to an agency in peril.
Deputy City Manager McDonald strongly disagrees. Rodriguez has had a "difficult set of circumstances to manage" and because he has to answer not only to the city but also has to be responsive to the county, not every challenge the agency faces "is in his purview." And he disagrees with the concerns Levy expresses about the ambulance staffing – paramedic/EMT staffing has been in place for years in agencies across the country. At the end of the day, McDonald says, the city remains committed to building on what ATCEMS has to create a smart and cohesive regional system.
To Hinchey, the stress over the staffing change, for example, is natural for those involved in a system that is changing and will continue to change over the next few years – as a result not only of internal pressures, but also in response to the fast-changing world of health care delivery of which EMS is a part. While responding to emergencies will always be at the core of any EMS system, health care reform that places a premium on keeping people out of hospitals and healthy in their communities is necessarily reshaping the industry.
That understanding is driving a lot of innovation at ATCEMS, says Hinchey. He started a citywide CPR instruction program that aims to educate at least 500,000 residents in compression-only CPR in order to help boost rates of bystander CPR – and thus increase cardiac survival rates. The system has instituted a nationally recognized community paramedicine program that seeks to reduce reliance on 911 and EMS by individuals who use emergency rooms as their source of health care – not uncommon in Texas, where fully 25% of the population lacks health insurance. The program connects residents in need with paramedics who can help them to access appropriate community services.
ATCEMS is evolving, not only in how it handles emergencies, but also to how it fits into the broader system of public health. In short, says Hinchey, although EMS systems have been around for some 40 years now, they're still relatively young agencies that for the first time are being asked to re-evaluate how they do what they do and what that will look like in the future. "I think it is a difficult time for changes in the county, changes in the city; there's a lot of pressure in different places and it's basically about change – this is a system in evolution, adapting to a changing world," he said. "My goal is that Austin's is a system that changes and evolves and meets the needs of the community in a better way than we've done in the past," he continued. "But we've got to be OK with smashing the good china to move on."
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