Last month, Multnomah County fined its ambulance service provider AMR more than $500,000 for slow response times to emergency 911 calls. According to its exclusive service contract with the county, AMR is required to respond to 90% of life-threatening calls within 8 minutes in urban areas. In August, AMR met that target just 86% of the time, but the delays started accruing much earlier, according to Dr. Paul Lewis, deputy health officer for Multnomah County.
“This problem has been going on for approximately 16 months now,” he said. “The county’s initial policy was not to enforce the monetary part of the fine but to work on alternative solutions in support of the company. But this summer, the policy changed to enforce the fine.”
AMR has appealed the fine and argues the delayed response times are largely because of the county’s staffing requirement of two paramedics per ambulance. Randy Lauer, vice president of operations at AMR says it’s difficult to meet that requirement amid a nationwide shortage of EMTs and paramedics.
”We are in crisis now,” said Lauer. In neighboring Washington, Clackamas and Clark counties, AMR is able to staff ambulances with one paramedic and an EMT.
Lauer said the company already spends $120,000 a month to incentivize staff to cover open shifts, and financially penalizing the company fails to address the root cause of the problem, which he expects to worsen.
“In September, we were 50 paramedics short in Multnomah County. In November, we were 55. By the first of the year, I assume that number is going to be around 60,” he said. “We are headed for an absolute catastrophe just by the number of more openings we’re having every month.”
Lauer believes it could take two to four years to graduate enough new paramedics to start relieving the shortage caused in part by the closure of EMS training programs during the pandemic. In the near term, he is asking county officials to temporarily allow ambulances to be crewed with one paramedic and an EMT.
“Within two days, we could staff four to six more ambulances every day. Within three to four months, we’d have all 50 shifts filled,” Lauer said.
But the county appears to have little interest in changing its policy for now.
“Multnomah County is in the top 10% in the entire country for survival after cardiac arrest,” Lewis said. “And we’re not willing to compromise or experiment with that quality.”
In the county, the fire department also often responds to emergencies, which can result in three paramedics and multiple EMTs being at the scene of a critical call. By replacing one paramedic with an EMT in the ambulance, Lauer thinks there would be no sacrifice in the level of patient care.
“You still have the fire paramedic, still have three fire EMTs. You have a total of six people, in either scenario, to take care of the patient,” he said.
Meanwhile, the physical and emotional toll of performing this life-saving work is leading to burnout and to some paramedics choosing to leave the profession altogether.
“Our paramedics wear ballistic vests … Most paramedics will tell me that during a four-day rotation … they’re going to get assaulted at least once,” Lauer said. “We had a very tenured paramedic recently who left to become a truck driver because he said, ‘It’s routine. I’m not getting threatened every day and it doesn’t have the stress that being a paramedic has.’”
Dave Schappe, who has known Lauer for many years, worked as an AMR paramedic in Multnomah County from 1998 to 2007.
“I also remember what the job was like then, and I know it’s different now,” he said. “The level of violence against the practitioners is so high. I mean, it just wasn’t like that before.”
Today, Schappe works in Bend as the Emergency Medical Services programs director at Central Oregon Community College to help train a new generation of EMTs and paramedics, including 69 currently enrolled students. Schappe said that all but three of the 24 students training to become paramedics are already working for an EMS provider, which in Central Oregon is typically a public agency such as a fire district.
Being employed by a public agency may also provide additional benefits such as a pension and higher pay which could, according to Schappe, help explain why the paramedic shortage is not being felt as severely in his region compared to the Portland metro area.
Training to become a paramedic also takes longer than the training required to become an EMT – typically, two to three years compared to just six months.
“There’s a really great risk versus benefit ratio for basic life support and then when you move to advanced life support … the risks go way up,” Schappe said. “The medications that (EMTs) are utilizing are extremely low-risk and they’re not directly injected into patients for the most part.”
But the educational foundations of paramedicine, such as doing a patient assessment, gathering medical history and identifying effective interventions, “all occur at the EMT level,” according to Schappe.
In Multnomah County, a solution AMR and the county can both agree on remains elusive. Lewis thinks the company should continue working on a pilot program that involves placing two EMTs in an ambulance to respond to “low-acuity calls like sprained ankles and spider bites,” which could boost the number of paramedics available to respond to critical calls. But Lauer said the Basic Life Support pilot program “isn’t working” because EMTs prefer the experience gained from working on an advanced life support ambulance.
“It makes no sense to me for people to suffer for the next 2 to 4 years because the county can’t get over whatever is holding it up on this two-paramedic system.”
Dr. Paul Lewis, Randy Lauer and Dave Schappe spoke to “Think Out Loud” host Dave Miller. Click play to listen to the full conversation: