This article was written in response to the presentation made by Dr. Marshall Isaacs’ and EMS Chief Richard Shortall’s to the Fire Commission. Dr. Isaacs and Chief Shortall provided an update relating to operations and performance by the Department’s 911 Emergency Medical Assistance Program.

The following statements were taken directly from the November 14, 2002 minutes:

“... Rapid Paramedic Response System (RPRS) and Advanced Life Support (ALS) Engine Program: Dr. Isaacs stated that the Department currently staffs eighteen ALS engines, ten 1-paramedic + 1-EMT

Secretary Kelly’s response to the above statement:

• Expanding the program as “rapidly” as possible has plagued the program since its inception. Expanding the program to ALS Engine companies in the downtown and Mission District corridors is a waste of resources. Ninety nine percent (99%) of calls in these sectors are BLS. Recent exposes aired on local news programs have shown that homeless addicts and alcoholics continue to crowd emergency rooms, forcing diversion at hospitals for longer periods of time as well as increased frequency of diversion. MAP units (mobile assistance program) should handle the majority of these calls and those patients should be transported to facilities other than emergency rooms where an on-duty nurse or paramedic may offer assistance if needed.

• I find it hard to believe that not one single complaint, Unusual Occurrence Report, or adverse patient outcome occurred because of the program. That’s an unusual occurrence in and of itself.

• Companies have been delayed or have missed working fires since engine companies began responding to resuscitations 30 years ago. I hope this clarifies the situation for you and your staff.

• In response to your statement that you’ve received numerous reports of lives saved, as well as pain and suffering diminished due to paramedics arriving earlier with fire engines ... paramedics and firefighters have been working together and have been saving lives and rendering assistance for decades. We have not been able to prove that this new program provides better service, but we can prove that it does cost more.

“... H3 Paramedic/Firefighter Academy: Dr. Isaacs pointed out that the ninth class of H3 lateral hires was conducted through the EMS In-Service Training Section and the Division of Training during September and October, 23 new members were graduated and are currently assigned to ambulances. A new class of 15 laterals has started, but even with these graduates, the number still falls short of the 48 H3’s that the Department was authorized to hire.” - Excerpt from the Minutes of the San Francisco Fire Commission November 14, 2002

Secretary Kelly’s response to the above statement:

H3 Paramedic/Firefighter Academy

• What Dr. Isaacs did not report here
is that it cost $35,000 per year more to hire lateral firefighters/paramedics than it does to hire H2 firefighters. We find ourselves mired in a budget crisis, yet we continue to spend money for new employees at an alarming rate. Forty-eight (48) new laterals cost the Fire Department an additional $1,680,000 in base wages alone.

“...Paramedic Training Program: Dr. Isaacs related that the sixth class of firefighter/EMT’s is undergoing training to become firefighters/paramedics. Classes are led by Michael Kasner, MD and Jane Smith, Section Chief, who are also discussing various issues for future training of high quality paramedics in San Francisco.” - Excerpt from the Minutes of the San Francisco Fire Commission November 14, 2002

Secretary Kelly’s response to the above statement:

• Paramedic Training Program

Who are we kidding here - eighty percent (80%) of students training in this program are not San Francisco Firefighters and never will be. In fact, there are only 4 firefighters in the class! Was there a paramedic training program prior to the merger? Did the expenditures come directly from the DPH budget? The answer is no. But because of the merger, somehow we needed to train paramedics. The money for this program comes directly from the Fire Department budget. What’s the cost? Nobody seems to know exactly. But it is clear to many that money to train paramedics could be put to better use to ease Fire Department budget constraints.

“...Quality Improvement / Risk Management: Dr. Isaacs noted that the Department continues to see a drop in the number and severity of complaints regarding EMS responses within the City. He believes the reduction is due to the QI program, the high level of supervision within the system and the high quality of EMS training within the Department. DPH’s Paramedic Division used to average one claim (pre-lawsuit) per month; in the past 35 months, the Department has had only 4 claims, one of which was dismissed as “without merit”, with the Department anticipating a similar outcome for the remaining three...” - Excerpt from the Minutes of the San Francisco Fire Commission November 14, 2002

Secretary Kelly’s response to the above statement:

• Quality Improvement / Risk Management

Saturate every 911 call with one or two engine companies, an ambulance and a rescue captain (and maybe if you’re a lucky patient, a truck company). This will definitely reduce the number of lawsuits against the City. How could anybody complain with this kind of response? However, Dr. Isaacs failed to mention two (2) lawsuits against the City filed by their own employees. The H1 rescue paramedics recently won a lawsuit worth close to 2 million dollars. The lawsuit claimed the Department violated FLSA 7k exemption laws which require anyone working 24 hour shifts must respond to fire related dispatches 80% of their actual work hours. The courts ruled that the City must pay H1 paramedics overtime for any hours worked over forty hours per week. This is what happens when you rapidly expand a program without using common sense.

• Those high level supervisors providing training and supervision of Quality Improvement and protocol are seeking arbitration for approximately six months back pay and continued contributions to the safety officers pension plan. There is little doubt that if we win the right to arbitrate, the H33’s will be victorious. Once again the Department is a victim of rapid expansion.

• Yet another lawsuit looms. Even after the change in 7k exemption rules, Departments around the country may not be in compliance. Is San Francisco the next city to fail? Rapid expansion will cost money. The Department must slow down and require paramedic firefighters to be fully trained for both professions. It’s the law. (Cedrick Cleveland vs. Los Angeles)

“ ... Response Times: Chief Shortall explained that response time standards mandate that SFFD ambulances respond to medical emergencies within ten minutes for “red lights and siren calls” (code 3) and within 20 minutes for “non-red light and siren calls” (code 2) 90% of the time. In October 2002, the 90% response times were 11 minutes and 50 seconds for code 3 calls and 18 minutes and 40 seconds for code 2 calls. Chief Shortall believes that the increase in time for code three calls is due to the earlier arrival of a paramedic on an ALS engine, who determines that the patient is not unstable, thereby slowing down the responding ambulance from code 3 to code 2. Chief Shortall illustrated the quicker response times by ALS engines with two examples when the patient’s lives were actually saved. Discussions are underway with the EMS Section and Department of Public Health, regarding the most appropriate way to measure response times since there is a considerable amount of evidence indicating that the Department can get a paramedic to many patients significantly faster before the ambulance actually arrives.” - Excerpt from the Minutes of the San Francisco Fire Commission November 14, 2002

• Response Times:
Response times in October 2002 were 11 minutes, 50 seconds for Code 3 calls. The standard mandated for the SFFD by EMSA ambulances responding to Code 3 calls is “within” 10 minutes. Were the October response times an anomaly? Chief Shortall stated discussions are underway with the EMS Section and DPH, regarding the most appropriate way to assure response times. I was unaware that measuring time from “dispatch” to “on the scene” was inappropriate.

• Times may be reduced if the closest
ambulance is dispatched.

• Times may be reduced if we eliminate the system “evening out” dispatches.

• Times may be reduced if we cancel diversions for ambulances in busy sectors.
• Times may be reduced when we realize that statically deployed ambulances are not by themselves the solution.

“... In closing, Dr. Isaacs believed that there are four critical issues facing EMS and will require the Commission’s continued support: (1) expansion of the Rapid Paramedic Response System and ALS engine programs; (2) need for more paramedics to accomplish the expansion; (3) need for an adequate number of equipped and safe ambulances; and (4) need to withstand future potential budget cuts to EMS management positions in order to carry out the EMS’ core mission. - Excerpt from the Minutes of the San Francisco Fire Commission November 14, 2002

Secretary Kelly’s response to the above statement:

• In response to the closing statement by Dr. Isaacs, contrary to Dr. Isaacs’s statement about EMS, EMS management has grown out of control. This merger joining DPH medics and the Fire Department was to be a “cost neutral” and equal proposition. The EMS Management Division of the SF Fire Department cloaked itself under the guise of patient care. Their “core mission” has been one of self-aggrandizement. Spurred by a group calling themselves the San Francisco Paramedic Association, paramedics from the DPH bullied their way into the SFFD. Where are those medics who spearheaded the merger? The majority of them hold management positions in the bloated EMS hierarchy. Dr. Isaacs’ plea to the Fire Commission to withstand future potential cuts to “EMS Management” smacks of the divisiveness that he and his underlings have accused this Union of repeatedly.

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