From the Archive: Welcome to Chaos

Crisis mentality at EMS

From the Archive: Welcome to Chaos

This feature was originally published on Nov. 12, 1993.

Conversation stops as a shrill siren cry starts howling from the bank of walkie-talkies on the shelf, and the teletype on the desk nearby furiously spits out a description of our call. Paramedic Jack Hart holsters his walkie-talkie and is already out the door. His partner Eric Stauffacher leans over the machine a moment, scans the emerging information, and quickly reaches for the door. Head-on collision at Burleson and Oltorf, he announces grimly as he strides toward the waiting ambulance. Within seconds, Medic 3 emerges from the darkened parking garage located beneath the helipad at Brackenridge Hospital and lurches roughly onto the street as it lights up like a Ferris wheel. Turning on the siren, Hart looks back through the small window that separates the cab from the vehicle's mobile emergency room, and grins. "We go in quick, buddy," he says, "tag and bag 'em." There's just enough light to see the adrenaline glint in his eyes.

Traffic is light for 10pm on a Friday evening, but when an ambulance comes screaming out of the night at you – lights flashing, sirens blaring and honking – most motorists either scatter roughshod all over the roadway or freeze like animals caught in oncoming headlights. Racing high-speed through city streets, the ambulance zig-zags wildly to avoid hitting these confused driers. When we barrel straight down the middle of a busy two-way turn lane, a dangerous game of chicken ensues as a large truck can't decide whether to move or stay put. Fortunately, it scoots out of the way at the last possible moment. "Shit, Jack, I hate it when you do that," groans Stauffacher from the passenger seat. On hills, the accelerator hits the floorboard and we fly airborne over the crest like Steve McQueen in Bullitt, landing with a jolt several yards from where we left ground. It's a harrowing, exhilarating ride that leaves hands clawing at armrests and hearts pounding. Only the freeway presents no obstacles as traffic parts swiftly and falls well behind the emergency vehicle. The entire trip lasts no longer than five minutes.

When we arrive on-scene, a half-dozen firemen – always the first respondents to potentially life-threatening calls – are already assisting the accident victims, while a small squad of policemen is trying to create order out of mayhem. A blue truck has mistakenly entered a one-way makeshift pylon lane on an under-construction roadway and rammed a small, white Buick sedan, buckling the front ends of both vehicles. On the sidewalk a few feet from the accident sits the truck driver, who is holding a handkerchief over his broken, bleeding nose. Though the front of the young man's shirt is covered with blood, he appears unhurt. As Hart will say later, "When they're sitting up, have good color, pink cheeks, and they're tracking you with their eyes, they're all right."

Not three feet away, however, lie the two women from the Buick in obvious shock and pain. Hart and Stauffacher quickly unload several bags of equipment from the ambulance and are briefed on the situation by a couple of firefighters. Preliminary indications are that neither woman is seriously injured (both driver and passenger side airbags inflated on impact), though in cases such as these, serious spinal injury isn't always readily apparent. Each paramedic attends to one of the women and after introducing themselves, they begin a battery of questions and procedures to ascertain the extent of their victim's injuries: What happened? Where does it hurt? Are you having trouble breathing? Are you nauseated? Dizzy? What drugs are you allergic to? – all this as they take the women's pulses, heart rates, and feel them from head to toe to see if anything is broken. There's a very real urgency to the situation, yet both men radiate a centering composure, tempered with a friendly, jocular demeanor, that goes a long way toward diffusing the fear that is so apparent in both women. They work quickly, without hesitation or doubt, absolutely sure of their ability to neutralize the worst situations. Luckily, this isn't one of those instances and before long, both women have been immobilized on wooden spin supports and loaded into the other ambulances now at the site. Only a small group of gawkers, who have crowded in like vultures to get a better look – smiling and laughing inexplicably in the face of this intense drama – seem sorry to see the ambulances depart for the hospital.

We arrive back at the Medic 3 station an hour later and no sooner have we walked through the door than the familiar siren wail of another call turns the two paramedics around and sends them back to their ambulance. I look at my watch. It's now 11pm and Hart and Stauffacher have been on the job 14 of their shift's 24 hours. This will be call number eight for them. They look tired and drawn. We all look pretty worn out, but for me a 14-hour shift is enough and I can go home. For them, the shift is barely half over. I stand in the garage and watch the ambulance bounce onto the road, imagining their cowboy cockiness and locker-room banter, and all I can think about is a phrase one of their shift commanders used on one of my ride-alongs:

Welcome to chaos; it's been a busy night.

A Tiered System

Medic 3 is one of Austin's 16 Emergency Medical Services (EMS) ambulances. Independent of the city's Fire and Police departments, EMS is Austin's third public safety service, and like the other 22 departments within the city structure, it comes under the direction of the city manager. Back in the Fifties, ambulance service had been a competitive business, with several mortuary companies racing all over town, trying to get to the scene first for "load and go" transport; no on-scene treatment, just get 'em to the hospital and step on it. Later, the city established a zone system where each mortuary was responsible for ambulance service in a certain area. It wasn't until 1967 that the city granted one private company, Austin Ambulance Service, exclusive franchise rights for providing emergency and non-emergency transfer service throughout the city. Eight years later, City Manager Dan Davidson recommended a somewhat radical and progressive idea: that Austin establish its own EMS department staffed by professionally trained city employees. When Austin EMS began operations on January 1, 1976, this was only the third major city in the country to have an Emergency Medical Services department incorporated into its municipal structure, yet operating independent of fire and police.

Today, Austin EMS has a total of 174 employees, a fleet of 22 vehicles, and an overall operating budget of $7.8 million. Taxpayer money makes up 70% of that budget, with the remainder coming from patient billing. The department provides service for nearly 600,000 people throughout Travis County, covering 1,044 square miles. Last year alone, EMS got 65,135 requests for help, dispatched ambulances on 48,696 of those calls, and made hospital transports on approximately half that number. Using a tiered response mechanism for these calls, Austin EMS provides two different levels of service. If an EMS Communications dispatcher decides a call is not life-threatening, an Aid Unit is dispatched to the scene. Staffed with two state-certified Emergency Medical Technicians (EMTs), Aid Units respond to all calls involving illness, broken bones, or lacerations, and provide "Basic Life Support" (BLS). When a call is determined as life-threatening, Austin EMS sends a Medic Unit to provide "Advanced Life Support" (ALS). These units are staffed with two state-certified paramedics, who are trained to deal with all cases of cardiac arrest and severe trauma. Currently, the system operates with four full-time Medic Units, one medivac helicopter (see box), and one "peak demand unit," which only operates 12-hour shifts of half-time. Additionally, there are eight full-time Aid Units, one peak demand unit and two Utility Units that are capable of both ALS and BLS calls. The higher number of Aid Units reflects the fact that 65% of all incoming calls are not life-threatening.

In 1989, when Dave Wuertz became director of Austin EMS, it was decided that the system would adopt a compliance standard for this tiered response mechanism. On 90% of all ALS calls, a Medic Unit would be required on-scene within 8 minutes of the initial request for help. For BLS calls, an Aid Unit would need to arrive within 10 minutes 90% of the time. Both standards were based on medical studies that show a high survival rate for cardiac arrest victims receiving aid within the ALS 8-minute window of time. And though no federal compliance standards currently exist, many EMS systems around the country adhere to these standards. Unfortunately, Austin EMS isn't meeting either of those self-applied compliance standards, and this is at the center of a whole storm of problems brewing within the system.

the Increasing Load

Ask anyone in Austin EMS – supervisor or paramedic – why the city hasn't met its own compliance standard and the answer echoes back the same every time: too many calls and not enough money. In the past five years, call volume has increased 42.8%, or about 8% annually, which according to the Journal of Emergency Medical Services, (JEMS) a national publication that tracks EMS systems around the country, is about 2-3% higher than the national average. In that same time, the EMS budget has increased 36%, a higher rate of increase than any other city department. This year's budget hike came in at $828,970, pushing the department's 1993-94 operating fund to nearly $8.7 million. With the added funds, EMS will augment the system with 19 new employees, convert one peak demand Medic Unit from half-time to full-time, and give a 5% pay raise to EMTs and a 7.2% increase to Senior EMTs and paramedics. The citywide increase for all other municipal employees was 3%. Even with this sizable budget increase, and the corresponding additions to the department, the system is still painfully underfunded, according to Wuertz.

"Have we gotten everything we wanted? No. Have we gotten everything we needed. No," says Wuertz calmly. "If we didn't do anything to the system, kept it the way it is, it would still take an additional four to six ambulances to reach our compliance goals. That's a 4.5 million hickey to the city. Sure, we can tinker with the current system and maybe squeeze another 2-3% of compliance out of it, but the system is stretched as tight as it can be stretched." Wuertz points to the department's unmet needs as outlined in the 1993-94 budget proposal. Though it doesn't specifically call for an additional four to six ambulances, the proposal does outline a need for more field and office personnel, training, and, perhaps most importantly, two reserve ambulances. At the present time, there is one reserve ambulance for every four units (this does not include two ambulances that are still being equipped for service), whereas the industry standard is closer to one reserve for every two ambulances. And though more ambulances are critical to meeting a rising call volume, staffing is the bigger issue. In a five-year departmental forecast delivered to City Manager Camille Barnett back in March, Wuertz wrote:

"Staffing shortages make it difficult for employees to obtain vacation leave. Presently, employees accrue more vacation days than the Department can allow them to use without exceeding overtime funding to provide coverage. The lack of available opportunities to be away from the workplace contributes to the already high stress levels of the employees.

"The twenty-four hour workday for most personnel has become a problem that requires creative solutions involving some additional staff and much thoughtful planning. The local medical community has begun voicing concerns about the ability of paramedics and EMTs to make the best decisions when they potentially have gone without sleep for over 24 hours. The Department plans to evaluate the potential of phasing in shorter shifts in the busiest stations. Any shift schedule other than the present one will require additional FTEs [Full Time Equivalents]."

War Zone Stress

When Austin EMS started up in 1976, a provision was also made to establish an EMS Quality Assurance Team (QAT), which would be made up of community volunteers, local physicians, and EMS field personnel and management. The board would be a formal review committee in charge of evaluating the department's performance and reporting its findings and recommendations to the City Council. Michael Levy, publisher of Texas Monthly magazine, has been a member of QAT since the beginning, and a vocal one. For the past several years he's led a crusade to abolish the 24-hour shift that most EMS paramedics and EMTs work on. He claims that a rising call volume, combined with personnel shortage, has made the 24-hour shift unfeasible because sleep deprivation and war zone stress are impacting the quality of patient care. In a letter to Mayor Bruce Todd, Levy cited a 1990 incident in Dallas where an exhausted paramedic mistakenly injected a diabetic with Lidocane, a heart medication, instead of the dextrose the patient required. The patient died, and Levy says it's only a matter of time before that happens here in Austin.

"It's bound to happen, and that's not something that either the City of Austin or EMS can afford from a liability standpoint," says Levy vehemently. "The troops are tired, call volume is through the roof, and response times are up. They're not getting there as fast as they used to, and when they do get there, they're tired. The situation has been bad for a while and no one is doing anything. Our city manager has a very high comfort level with mediocrity. I'm turning up the heat." Brackenridge Emergency Medicine Chief Patrick Crocker is also a member of QAT and works regularly with EMS personnel as they bring patients into the hospital's emergency room (ER). He agrees with Levy that 24-hour shifts are a problem. "I think very busy units, particularly ALS Units, shouldn't work 24-hour shifts," says Crocker. "If you're busy and you're up for 24 hours, what you're providing the last half of the shift is not high quality care." In fact, he says, some states have made it illegal for EMS workers to work as long as 24 hours without sleep. At Brackenridge, ER physicians are limited to 10-hour shifts and even that is "pushing the envelope." Upping staff levels may alleviate the problem, but is it really a question of a personnel shortage or is the notion of medical personnel working 24-hour shifts intrinsically flawed? Crocker isn't sure, but adds that QAT will be studying the question over the next three years – the same time it's given EMS to start meeting the 90% compliance standard.

Still, the biggest stumbling block to eliminating the 24-hour shift may be the paramedics and EMTs themselves. Crocker says that most EMS field personnel like the long shifts because it gives them more days off. 24 hours on, 48 off. The 72-hour cycle is endorsed by all but a few EMS field personnel. But, insists Crocker, that doesn't mean it's good for the patient, system, or worker. "We went through this period where we treated three or four otherwise healthy paramedics for acute and relatively severe hyper-tension," he says. "And when I asked the EMS personnel society to try and get more info on how many EMS personnel had hyper-tension, suffered anxiety, and were under the care of a physician, they came back and said [personnel] didn't want to participate in the study."

Geoff Cady, research director at JEMS' Emergency Care Information Center, says that 80% of EMS systems across the country still use a 24-on/48-off shift system, but that seems to be changing for "high performance" systems – those which use the 8-minute ALS/10-minute BLS compliance standard. Those busier systems simply can't afford the grind because it's too hard on the personnel, and as one of Cady's co-workers says, the 24-hour shift seems to be "going the way of the horse and buggy."

One Austin EMT, Ken Saunders, confirms that most of his co-workers like the 24-hour shift. It's the mandatory overtime that's killing them – the two overtime shifts each employee must work every month, Saunders says. Every day, shift supervisors determine who will "volunteer" for two empty slots by looking at a cumulative list with the total number of overtime hours each EMS employee has put in over the last year. Low numbers normally get volunteered one hour before their current shift is up, forcing them to work continuously for 48 hours (by law EMS personnel can only work 52 hours straight). After an extended shift, instead of the normal 48 hours off, paramedics and EMTs only get 24 hours off.

"When you're doing it, making that call, the adrenaline's running and endorphins are being released so you get pumped for the call," says Saunders, "but that only carries you to a certain point. I've worked a 24 on Friday, which is traditionally a busy shift, and then was put in the position where I had no choice but to work a 24 on Saturday. So I'm working 48 hours straight and making like 30-35 calls. I mean, that's ridiculous."

Like many problems in EMS, Wuertz says management is looking at the problem: "We're committed to working with staff to identify the most reasonable schedule we can mutually agree on."

The Utility Experiment

One possible way to ease the strain on the EMS system and better meet city compliance standards is through the use of Utility Units. Whereas Medic Units handle all life-threatening emergencies and Aid Units only non life-threatening situations, Utility Units are capable of handling both types of calls. With this flexibility, it was thought that Utility Units could ease the strain on Medic Units in busy sections of the city – a strain that paramedic Stauffacher says comes as much from call volume as it does from being sent on calls that are normally meant for Aid Units. "It's frustrating because we're not being utilized the way we're supposed," says Stauffacher. "When you save someone's life, actually bring them back from the dead, it's the best feeling in the world. But often we're running 15-20 calls a day about sore throats, cold hands. 50% of our calls are bullshit." Like Stauffacher, several Medic Unit paramedics interviewed for this story confirmed that fielding Aid Unit calls was probably the most stressful part of their jobs.

Last May, EMS temporarily converted one Aid and two Medic units into Utility units to go along with the already existing Utility Unit stationed out in the county. The experiment was given 180 days to see whether these three units actually alleviated the heavy call load in the areas where they were located. Yet some EMS field personnel were unhappy with the whole concept from the beginning. Paramedic Brian Anderson, who was switched over from a Medic Unit to one of the experimental Utility Units, explains. "Sure it gives you flexibility, but I'm not sure it's the wisest use of your resources," he explains. "You have so many BLS calls that don't require even an ambulance – much less an ALS-equipped ambulance – and you're sending a vehicle with a [heart] monitor that costs $10,000, plus all the drugs, and other equipment out to a scratched finger. Like this afternoon they sent us to a lady that wanted us to make her a cup of coffee. So here you're sending a Medic Unit with all this equipment with all the expense of keeping it up."

There's also the case where paramedics trained to deal with life-threatening emergencies on a daily basis are making more and more BLS calls on the Utility Units and aren't able to practice their ALS skills. It's the athlete on the bench syndrome. Will they be as sharp in the heat of the game if they're out of practice? Director of Training and Quality Management Bill Coll says no. "I had a paramedic tell me a story one day, where he was on a utility unity, they [responded to] a collision and he turned to his partner and said, 'You're going to be the incident command on this call, because I haven't practiced my skills in weeks.' He was starved because he hadn't done an ALS call in weeks. That's one of the reasons the city went to the tiered system back in 1980."

On October 15, an EMS evaluation team voted to take two of the experimental units off-line, leaving only one Utility Unit to go with the already existing county unit. "The general feeling among the staff was that it wasn't working well," says Coll.

County Compliance

One of EMS' largest problem areas encompasses nearly 800 square miles of Travis County which lies outside the city limits. While 85% of the county's 600,000 people live within the city's 225 square miles, Austin EMS is also responsible for the rest of Travis County – all 1,012 miles of it. Through an inter-local agreement with the city, Travis County pays for its emergency medical services and also supplies the STAR Flight helicopter to bear the brunt of ALS calls outside the city. In addition, the county First Responder program enlists the help of 250 volunteers who are certified by the Texas Department of Health to serves as an informal BLS network.

In 1992, Austin EMS responded to 5,150 requests for help outside the city limits. ALS response time for these calls averaged 21 minutes 90% of the time, while BLS response time hovered around 23 minutes. Because the county's only compliance standard is that an ambulance be dispatched within one minute of the initial call, Austin EMS isn't required on-scene within any specific amount of time – could be 21 minutes or 21 hours. But that's only part of the problem. While the average ALS/BLS county response time falls between 21-23 minutes, it can take as long as 45 minutes to reach some outlying regions of the county. Combined with 30 minutes of on-scene time and another 45-60 minutes to Brackenridge, a county call can take as long as three hours in some cases. That's three hours that an Aid or Medic Unit isn't available to cover its usual turf in the city, forcing other units to compensate for the gap in the system and straining the ambulance network even further. "The county's essentially a dark hole which absorbs our resources," says Gordon Berg, an EMS Shift Commander. "And until you can honestly and objectively evaluate the role the county plays relative to the whole operation, the lack of compliance standards is going to be a problem. They have to meet the same standards that we have, otherwise they can't be part of the system – yet they are. That's part of our schizophrenic situation right now."

Debbie Rich, director of Travis County EMS, a largely administrative body with a staff of 13 and a $1.3 million budget, says the county tries to maintain a 10-minute compliance standard for their First Responders corps, but it's difficult to impose any standards on volunteers. Still, she'd like to see the county implement the same compliance standards the city uses. That, however, would mean putting more ambulances out in the county, and at an estimated cost of $350-$400,000 per ambulance – $80,000 for the actual vehicle and the rest to equip and staff it –that doesn't seem likely to happen. Therefore, things will most likely stay the same until the inter-local agreement comes up for renewal in 1995. "The heaviest burden on the system is within the city," says Rich. "That's where the bulk of the calls are. Now to comply with national [compliance] standards, where they factor in runs into the county, yes, it slows them down. If you look at response times in the city, they're pretty close. But does that mean it's acceptable for response times out in the county to be as long as 30-40 minutes? That's something the Commissioners Court has to make a decision on, and since they listen to the voters and taxpayers, people in the county have to decide what they want and what they're willing to pay for."

According to the EMS Employees Association, the county isn't even willing to pay for current EMS services, let alone for any future increases. Despite an 11% increase in the county's EMS funding, the Employees Association's 1992-93 Budget Issues balance sheet shows the city subsidizing county EMS care to the tune of $595,798. Their figures show emergency medical services in Travis County costing $870,975, whereas county reimbursement was only $275,177. When asked whether the county was pulling its financial weight in funding EMS operations, Travis County Judge Bill Aleshire said the city had not shown him anything to indicate otherwise. "There's been pressure in the last couple of years to greatly jack up the amount of money paid to the city," says Aleshire, "but we don't have any evidence that the county has not paid its way in the overall city EMS budget – though if that is the case, we're willing to sit down with the city and work something out."

Consolidation Conundrum

So far, city and county have not been able to agree on a myriad of EMS issues. In 1991, at the behest of Mayor Bruce Todd and the County Commissioners Court, the Action for Metropolitan Government Committee (AMEGO) was commissioned to identify various functions of city government that could be consolidated. The two-page recommendation for EMS was simple; consolidate county and city services under one administration within the City of Austin and have the city's First Responder volunteers take a more formal and active role in the delivery of EMS care. Though the overall AMEGO report was criticized (and eventually all but dismissed) for its superficial nature, its recommendations for the consolidation of city and county EMS services prompted both the Austin City Council and the Travis County Commissioners Court to order a second, more in-depth study of the system. The findings of this second report, delivered in the fall of 1992 by Project Manager Bill Coll and his assistant Gordon Berg, were familiar – and this time there was an added twist: consolidate EMS within 36 months under a separate, regional government entity with EMS taxing authority.

With a separate taxing authority, EMS hoped to become like Capital Metro: a semi-autonomous, self-governing body, whose own budget is generated by a portion of the city's sales tax going directly to the city transit service. Once again, the report recommended that First Responder volunteers take up more of the slack in the county, primarily by uniting them under the aegis of the city's Medical Director. Empowering the county volunteers with the same arrangement under which EMS paramedics and EMTs practice field medicine would greatly increase their ability to provide more advanced medical care. In the same report, the Travis County Auditor also came out in favor of consolidation and having the First Responder volunteers placed under medical direction.

As with the 24-hour shift, the only problem with the plan was that the county's First Responders didn't like it. They questioned EMS' desire to run a county-wide system from a city department. Shouldn't a county body run a county-wide system? "They weren't comfortable with that," says County EMS director Rich. "A lot has to do with not having the specifics as to exactly how it will take place and what it will entail from the volunteer. How much more training time? How much more commitment? People out there are already giving a tremendous amount of time; they use their own vehicles, buy their own gas, and if they run short of supplies and can't get here to get more, they buy them themselves."

"They take care of themselves and the small communities around them. When they need more money than what is provided to them through the county or the fire district, they still have their bakes sales, barbecues, and fundraisers. It's a small community effort and it's very different from how it operates in city government." Project coordinator Coll says county volunteers were ultimately afraid that they would be eliminated from the process, that consolidation would absorb them into a system they already distrusted. They'd have to answer to the city, and as Judge Aleshire put it, the quickest way to lose volunteers is to treat them like they're paid.

This was never the city's intention, insists Coll. After all, volunteers are a free resource, and when you consider that each EMS station costs in the neighborhood of half a million dollars, why not take advantage of this untapped resource? Besides, giving Austin EMS its own separate taxing authority would give the department a certain autonomy from the city. But volunteers didn't see things this way, so they raised a cry to the champion of their cause, Judge Aleshire.

Aleshire responded by telling the city council that housing a county-wide EMS system in the city would alienate most of the small communities in the county, particularly because there would be no mechanism for people to hold the City of Austin accountable for service. That wouldn't be a problem if that responsibility were placed at the county level, either at the County Commissioners Court or with a county-wide EMS district that had an elected board, claimed Aleshire. "What we got back from the city," he says, "was that some council members and city leaders felt that EMS was one of the things that made city government look good, and they didn't want to see it go off the city's books. ... Therefore no further consideration was going to be given to any further consolidation that wasn't hosted by the Austin city government. As far as I'm concerned, that discussion is over."

Casey Ping, an EMT stationed at an Aid Unit in the county, is frustrated that consolidation efforts have failed. "What's holding us back," posits Ping, "is that you've got two kids fighting over who gets control of their little sister. It's just ludicrous that you've got two entities saying: 'We should have control because we're county government.' 'Well, no, we should have control because we're city government.' You know, they just need to put their petty garbage aside and come up with a system that works – whether it's the county or the city that's going to have overall responsibility." Ping's Shift Commander and Coll's project assistant, Gordon Berg, says the government with the most resources should be the one to oversee a consolidated EMS system. That government is the City of Austin. "The city is far more diversified in its ability to raise funds and set certain ordinances," says Berg. "The county doesn't have any of that; it's basically a toothless animal that is not the most effective entity."

Although both county and city EMS directors Rich and Wuertz say they're working on getting the county's First Responder volunteers under medical direction, they concede that consolidation is dead in the water.

Putting Out Morale Fires

The failed Utility Unit experiment and botched attempts at county-wide EMS consolidation, according to many field personnel, are the best indications that management isn't doing enough to ease the strain on an overburdened system. In a city that is currently experiencing another mini-boom, even while the country's general population is growing older and more and more Americans are without health insurance – not to mention increasing urban violence and the spread of AIDS – what plans are being made to meet future demands on EMS? With a call volume of 50,000 calls and only 24,000 hospital transports, any paramedic or EMT will tell you that our local populace is using EMS service as a kind of roving social clinic. Will the EMS of the future include non-transport clinical care?

"You have to be paying attention to trends and directions," says Berg, "and you have to be looking at tactical plans to anticipate changes in the demographics and the effects those have within the city. Unfortunately, we are a truly reactive organization, and in terms of management style, that's very inefficient. We are constantly focused on the fires as opposed to responding with anticipation and with measured responses." EMT Ken Saunders is in total agreement. "The executive management, in my opinion, lacks vision," states Saunders firmly. "They lack the ability to take risks. They lack the skills necessary from a leadership perspective to do any specific, strategic planning or even have the foresight to realize that strategic planning is just a part of doing business."

Saunders and Berg cite two employee surveys as proof that the most EMS field personnel think management is inept. The first, an internal audit conducted in 1991, reveals that in categories such as "innovation," "solution oriented," and "open-mindedness," EMS leadership scored in the neutral zone between agree and disagree, while "lead by example," "supportive" and "communicative" were met with disagree. The second poll, a 1993 Austin Quality survey, revealed an overall employee dissatisfaction with management and again ranked management's responsiveness to problems in the neutral to unfavorable category. The most telling survey results, however, were in the "Examples of Responses" section. Under "Improve Management Practices," the following comments were taken from EMS employee questionnaires:

- To have our service be led by common sense and care for patient & employees, not by politics or fear. Have more real leadership.

- For the manager to look at his job as a career and not a stepping stone to go other places. Experienced personnel save lives! People die as a result of inexperience!

- Get rid of managerial "fat" that is slowing the department down as a whole. They have lost touch with what it is like to do the job. If they would listen to the folks who do the job and make decisions based on that fact, this department would be the leader in pre-hospital care it once was before.

- Blow up the Ivory Tower. The upper management ... is completely out of touch. We need direction, focus, and planning! The current management can not provide this.

Palmer Buck, president of the EMS Employees Association, confirms that departmental morale is low and says it's been declining steadily since Austin won the "EMS System of the Year" award in 1984, given by the National Association of EMTs. Buck contends that stagnation occurred after reaching the industry pinnacle. And the situation worsened with the late Eighties' economic bust. Suddenly raises stopped, benefits declined, training fell by the wayside, and budget dollars strained to keep ambulances on the street. When people started leaving for other EMS systems, morale hit an all-time low.

"Ten years ago we were growing and on the cutting edge of our advanced care," says Buck. "Our paramedics were able to do things in the field that were unheard of anywhere else. It was a real exciting time and we were going from a 'mom and pop' organization to one where administrators in other cities were learning from us. Since the bust, people feel that management has not adequately represented the department's problems to city managers – like management is afraid to admit we're in trouble for fear of making us look bad." Consequently, resources are scarce, wages are still low – especially compared to fire department pay scales – and EMS field personnel fear management.

Even Betty Till at the Journal of Emergency Medical Services, who taught at Austin Community College from 1980-86 in one of the country's first Associate Degree programs in Paramedic Technology, has seen this decline in morale. "Back in the early Eighties, city managers were real visionaries," recalls Till. "They had made a commitment to hiring strong leaders with dynamic personalities and that's what propelled EMS. This whole deal that is going on now has to do with leadership. The lack of it now is what is really affecting morale." But just as quickly as Till criticizes management, Cady points out that it doesn't seem to be affecting the department's performance, as Austin EMS still ranks in the top 25% of EMS systems around the country, based purely on the department's self-reported response times. Cady also reports that while Austin EMS has a dispatch-to-transport ratio of less than 50%, the national average hovers near 75%. In other words, most EMS runs are for situations which aren't really emergencies. Moreover, Cady says, figures show that local field personnel may not be as over-burdened as they claim. "When you divide 50,000 calls by 16 units," calculates Cady, "that means your units are busy 32% of the time, and that's pretty reasonable." As for the pay scale, Cady says Austin EMS is about on par with the rest of the central United States. In fact with overtime, Austin EMS field personnel are probably paid a little higher.

District Commander Pera says there's lots of data to scatter around, but it still comes down to management being out of touch with day-to-day activities in the field. The buck stops with Dave Wuertz, says Pera.

"I would be surprised – more than surprised – if anyone really thought my style of personnel leadership was responsible for some of the problems Austin EMS has," says Wuertz. "I don't see myself as feared. I see myself as open to anything. I think management in this organization has tended to be too reactive over the years and we haven't been very good at communicating. That's certainly something I own and something that every manager in the department owns, but American companies are famous for being top-down organizations. We're a paramilitary organization that needs to re-tool and re-engineer the way we go about doing our business and we're in the process of doing it. But it's not easy and it's not painless. Self-study and self-criticism are not always pleasant, but we have a commitment to change.

"I just hope that this story is not about some of the struggles that various personalities in the organization have had, but that this is a system that is doing a fabulous job medically under some very trying times."

Sidebar: Taking Flight

Under an inter-local agreement, Travis County supplies two Shock Trauma Air Rescue (STAR) helicopters to the City of Austin in order to facilitate the quick delivery of emergency medical services outside the city. STAR Flight helicopters serve as the county's primary Medic Units. Austin EMS supplies a flight paramedic and coordinates all dispatching efforts, while the county provides the helicopters, pilots and all required maintenance. A third partner, Brackenridge Hospital, houses the helicopters, the crew's flight quarters, and provides a field nurse as well as all necessary medical equipment. Together these three entities share STAR Flight's administrative duties, and all three concede this is probably two partners too many.

"Triumvirates are hard to work," says Dave Wuertz, Director of Austin EMS. "Any time you have three entities with three different sets of personnel issues and at times, competing missions, it gets tough." Like his two managerial counterparts – Travis County EMS Director Debbie Rich and Brackenridge Emergency Medicine Chief Dr. Patrick Crocker – Wuertz is hesitant to criticize STAR Flight's current mode of management, but clearly believes the system would be better served under one roof, not three. The same conclusion was reached by the Action For Metropolitan Government Committee (AMEGO) in 1991 and again last year in the City of Austin/Travis County Consolidation of EMS report. In last year's report, the three-way management arrangement was labeled "cumbersome," and it was recommended that Austin EMS take sole leadership of the program. Later in the same report, however, Travis County Auditor Susan Spitaro advocated for the same thing for the county.

Disagreements over who should manage STAR Flight aside, all parties agree that the helicopters are overused. The original forecast for STAR Flight, when the system was brought on-line in 1985, was that the helicopter would make between 100-200 flights a year. In contrast, fiscal year 92-93 saw STAR Flight make 1,210 calls. Part of the problem, says Wuertz, is that the helicopters are working too many injuries that don't require an Advanced Life Support (ALS) response – calls that are often canceled after a county First Responder volunteer arrives on-scene and determines that STAR Flight is not needed. Out of the 1,210 calls made by STAR Flight last year, only 812 patients were actually transported. Wuertz's department is working to identify the calls on which STAR Flight response can be delayed.

Vociferous EMS Quality Assurance Team member Michael Levy has already identified those calls: all calls outside Travis County. STAR Flight's stated mission is to service Travis County, yet the helicopters service a much larger, ten-county area of the Austin region. Though 812 patients were transported by STAR Flight last year, 250 of those were from outside Travis County. Levy contends that Brackenridge Hospital's role as trauma center for Central Texas is at odds with STAR Flight's county mission, because it forces the helicopter to make too many out-of-county calls and inter-hospital transports – all at the expense of Travis County residents who pay for the system form their property taxes. Indeed, Austin EMS has identified at least 193 in-county calls that were missed last year because STAR Flight was already busy. Though it is hard to calculate how many of these in-county calls were missed because STAR Flight was out-of-county on a Brackenridge mission, Levy has at least one example where that was the case. In a letter to Crocker last July, Levy cited an instance where a CPR patient in South Travis County died after a Medic Unit ambulance took 20 minutes to reach him, because STAR Flight was making an inter-hospital transfer for Brackenridge. Crocker, though, says this is the exception, not the rule.

"The number of cases where it was documented that [STAR Flight] was unable to do an in-county call because they were on an out-of-county call is relatively small," he says. "If anyone is trying to imply that Brackenridge is the great beneficiary of these out-of-county calls, I think they're mistaken. We're going out of an obligation that is felt to the people of Central Texas who have no other option when they suffer a critical injury." Debbie Rich concedes that the county funds the transport for Brackenridge's trauma center, while County Judge Bill Aleshire says that the surrounding counties should pay for whatever helicopter service they receive. Once fees are negotiated, and STAR Flight's mission is revised to include surrounding counties, this will mean even more calls to an already overburdened resource.

Even aside from financial resources, managerial control remains problematic. There are no current plans to leave STAR Flight leadership to one entity. "We're all stakeholders in this," says Wuertz, "and because we all have certain needs in the system, I think things will work okay in the immediate future." – R.H.

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