High Stress at EMS

Austin-Travis County Emergency Medical Services has a rep as one of the best services in the country. But after years of structural problems – highlighted by recent suicides – its own personnel might call it the worst.

High Stress at EMS
Illustration by Jason Stout

On Jan. 13, three weeks after making a New Year's resolution to "be done with this place," Austin-Travis County Emergency Medical Services paramedic Ryan Burger took a Glock 40 pistol to his head and shot himself to death. He was 29, engaged, and in preparations with his fiancée Stephanie Cunningham to leave Austin's EMS system for what he'd determined was a better, more progressive opportunity in west Australia.

Burger got to Austin in 2010 after half a decade as a first responder in his native San Diego. He came here for the practice: the protocols, the pit-crew style, and high save rates ATCEMS boasts for critical patients. He'd heard that ATCEMS ran one of the best Advanced Life Support programs outside of Washington's King County, where Medic One – which pioneered the practice – keeps watch over Seattle. He wanted a career in emergency services, and strived to climb Austin's ladder. But by 2014, after four years in the organization, he started looking to get out.

ATCEMS weighed on Burger, his friends and colleagues said after his death. He grew stressed, disillusioned, angry, bitter, and dejected; tired of the small calls and sick of his own professional stagnation. "I feel like I have to sell an ambulance ride," he told Cunningham, after a particularly rote call to a low-risk patient. "I have to tell them that I can't evaluate them as a provider, as somebody with 10 years of experience." (The system's protocols promote rapid transport and not on-scene diagnosis.)

He dealt with bad calls, too, ones hard to think about. Like three dead babies in a week or crash scenes with brains strewn out across the freeway. His old ambulance partner and roommate Eric Sitterle once asked him what he did with his worst calls. "I take those things and I put them in a dark box under my bed," Burger told him. "And I leave them there and never look at that."

Burger dealt with depression, as medics often do. He visited staff psychologists. He went to work every day feeling like anything he did could lead to a scolding; making the decision he thought was right could land him in deep trouble.

So he made the Australia pact with Cun­ning­ham, their goal by this December. On Jan. 13, after some rough days on the truck and at home, he locked himself in a room and shot himself. He's one of more than 40 American fire and emergency medical workers to kill themselves so far this year.

Burger could be considered a regrettable yet random casualty of the profession without context. But six months prior, on June 9, 2014, 37-year-old ATCEMS rescue paramedic James Arizpe committed suicide at his apartment. A year and a half before that, in Dec. 2012, his good friend and colleague Randy Trinkle crashed his car and died on his way home from a shift. He'd run 24 hours out on an ambulance; he fell asleep on the way to Fredericksburg.

The days following Burger's death were filled with medics both active and separated expressing sorrow and casting blame. They lashed out on Facebook. One post that was screenshotted and emailed to the Chronicle stuck out in particular: "I myself have been struggling and can't get the help I need out of fear of losing my job for taking medication or for asking for help and seen as not fit for duty," it read. "This is what this department has done. Made it basically impossible to reach out for help."

Sitterle, who moved to St. Louis in 2013, visited Austin for Burger's funeral. "I talked to pretty much as many people as I could possibly talk to: his friends, his supervisors, the ambulance crew that responded to his house that day. I talked to his family members," he said. "There were a lot of personal things that were going on with Ryan, but I firmly believe that if he wasn't as disillusioned with being a paramedic as he was, because of working at ATCEMS, I do not see this happening to him."

"Death, Dying, Injury, and Illness"

ATCEMS medic Ryan Burger, who committed suicide in January.
ATCEMS medic Ryan Burger, who committed suicide in January. (Courtesy of Stephanie Cunningham)

You don't know what it's like to be an emergency services provider until you've stood in the piss-soaked bedroom of a house and watched a team of medics try to revive an old, lonely guy though 15 minutes of automated CPR. It's a small part of the job, but unavoidable. When the call goes off for a critical emergency, medics have no choice but to make haste.

"We exist around death, dying, injury, and illness," remarked Jay Cloud, a paramedic with 33 years of experience outside of Houston. "When we see these horrible situations, we can't turn off our biological insistence that this is a critical situation. We have to learn to rein in our reactions and refocus that to getting [the situation] resolved. And it is terrible to have to deal with these things. Usually it involves children or senior citizens."

Indeed, the life of a first responder is one of the most stressful in the nation, one where the non-life-threatening situations can be seen as nuisances, and the high-pressure ones cause nightmares.

"People are doing work, day in and day out, at such a high level of stress and activity that it's like being continuously deployed in Afghanistan," relayed Sitterle. "Obviously your friends aren't getting blown up left and right, but other people are. Other people are getting shot and stabbed – all of these traumatic events."

Calls that aren't life-or-death can be just as troubling. Paramedics interviewed for this story (who requested anonymity for fear of departmental retaliation) recounted instances of being bitten and punched in the crotch by drunks on Sixth Street. That's if something actually happens; most calls are less eventful. Stubbed toes, sore throats, stomach pains, and headaches. Not everybody knows how to access health care without calling 9-1-1. First responders almost always carry aspirin.

Medics are often the most resilient people you will meet: selfless, loyal individuals willing to literally throw themselves into fires for strangers. They can be cynical and are often loners, prone to dark humor to shake off the stress. For instance, during a ride-along, one medic regaled the other about the zits he'd seen on a corpse. And each rides out, for 12 or 24 hours at a time, with only one partner in the ambulance. Many sleep poorly, and turn to alcohol for relief. "We all have ghosts," said Fiona Campbell, an ATCEMS emergency medical technician and secretary at the Code Green Campaign, a national organization designed to increase education and awareness about depression and PTSD among first responders. "It's about figuring out what you have to do to not have those ghosts keep you up at night." According to Campbell, a third of the people in her industry suffer from PTSD. "But we're extremely resilient. While we suffer from it, it doesn't affect our ability to perform the job."

Those who can't suppress it often struggle to cope with hard times off the job. "Unfortunately, we have people who do commit suicide – because they feel like they have reached the end of their rope," said Cloud. "In many cases, they think of themselves as no longer valuable. They think of themselves as a failure."

ATCEMS has seen more than 2,700 first responders climb into its ambulances throughout its 39-year history. Before 2014 it had seen just one suicide. Two in a six-month period has shaken the community to its core.

High-Achieving, but Short-Staffed

On Jan. 1, 1976, after nine years operating under the privatized monopoly of Austin Ambulance Service, Austin became the third major city in the United States to employ a governmental, third-service emergency medical department (the police and fire departments are the other two services). The Austin-Travis County EMS quickly grew into one of the finest in the country. In 1984, after nine years in the business, it won the National Association of EMTs award for System of the Year.

The design premise of ATCEMS was simple: The bulk of the need for emergency services sat within city limits, but even those who lived in Austin sometimes ventured into the county. Those within the county but outside of city lines deserved the same quality care, whether they lived there or were visiting. A plan was hatched that would put the city on the tab for most of the budget, with Travis County Emergency Services contributing the rest in exchange for ample services.

There were to be two tiers of medical care: Some trucks would be equipped for Advanced Life Support (ALS) and others designed for Basic Life Support (BLS). Paramedics are expensive and highly skilled, and are trained to handle various emergency medical procedures, like trach­e­al intubation and cardiac defibrillation, through up to 2,000 hours of intensive education. They would be in ALS ambulances, responding to the area's most critical calls, while BLS trucks would handle less critical calls, staffed by EMTs – emergency medical technicians, first responders with the skills necessary to perform basic life-saving techniques (like choking, first-aid, requests for transport, and hypothermia) but who only go through a couple hundred hours of training. Whoever was dispatched had one top-flight standard to follow: On at least 90% of the most important calls inside the city, a unit would be on the scene within 10 minutes. ATCEMS was and continues to be extremely diligent in its adherence to this standard. Recent statistics indicate that it's achieved roughly 95% of the time.

In the mid-Nineties, after a much-maligned run by director David Wuertz, Sue Edwards took over ATCEMS and converted all its trucks to ALS. She found the two-tiered system was expensive to maintain, medics said, and "we were throwing dice on whether we were sending the right resource." EMTs were cut completely and paramedics took over. ATCEMS operated that way until 2012, when the department changed course again and began staffing each ambulance with one paramedic, also known as a Medic II, and one EMT, or Medic I.

Today, ATCEMS deploys 37 full-time ambulances and five commander trucks covering 990 square miles of Travis County, looking after a population of 1.15 million people (roughly 885,000 within the city). Included in that tally are three demand ambulances working shorter shifts during peak hours, and one tactical ambulance, as well as two demand commanders who run on heavy work shifts. ATCEMS also deploys up to six mobile community health paramedic clinics staffed by seven trained community health paramedics, Monday through Saturday from 8am to 6pm.

The department's budget during the fiscal year 2014-15 stands at $42.2 million, up $5.7 million from the previous year, with roughly 75% of funds coming from the city and 25% from the county. More than 138,000 incidents were reported last year, with medics responding to 113,848 of them.

Historically, ATCEMS has run as one of the most respected systems in the nation, despite constant calls for more staffing support. A Nov. 1993 Chronicle exposé of the department (available with this story online) quoted Wuertz saying that the system was "stretched as tight as it can be." In a letter to former City Manager Camille Barnett, Wuertz dug deeper. "Employees accrued more vacation time than the department can allow without exceeding overtime funding to provide additional coverage," he wrote. "The local medic 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."

In 2006, amidst those same concerns, the department reduced workweek hours for field providers from 56 to 48.

Today, ATCEMS runs an authorized strength (number of full-time employees approved by City Council) of 489, but currently has 43 open positions, with a uniformed staff of 446. That includes 136 Medic Is (EMTs), 209 Medic IIs (paramedics), 52 captains, and 38 commanders. But that number is deceiving.

For example, on April 1, management delivered to Austin's Public Safety Com­mis­sion figures listing 33 vacancies in its field division – three Medic II vacancies and 30 for Medic I – plus 17 sworn staffers who can't currently work on a truck for reasons related to on-the-job injuries, family or medical leaves of absence, military duties, or active investigations. The report's 446 reported sworn staffers included the 23 field medics and three communications medics currently in cadet training who can't work, either. Those discrepancies, along with the 33 acknowledged vacancies, contributes to the remaining staff working a tremendous amount of overtime. In fact, this year's ATCEMS overtime budget is nearly the same as that for the fire and police departments ($7 million, ATCEMS Chief of Staff James Shamard told the PSC last month), yet its staff size isn't even half that of either of the other two. Field workers at ATCEMS encounter mandatory overtime, stand on-call during predetermined off days, and are regularly sent around the city to fill in at short-staffed stations.

Today's ATCEMS landscape has been marked up by a number of department changes, most notably the 2008 arrival of Chief Ernie Rodriguez, who previously served as director of operations at Ft. Worth's MedStar Mobile Healthcare program, and Medical Director Dr. Paul Hin­chey, formerly a paramedic, now a physician, who came from Wake County, N.C., in June 2009.

In 2012, the department joined APD and AFD as part of the city's Civil Ser­vice, converting workers from "at-will" employees of the city to a staff that negotiates its contracts as a collective body with ATCEMS management. Employee Association Pres­ident Tony Marquardt told the Statesman at the time that the change would prove "the most important issue we've come across in our existence." Field staff were immediately granted a better promotion structure and given stronger arbitration rights in job disputes. But it also changed the way the trucks were staffed: Because of it, providers under investigation had to be taken off the schedule, creating more holes for medics to fill with overtime.

That same year, ATCEMS converted its stock of ambulances to the two-tiered staffing model that brought EMTs (Medic Is) back into the fold. The decision came from Hinchey, who noted that changing opinions in medical studies indicated that two-tiered ambulances (a practice employed in many systems) had an advantageous effect on patient care. The studies claimed it was a better use of a paramedic's training to have one paramedic handling all the high-priority calls per unit and one EMT taking on the remaining calls, rather than two paramedics sharing the load and also attending to the less critical calls. Plus, the inclusion of EMTs could help to solve the program's staffing issues by allowing a greater pool of providers to apply.

Field providers still reject Hinchey's reasoning. If critical calls account for only 7% of a paramedic's job, they say, that's a difference of only three or four calls per month per medic – hardly enough to drastically enhance precision. Rather, the model wears on medics – requires that they be attentive through critical situations for longer periods of each shift. And the staffing issues? Not satisfied. Just look at current figures.

"They told City Council that it would help the applicant pool," Marquardt remembered. "I don't see that as a big goal. We can do that. To me, the sign of success is increasing the amount of employees we have and decreasing the amount of people leaving. That's what hiring's about."

A System in Need of Repair

Organizationally, the years surrounding 2012 could be best described as grim. There were problems with accounting and payroll, and various lawsuits from commanders.

Safety measures crumbled. An audit conducted in Feb. 2013 noted a two-year period during which 278 on-the-job injuries resulted in more than 4,234 days (and $1.6 million) lost to rehab. Injury costs per full-time employee grew from 100% more than the city average in 2010 to 350% more by 2012. Staffing got so bad in Aug. 2012 that ATCEMS came in $745,411 over its annual budget – and didn't tell Travis County Emer­gency Services Manager Danny Hob­by that it anticipated this issue until the end of the fiscal year. Yet medics at ATCEMS were being offered overtime hours to work construction projects for the department – resulting in even more overtime being accrued.

Problems with its fleet brought 338 ambulance breakdowns to the department over a three-year period, a figure, as the Statesman reported in Jan. 2014, eclipsing that of similarly sized cities by nearly three times. More than one-third of those issues derived from the department's decision to use what turned out to be defective Ford F-450 ambulances. (Shamard says the department has since converted to a Dodge chassis and solved the problems.)

A Feb. 2014 city audit slammed ATCEMS inventory management practices. Another audit, issued in Sept. 2013, had derided the department's vision. "ATCEMS management has not established a comprehensive long-range plan on how the organization will provide effective, efficient, and economical services to meet the demands of a growing Austin," wrote Ken Mory, Austin's city auditor at the time. He based his conclusions on a Jan. 2012 strategic plan issued by Rodriguez and his executive branch. The first strategic plan in the organization's history, it was so rudimentary that its breakdown of the "Current Situation" carried no statistics.

The department began to notice that the majority of its calls – particularly those of Downtown ambulances – were low-priority/high-frequency instances, quite often involving transients without other health care options. Mory's audit determined that ATCEMS maintained no "standardized guidelines" for reviewing these types of calls, which were taking their toll on medic morale (not to mention taxpayer dollars). In 2013, Rodriguez told KVUE that he'd begun developing a pilot program to station medics around the Austin Resource Center for the Homeless. Two years later, Rodriguez says the program is still in planning stages.

The course of events was enough to drive departed ATCEMS paramedic David Wil­liams, who had since earned a Ph.D. and become a consultant for emergency medical systems, to pen an Aug. 2013 essay for the Journal of Emergency Medical Services titled "Is Austin's EMS System Broken?"

"The system is not 'broken' and could be repaired," he wrote. "Doing so would require laser focus on shared outcomes, heavy emphasis on engagement and communication, and a collaborative action plan to change. The will and resources are present to achieve the aim if there's community interest and strong leadership to do so."

Passing the Buck

ATCEMS Employee Association Pres­ident Tony Marquardt
ATCEMS Employee Association Pres­ident Tony Marquardt (Photo by Jana Birchum)

The medics at ATCEMS continue to do good public work. Mory's audit noted how medical providers at area hospitals considered ATCEMS delivery practices to be "exceptional or above average." The department repeatedly hits its transport rates, and in 2013 answered more than 90% of calls within 10 minutes (and got to scenes on time at rates far better than its targets). Since 2008, its 40% survival rate for cardiac patients (in which the individual's collapse was witnessed) is 10 percentage points over the national average. But its perennial problems continue to burden medics, and put them into precarious positions where their exhaustion makes them prone to otherwise avoidable mistakes. Sitterle remembers one instance, in particular, when he was on a truck for over 24 hours. "My partner was in the back and I was driving," he said. "I couldn't see more than 30 feet in front of the ambulance.

ATCEMS Chief of Staff James Shamard
ATCEMS Chief of Staff James Shamard (Photo by Jana Birchum)

"All I was doing was trying to stay between the lines."

ATCEMS Chief Ernie Rodriguez
ATCEMS Chief Ernie Rodriguez

By late 2013, the relationship between the Employee Association and ATCEMS management had reached a boiling point. The summer before, at the behest of staff psychologist Dr. Marc Kruse, employees filled out a survey designed to "identify factors associated with job satisfaction and occupational stress in paramedics" and "examine the prevalence of depression & PTSD symptoms." Out of a possible 320, 256 employees participated, with 76% participation from paramedics. Results detailed symptoms of depression and PTSD, and indicated that medics suffered from poor diet, anxiety, and a general loss of interest and pleasure in various activities.

The study showed that medics were quick to help others, able to work without close supervision, and valued their relationships with other paramedics. But satisfaction figures plummeted when they were asked about the relationships they had with field supervisors and department leadership. In fact, the five lowest-scoring items on Kruse's job satisfaction poll all dealt with management: relationship with commanders, relationship with department leadership, work schedules, opportunities for career advancement, and the "job in general." Kruse and ATCEMS management chose to focus on occupational stresses, and produced two posters with data points concerning sleep habits and medic alcohol abuse. Marquardt maintains they passed the buck.

"If you are an organization concerned with the welfare of your employees, why do you focus on the symptoms of off-duty sleep patterns and off-duty alcohol abuse?" he asked. "I think I speak for the majority of us when we wonder why they're doing studies on sleep patterns, and that we should avoid sleeping with our pets or sleep with a sleep machine. That means very little to us in the cab of an ambulance. It was very remedial and almost insulting, and it pointed the finger away from any managerial responsibility." He commissioned UT professor Noel Landuyt to run a similar survey and found that employee morale at ATCEMS was lower than that of workers in every other industry except prison guards. Marquardt said he took the survey to management and to former assistant city manager Mike McDonald, who both "gave lip service to it."

"Let's focus on the things we can do," he pleaded. "Which is organizational improvement."

Medics pointed to Rodriguez's lack of presence on the ambulances he watched over in conversations and in emails. They never saw him on the trucks, they said, and noted in contrast the way Police Chief Art Acevedo regularly rides out on patrols. They took issue with his surveillance of medics' Facebook pages, and attacked his love of referencing "wellness." In Jan. 2012, he was roundly criticized for attempting to implement his first strategic plan via a faceless YouTube video.

"You Call, We Haul"

Staffing numbers continue to dwindle. ATCEMS saw 66 separations between 2008 and 2012, said Marquardt, and 122 since then. "You're seeing more and more separations are because of a dissatisfaction overall with how things are going," he continued. "The Medic I program causes more work for the Medic IIs, more liability, and has led to more de-accreditation issues." People are scared, he said, of messing up and facing consequences.

Shamard said that numbers provided by the Association fail to tell the story. "We've increased in the number of people we've lost," he conceded, "but we've been getting more positions. So the pool is bigger." He rattled off attrition rates for each year: 1.6% in 2011, 7.2% in 2012; 6.7% in 2013 and 5.5% in 2014. Attrition's at 3% in 2015 and, he said, "we're halfway through the [fiscal] year," so should end this year at around 6%.

Rodriguez told the Chronicle that it's hard to know why good medics are leaving his system. "I think there are some things that they tell us when they're leaving, and some things that they don't tell us," he said. "It's those things [they don't say] that might help me more than what they are saying." He said he's been encouraged to reach out to those departing through more than a standard exit interview, and pledged to implement that practice.

What they tell one another is that they missed having their own lives; missed having some semblance of a weekend and days off that they can count on – small pleasures like going to church or their kids' baseball games. They missed being considered someone more than a taxi driver, following a "You call, we haul" system that believes the best practice is to always take patients to hospitals.

"They're not given the ability to actually think like medical professionals and get people where they need to go," said Sitterle, now an advanced practice paramedic with the ability to diagnose patients at Christian Hospital EMS outside St. Louis. "It's incredibly frustrating. It's like having to bang your head against the wall every day, because you know that you're not doing the right thing on so many levels."

They feared telling their patients that they couldn't go to a hospital in Round Rock if they lived near South Austin, because they could get in trouble for refusing service. "I have no problem taking care of somebody who's having a heart attack and taking them to the closest appropriate hospital and doing everything I have to do," continued Sitterle. "But in addition to all the really bad psychological trauma – bad calls, emotionally disturbing things – you have this constant onslaught of feeling like you are a yo-yo."

ATCEMS operates with such short intellectual leashes for its medics because of Texas Medical Board Code 197, which dictates that emergency medical providers in Texas operate under the license of their medical director. Hinchey, as medical director for Austin and Travis County, wields the utmost power: Any medic who, in Hinchey's judgment, violates any one of five industry standards can get de-accredited and fired from the department. In place since 1999, the standard has irked Mar­quardt since Hinchey first came to Travis County in 2009.

"What Hinchey is doing is exactly what's wrong with the process," said Marquardt. "You can't have credentialing issues without oversight at all. He can bring people in for any reason, and they're brought in for this process. No representation. The panel is no longer peer-review." The final decision is that of one man.

Hinchey said he can't talk about specific de-accreditations, but told the Chronicle that "if people knew the full extent of what happened, I'm confident they'd say, 'Yeah, I don't want a provider who hits a patient or comes to work drunk.'"

"The center of all medical care, EMS and all that we do, is the patient," he added. "It's the reason why we exist, why EMS exists, and the reason why the health care system exists. Our protocols are written that way, our policies are written that way: to address the needs of the patient. My job, in terms of everything we do, is about the patient."

Questioned at a February Public Safety Commission meeting about his hard stance against what he considers "non-remedial circumstances" in the face of departmental morale issues, he stressed that he's responsible for a department of 10 staff members (separate from ATCEMS) and that no one in his department faces morale issues. "I'm not an employer," he explained when asked about the correspondence in April. "I don't employ any of these [medics]. Our goal is a partnership to try to take care of patients. So the treatments and the protocols and modalities are all built around that."

The Employee Association believes he rules with a heavy hand. In the six years since taking office, Hinchey has de-accredited eight different medics who've been in turn fired by ATCEMS. Marquardt believes he's forced many others into quitting through intimidation. Medical directors in Houston, San Antonio, and Montgomery County (just north of Houston), Marquardt explained, haven't de-credentialed and then fired a single staffer.

Road to Recovery?

Rodriguez has his own take on Hinchey's credential practices. "What I'd like to see is: If he feels the need to take someone's credential, I'd like to be able to consider, instead of firing that individual, maybe changing their credential so they can still be employed," he said. "If a medic needs to step down and be an EMT for a year while they recoup and re-train."

Medics are Rodriguez's responsibility, and despite years of struggling to support them, he'd rather deal with a full and happy staff than one that's shorted and unhappy.

He's making efforts to become more medic-friendly, he says, and started taking classes at the Institute of Healthcare Improve­ment to better understand his workers. Recently, he installed a policy requiring him and his executive staff to spend one eight-hour shift per month on an ambulance with their medics – small potatoes for the field staff who work the city more than 220 hours a month, but still better than nothing.

He's implementing a program called Just Culture to help fix cultural issues. "It's an algorithmic process that actually hopes for human mistakes," Rodriguez explained. The goal is to eradicate investigative systems. "Instead of doing punishment, you send the employee back to work and say, 'Thanks for making that mistake and pointing us to something we didn't know about before.' Now let's put our concentration toward the cause of this thing." He says he contacted the Code Green Campaign to help support and educate medics after the suicides, and has retained PTSD psychologist Tania Glenn to assist Kruse with potential patients.

He's resolved to get problems solved down at the Salvation Army and the ARCH, where he says he's finally getting that pilot program off the ground. "It turned out to be more complicated than I thought it would be, and it's caused me to walk a lot slower," he said. "But I do think we're making progress."

Most significantly, he's resolved to get a handle on the staffing. Rodriguez says his No. 1 goal this year with the budget is to reduce medic workweeks to 42 hours, and he touts his efforts recruiting Hispanic medics at community colleges around the coastal bend. He believes a change in the academy structure (cadets now undergo four months of intensive training before moving to the trucks immediately) brought on by Hinchey will allow ATCEMS to close the vacancy gap much more quickly. The first class concludes at the end of this month and will bring on 19 cadets, with another planned to close this summer and welcome another 20. Hinchey, too, has begun considerations for another change to the ambulance arrangement that would reintroduce BLS trucks staffed entirely by EMTs, and keep the paramedic/EMT pairing on ALS trucks. "We're taking bites," said Hinchey. "We're doing it in pieces."

Together, ATCEMS management and the office of the medical director point to the improvements local providers have made in community health care and its new pilot program for advanced paramedics that's seen three meetings so far and, Shamard reported, "identified the types of people we think will benefit from a community health paramedic program." The goal is to expand medics' role from the "You call, we haul" system, said Hinchey, to being able to tell a patient, "'Clearly you're uncomfortable, and you're going to need someone to look at your ear, but it's not going to be at the emergency department at 3am. So we'll give you something for your pain, and we'll come back in the morning or give you an Uber voucher.'" Shamard points to internships offered within the department that allow medics to see other sides of the system.

Marquardt, too, has been busy trying to enact change, working with Rep. Celia Israel, D-Austin, to pass HB 3488, which would afford de-accredited medics a chance to have their hearings heard before the State Office of Administrative Hearings. (Hinchey has opposed the bill, saying that it takes the decision out of the medical director's hands and gives SOAH the chance to "render an opinion that could potentially force me to put back into practice someone I think is a danger to the public." On April 22, he introduced a peer review system that would allow an appointed team of medics to anonymously peruse the facts of each credentialing review.)

"My sense is that there are some things that EMS has been doing to try to address these issues, but it takes some time, and it takes resources," says Rey Arellano, Aus­tin assistant city manager since Dec. 2014. "Balancing all of those things is something I'm looking at with [Rodriguez], to try to make sure we can balance it best we can."

Animal House

Everybody's aiming for improvements; the issue is whether or not ATCEMS can achieve positive change.

By now, the Employee Association and certain medics have all but lost faith in Rodriguez's ability to drive change, and view with disdain his efforts to obtain more education in hopes of changing departmental culture. Management has shown a history of not following through: Marquardt has criticized them quite publicly for a lack of preparation for last year's Ebola outbreak, and members of the Public Safety Commission took them to task for their hurried implementation of the two-tiered medic program (Shamard and Rodriguez maintain they gave a pilot program ample testing time). Management knew the city's 2011 worker safety audit showed turn-of-the-century practices weren't up to current standards, and still did nothing to fix it. The EMS safety committee founded in 2005 in the wake of earlier audits, Mory noted, had become dormant by 2012. "The pattern [from the chief regarding concerns] is 'very receptive' almost all of the time," says Marquardt. "We can get a meeting and talk about the issue. But the follow-through on everything is almost nonexistent."

One nameless paramedic takes it one step further. "You know that scene at the end of Animal House, during the parade?" he asked. "Everything's going haywire, and there's this one ROTC in the middle shouting, 'Everybody remain calm. Everything is under control!' That's Ernie. There's all this chaos, but he's saying everything's okay. It's not okay. And the fact that it hasn't blown up in their face is all chance."

Recently, it seems, those involved with the decisions at ATCEMS have displayed a knack for missing the forest for the trees. In April, after City Council's Public Safety Com­mit­tee meeting featured heated comments concerning credentialing from Marquardt and testimony from Cunning­ham about Burger's suicide, Council mem­ber and Committee Chair Don Zim­mer­man, in an interview with KXAN, advocated for using more overtime rather than hiring more full-time staffers. "Econom­ic­ally," he said, "it makes sense to do more overtime than to bump up the head count, because the head count is so expensive." (Zimmer­man has not responded to repeated requests for comment concerning worker fatigue.)

This spring, the department also assumed the role of assisting APD blood draws on arrestees, a new source of overtime Sham­ard said was greeted with "120 people" responding via email about their enthusiasm for the opportunity. (He said that no one sent a dissenting email.) It's easy work, he maintained: You can read a book or do some homework. But it also creates more overtime for a population already stretched super-thin by too many special events, and eats into necessary time for employee recuperation. "Those are being done by people who are on call during their days off," pressed Sit­ter­le. "Is it demanding? No, but it's still your day off."

Meanwhile, his old colleagues wonder how many more low-priority calls EMTs will have to take each month if they're on trucks that only offer BLS.

"What might frustrate our providers is that we've seen a glimpse of what we can become, and we want it to happen right away," said Hinchey. "You can only move so fast. We're trying to get there and be ready, because the health care system is changing."

Marquardt said he's met with professor Landuyt this spring, and they've begun talks to do a second round of their survey.

"Management and the medical director are critical of [the first survey] for various reasons, but as the professor says, 'It is a snapshot in time,'" he said. "It is a legitimate overview of our organization at a time when things were turbulent: The schedule was up in the air, alternative staffing was happening. We wanted to do it again [last winter] but we had the suicide at the time that we wanted to deploy it. That would have also been a snapshot in time.

"I don't know that there's ever going to be a time when things are neutral."

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ATCEMS, Austin Travis County Emergency Medical Service, Tony Marquardt, Paul Hinchey, Ernie Rodriguez, James Shamard

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