Perspectives on addressing Multnomah County ambulance delays amid staffing woes

Last month, Multnomah County fined ambulance service provider AMR more than $500,000 for slow response times to emergency 911 calls. According to its exclusive contract service with the county, AMR is required to respond to 90% of life-threatening calls within 8 minutes in urban areas. But in August, AMR ambulances were delayed in responding to 14% of emergency calls. The company has appealed the fine and claims the problem is largely due to the county’s staffing requirement of two paramedics per ambulance. In Washington, Clackamas and Clark counties, for example, no such requirement exists, and AMR is able to staff ambulances with one paramedic and an EMT.

Meanwhile, there’s a growing shortage of EMTs and paramedics across the nation, including Oregon, which community colleges are helping to address through training courses. Joining us to talk about these issues are Dr. Paul Lewis, deputy health officer for Multnomah County; Randy Lauer, vice president of operations for AMR; and Dave Schappe, EMS programs director at Central Oregon Community College in Bend.

The following transcript was created by a computer and edited by a volunteer:

Dave Miller:  This is Think Out Loud on OPB. I’m Dave Miller. Last month, Multnomah County fined its ambulance service provider, AMR, more than half a million dollars for slow response times to 911 calls. According to its exclusive contract with the County, AMR is required to respond to 90% of life threatening calls within eight minutes, in urban areas. In August, AMR ambulances only hit that target 86% of the time. The company has appealed the fine and says the problem is directly tied to the County’s unique staffing requirements and to a nationwide paramedic shortage. We’ll hear from the company in just a bit along with the EMS programs director at Central Oregon Community College. They are working to create more paramedics in Central Oregon.

We start with Doctor Paul Lewis. He is the deputy health officer for Multnomah County. Welcome back to the show.

Dr. Paul Lewis:  Thanks for having me, Dave.

Miller:  Can you give us a sense for the level of services, in terms of ambulances, that are being provided in Multnomah County right now? What happens in general when people are calling?

Lewis: That’s a great question. One of the things I wanted to emphasize was that the EMS system is a lot more than an ambulance. It starts with well prepared bystanders who notice something’s wrong, followed typically by a phone call to the 911 dispatchers, operated by the City of Portland, who then try to figure out what the problem is. Typically they ask you, “Is your problem fire, police or medical?” If it’s medical, they try to decide, to the best of their ability, what kind of resource needs to be dispatched. Then they work together directly with AMR to dispatch the right kind of ambulance, at the right speed, for that kind of a problem.

Miller:  You say, “The right kind of ambulance.” You mean there are different ambulances that might be sent?

Lewis: One of the things we’ve been worked on for the last year is having both advanced life support ambulances which are staffed with two paramedics, who can do basically ICU care with needles and hoses and intubation and defibrillation, and basic life support or BLS, which is staffed by emergency medical technicians who can do first aid but no invasive procedures and no medications. So you try to send the right resource to the right degree of problem. If someone has a sprained ankle or an earache, it’s not an urgent thing and you don’t need an advanced life support ambulance.

Miller:  Do you need an ambulance at all?

Lewis: Well, that’s a whole nother topic on the scope of this thing, the appropriate use of 911. But then, following the response to the scene which, for bigger emergencies, includes typically a fire first response with an engine which typically has multiple EMTs plus a paramedic. AMR is the exclusive provider of transportation for those calls to the hospital where people go to an emergency room and either get definitive care there or end up getting admitted. Then hopefully, the end of the story is that people end up at home healthy again.

Miller:  Let’s turn to the fine here. Why is it that the County is saying “Give us half a million dollars”?

Lewis: Well the contract we’ve had with AMR since 2018 includes many, many provisions about what the County will do, what AMR will do. And one of the parameters, there’s nearly 200, one of them, is the one you mentioned at the top of the show, which is 90% response within eight minutes for the highest priority calls.

Miller:  Why is that? And the company didn’t meet that?

Lewis:  Correct. We’ve contracted with AMR since 1995 in Multnomah County. And I’m not aware…there may have been small fines that may have been forgiven in the past… but this problem has been going on for approximately 16 months now. And actually 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. And it may be having some effect with a smaller number of late calls since it was imposed.

Miller:  What do you mean by that? Response times have already improved?

Lewis: Well, the rough numbers I have are that there were, I think in August, 1,800 late calls and in November there were only 700.

Miller:  Why is the response time so important? What’s the connection between average outcome and response time?

Lewis: That’s another great question, Dave. We actually emphasize different outcomes. We emphasize survival after cardiac arrest. There’s a big national registry on that. And Multnomah County is in the top 10% in the entire country for survival after cardiac arrest. Our medical director, Dr. Jui, attributes that not only to the advice that the 911 dispatchers give to the people on the scene, how to give CPR, how often, to the fire first response particularly, and then to the two-paramedic response, which literally allows ICU care to be delivered in the field and while being transported to the hospital.

Miller:  So let’s turn then to this question of the two-paramedic ruling. As people who may have been paying attention over the last few weeks may have heard, that’s at the heart of the disagreement now between you, the County, and the company, because they say that the response times they’ve been providing recently, are a direct result of the confluence of two things: a nationwide shortage of paramedics and the County unique two-paramedic rule. Why does the County have this rule?

Lewis: Yeah, another great question, Dave. So the national standard across all of EMS is to have two paramedics on these high level responses. It doesn’t say how they have to get there. It just says the standard is to have two. So two paramedics is standard. It’s standard actually in Washington and Clackamas County. It’s just organized differently. So “unique” is really the wrong vocabulary word here. It’s the national standard to have two paramedics.

Miller:  Now I’m deeply confused because AMR has said, and we’ll talk to them in a few minutes, that they provide 911 ambulance response all over the country and that out of 267 operations, and I think it’s 49 states, Multnomah County is the only one with this requirement. So what am I misunderstanding?

Lewis: Again, other jurisdictions that meet the national standard may provide the paramedics in a different way, but just as a counterpoint, AMR does not have a monopoly around the country. And San Diego, Denver, Seattle, Minneapolis, Boston, Houston, New York City, Pittsburgh, San Antonio, LA County, all have two paramedics on an ambulance. So I think the use of the word “unique” is really inappropriate.

Miller:  When you say they may provide a second paramedic in a different way, meaning not an ambulance. Is it just that somebody’s showing up in their Ford Focus? I mean, what does it mean?

Lewis: Every county organizes its ambulance service in a way that meets its needs. So for example, in our neighboring counties, they have a different system where AMR can provide one paramedic because they have an agreement with their fire agencies to actually be the first ones to get there on every call. So it’s a different system than we have in Multnomah County, where if we were going to have the fire agencies respond to every 911 call, we’d need twice the size of our fire department. And I think that’s the important point when these comparisons are made to neighboring counties.

They’ve worked really hard on their plans just like we have to provide the best service to the residents. And each one is different. Those counties have something called fire districts whereas we have fire departments that are part of cities. They’re different systems. And again, I want to emphasize that Multnomah County has outstanding survival rates compared to the rest of the country with the most severe cases. And we’re not willing to compromise or experiment with that quality.

Miller:  Have those survival rates that you’re saying we should be proud of and that you’re saying are tied to the two-paramedic rule, at least on some level, gone down over the last 16 months as response times have gone up?

Lewis: Yeah, that’s the million dollar question. This kind of data is always lagging by a couple of years. I think I’m quoting from ‘21 or ‘22 but we don’t have more recent data than that. But that’s clearly something we’re looking at. By the rough review, Dr. Jui thinks that the outcomes appear to be about the same this year. And fortunately on many of those responses, we do get not just two paramedics but three paramedics because we have fire there as well. And if you can imagine your television scene of the ICU, you need a lot of people when someone is basically dead and you’re trying to revive them. More hands is better.

Miller:  From just the perspective of a county resident who wants a couple of things, I think the most basic thing is they want to know that if they or a loved one has a heart attack or has some emergency, that they have the best chance of getting care as soon as they can get it and of surviving. There’s also the question of county taxpayer money going to services. And if there’s some contract, we want that contract to be honored. We want to get the services that we are paying for.

The question of the fine though, seems a little bit different to me. Let’s say that AMR, their appeal doesn’t work and they give you the half a million dollars. How is that going to help response times?

Lewis: The fine structure and what the fines can be used for is all specified in the contract. Any fine money has to be used for what’s called system enhancement, which is making things better. And typically in the past, with smaller fines, it goes to buying stuff like defibrillators or better equipment. This is a different magnitude and a group will need to be convened to figure that out.

Miller:  But you can’t buy new paramedics, right?

Lewis: Fair enough. But Dave, I wanted to clarify one thing you said, that “county taxpayers want to get what they’re paying for.” The County doesn’t pay AMR. AMR is a regulated monopoly. They get to go on every single 911 medical call. No one else is allowed to. And in response, they need to follow the contractual requirements that they agreed to in 2018 and then renewed just recently in 2022, which included the two-paramedic requirement.

Miller:  Well, if County taxpayers are not paying AMR who is?

Lewis: It’s the health insurance market. They have exclusive right to bill insurance for ambulance transports and they got a substantial increase in their fees in 2018.

Miller:  What options are you saying AMR has right now? As we’ll hear in just a few minutes, they say that this is because there aren’t enough paramedics. And, “even if we wanted to, we couldn’t hire more,” and that’s the hold-up. What options do you think the company has?

Lewis: Right. So, [since] more than 12 months ago, we’ve been working with the County. Ever since the response time failure began.

Miller:  With the company?

Lewis: Yes, without financial penalty. And I proposed [to] them more than 12 months ago that they could start using two EMTs, which they wanna increase in their system, on that basic life support ambulance for the low acuity calls like sprained ankles and spider bites. They didn’t start hiring for that until well into this year and didn’t really launch it until this summer. And they can’t find enough EMTs to staff the basic life support ambulances. So we find it a little inconsistent for them to say all we need is more EMTs when they can’t even find enough EMTs to run the pilot project that would take pressure off those advanced life support ambulances.

Miller:  OK, so that’s an extra wrinkle, I mean, a reason that you are mistrustful of what they’re saying. But what options do you think they have?

Lewis: Well, we think that continuing to expand and evaluate that pilot project with a basic life support ambulance for the simple calls will take pressure off the paramedic units that we rely on for the high quality, most urgent care.

Miller:  Paul Lewis, thanks very much.

Lewis:  Thanks for having me, Dave.

Miller:  Paul Lewis is the deputy health officer for Multnomah County.

Randy Lauer joins us now, he’s the Vice President of Operations for AMR which has the exclusive ambulance contract with the County. It’s good to have you here.

Randy Lauer:  Thank you.

Miller:  On what grounds are you appealing this fine?

Lauer: I think the core of it is that we don’t have an ability to fix the problem with a fine. And listen to Dr. Lewis. Because we’re kind of curious about what the County would apply that fine money for. And it would be a lot of the same things I think we’re already spending money on. For example, we spend about $120,000 a month on incentives, incentivizing people above overtime to cover open shifts. So if we just use that money from fine money versus our regular finances, what’s the real difference? It won’t do anything different. It’s just taking the money from a different bucket.

And then scholarships are another thing, like in Clackamas County. Clackamas County, rather than fining us, asked us to invest that money into paramedic scholarships, which is a full ride scholarship at the paramedic course we have in Clackamas County. That is about $18,000 a year. So we have now both of the classes, the cohorts in that college, full largely with scholarship students and I think a little over 30 total EMTs in paramedic school right now.

Miller:  That is a medium-term solution, right? I mean, we’re talking about an immediate shortage and now diverting, in Clackamas County, some fine money so that, in the pipeline there are future EMTs or eventually paramedics. But what about right now?

Lauer: Yeah. No, you’re spot on because I would think this is both a short-term and a long-term problem. My thoughts have been, it’s gonna take another year to two for this unprecedented national paramedic shortage to resolve. I’m hearing lately from academic folks who study this, that it’s more likely to be four years. So we need to plan short-term and long-term. First thing is we need to solve the problem short-term, right now, so we can start fielding more ambulances right away.

Miller:  Well, what is the problem as you see it?

Lauer: The problem is the unprecedented national paramedic shortage.

Miller:  So what’s the cause for that? Why are there not enough paramedics?

Lauer: A lot of people may not have understood the impact of this, but the paramedic schools closed down for at least two years. So that’s one of the larger drivers. The other thing that occurred specifically in Multnomah County, in the beginning of the pandemic, we had a lot of civil unrest. We have had an explosion of overdoses and fentanyl use and behavioral health. So our call volume along those kinds of calls has gone up dramatically.

Miller:  More in Multnomah County than in, say, Washington or Clackamas? I mean, the civil unrest was more acute, clearly, in Portland than, say, in Beaverton. But we’ve heard about fentanyl overdoses all over the country?

Lauer: I think you’re correct. It’s not specific to Multnomah County. I think it’s amplified in Multnomah County because there are more unhoused individuals, there are more people who are substance addicted, and there are more people who are mentally ill. It’s more of a concentration of those folks in Multnomah County.

Miller:  So what effect has that had on the workforce?

Lauer: Our paramedics wear ballistic vests. About two years ago, we had a paramedic stabbed by a mentally ill patient. They get assaulted. Most paramedics will tell me that during a four-day rotation, where they work four 12-hour shifts in four days, they’re gonna get assaulted at least once. So it’s dangerous. It’s risky to our paramedics. We’re still running the same number of calls. But today, we are 18 ambulances short or 18 shifts short. We should deploy 50, 12-hour shifts every day. We’re only able to deploy 32. So you’ve got 32 shifts, ambulances, is running the same number of calls that 50 should be running. So you can imagine that extra workload on the people who are out there working. And that’s burning them out.

Not only the nature of the calls being more of a risk and a threat to them but also just the volume of calls. They’re running back to back and back and late calls that run that 12-hour shift into a 14-hour shift. And they’re just getting fatigued. They’re leaving the industry. It used to be that all of our turnover went to the fire service, which was fine because we continue to work with the fire service, taking care of the same patients. And that familiarity I think is good for patient care.

Miller:  They were doing the same work. They just had a different paycheck?

Lauer: Exactly. A different uniform.

Miller:  Now, where is it a highly trained worker will go if they want to keep working, but they no longer want to be in an ambulance?

Lauer: A lot of them still go to the fire service. The fire service had the same problem during the pandemic. A lot of people didn’t retire because of the uncertainty around what the future looked like. And they didn’t promote and they didn’t hire. So then, all of a sudden, we get out of the pandemic and they’re short staffed as well. So they’re hiring to replenish their ranks. And a lot of that comes from companies like AMR. But then in addition to that, I talked to a paramedic last week who’s gonna finish nursing school probably this week. And he’s gonna leave and become a nurse.

So people are going for more of a brick and mortar environment, where they sense it’s safer to provide health care. But some people are just going to totally different industries. 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.” So that’s kind of what’s happening. There’s sort of an exodus of paramedics from Multnomah County.

We have, at the last count, 12 Multnomah County paramedics who want to transfer to Washington County, where we began providing service on August 1st of this year. But we’ve not let anybody transfer because we’re not gonna rob Peter to pay Paul. So those 12 paramedics who want to work in Washington County are still in Multnomah County.  Washington County is very close to being fully staffed. Clackamas County is closer, and that’s because they have a paramedic EMT model versus a two-paramedic model. 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. That’s a big hole in paramedic availability.

Miller:  So let’s turn to the solution that you have been very public about pushing for,  that your company sees in recent weeks or recent months, which is Multnomah County scrapping its two-paramedic rule and going to one EMT and one paramedic. As you heard from Paul Lewis, he says it’s not fair to say that Multnomah County is unique in this because other paramedics arrive on the scene, say from a fire district. And he also points to many other large cities that aren’t served by AMR. Places like San Diego and Denver, Seattle, Minneapolis, Houston, New York City, LA County, he says, do have two-paramedic rules. So why are you so focused on the County changing this requirement?

Lauer: It’s a temporary change, to solve the problem and to get the 50 shifts a day filled. And if they would allow paramedic EMT staffing about half of our shifts, we could fill with paramedic EMTs.

Miller:  How quickly?

Lauer: Within two days, we could staff four to six more ambulances every day. Within 3 to 4 months, we’d have all 50 shifts filled.

Miller:  I’m a little confused because he said that for the Basic Life Skills program, which he said is about a year old - the idea there being, if you get a sprained ankle or a spider bite, which, as you said, is a different conversation. I still don’t know why an ambulance should be going there at all. But we’ll set that aside. He said that for that program, your company has said you haven’t been able to hire enough EMTs for that. If that’s the case, how can you say that there are currently enough EMTs where you could immediately or within days staff more EMT/paramedic ambulances?

Lauer: Well, first of all, I’d like to address that BLS, Basic Life Support, pilot, which isn’t working. And it isn’t working because we can’t keep EMTs on those ambulances. We’ve hired and trained over 50. But they leave when an EMT opens. If an EMT wants to transfer, they get to transfer. So, an EMT opening in Clackamas County, because one of their EMTs became a paramedic or something, one of those BLS pilot EMTs will transfer to Clackamas County. They would rather work on an advanced life support ambulance than they would on a basic life support ambulance.

Miller:  Do they get more money?

Lauer: No, and here’s the reason they’d rather work with a paramedic on an advanced life support ambulance. On the BLS ambulance there’s another EMT. They’re very restricted in what kind of calls they can go on. Many of them still require that the patient be assessed by a paramedic before they’re even called. And in talking to paramedics, in that scenario, they say by the time we get to the call, we do a full assessment of the patient, the hospital is probably five or six minutes away, the BLS unit is 20 minutes away. We’re just gonna transport to the hospital. So that’s an example of why it’s not efficient and why it’s not working.

Miller:  So you’re saying, this is an important point, you’re basically saying that the pilot was good to have. We now know we should not make this a broader program?

Lauer: The pilot is really driven because the 911 center hasn’t had enough time yet with the newer dispatch system that they’ve adopted to get sophisticated enough to know when to send a BLS unit instead of an ALS unit. Conversely, like in Clark County which has a paramedic EMT system and BLS units, the 911 center there can directly dispatch the BLS units. Same situation in Washington County. In Multnomah County, the 911 center can’t directly dispatch the BLS units and that’s why they’re ineffective. I think we need to put a fork in the pilot. I think we should put a paramedic with an EMT on those units, make them an ALS unit and you solve the problem quickly rather than try to run around with the pilot that’s not really working.

Miller:  The sense I got from Paul Lewis and certainly the sense I’ve gotten in previous interviews and reports I’ve read from Multnomah County officials is, they’re not interested right now, at least publicly, in scrapping, even temporarily, the two-paramedic requirement. That might change but I’ve seen no evidence yet that they’re interested in doing that. So, where does that leave us?

Lauer: Well, there’s a bit of a myth that’s been propagated by the medical director. And Dr. Lewis actually talked about it. He said that you need two paramedics on the scene of a critical call. I don’t disagree with that. He’s absolutely true. Right now, on the scene of a critical call, we have three paramedics and three EMTs -  two paramedics from AMR ambulance, one from the fire engine and three EMTs and the fire engine. What we’re proposing is that we have two paramedics and four EMTs. So we put an EMT with an AMR paramedic. 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. Just one more being an EMT.

Miller:  What I’m asking is what happens if they say “No, we don’t want to do that?”

Lauer: Then we’re stuck with this problem that is gonna get worse. And that’s the thing that really keeps me up at night. We are in crisis now. We are headed for an absolute catastrophe just by the number of more openings we’re having every month. We cannot sustain a two-paramedic system in Multnomah County until a paramedic crisis is overcome and we have trained and graduated enough paramedics. And now people are saying that’s two to four years out. So let’s do this temporarily until there are enough paramedics. And then we get back to a two-paramedic system in all the ambulances. But it makes no sense to me for people to suffer for the next two to four years because the County can’t get over whatever is holding it up on this two-paramedic system. Again, it’s only one of 267 operations AMR has in the country that has a two-paramedic requirement.

Miller:  You knew about this requirement when you signed the contract, right? So what has changed since the most recent contract was signed?

Lauer: The 2018 contract was pre-pandemic. Everything was fine going through 2019. When the pandemic hit in March of 2020, our call volume dropped 30% almost overnight, because people were afraid to go to the hospital, afraid to access health care. And that persisted for a while. So we had all kinds of extra staff. And then the wheels started shifting quite a bit. In about March of ‘22 we really started getting into this crisis level of paramedic shortage. So that’s been a year and a half ago and it’s only gotten worse in that year and a half. And it’s gonna get worse in the next year and a half.

Miller:  Randy Lauer thanks very much.

Lauer:  Thank you.

Miller:  Randy Lauer is vice president of operations at American Medical Response.

As we’ve heard, one of the overarching issues in the slow response time for ambulances is a shortage of paramedics and EMTs. Dave Schappe is one of the people who is trying to change that. He is the EMS programs director at Central Oregon Community College. Welcome to the show.

Dave Schappe:  Thanks for having me.

Miller:  How do you explain the nationwide paramedic and EMT shortage right now?

Schappe: Well, that’s a difficult thing for me to do. I’m no expert on the nationwide shortage. I’ve read the same articles as other people and certainly every region has its own level of struggle. But there’s a lot of conjecture about whether it’s because the job is more stressful, whether it’s because during the pandemic there were so many retirements. There are people who claim that in areas where educational requirements are higher, that the shortage is worse. There are a lot of different perspectives.

I would say that being in Central Oregon, we have sort of a microcosmic view of this problem. We don’t have the same level of shortage in our region that other regions do. And certainly we’re at the other end of the spectrum from what Randy is experiencing in Multnomah County.

Miller:  How do you explain that?

Schappe: We have a public-based EMS system largely, here in Central Oregon. So our students are generally linked with agencies when they’re in our paramedic program. So we have a current cohort of 24 students, which is our full class size. And all but three of them are already affiliated with a regional EMS provider. So while I have a very strong relationship with Randy’s operation and send our students for internships and experience at the end of our program to Multnomah County, they choose to remain here as employees of public agencies. So like Randy was saying, a lot of the training effort of the private agencies in cities like Portland goes to get people to a certain level.

They get a lot of experience in the street, treat a lot of really sick patients, and they will take that experience to the partner agencies that are public, for a number of reasons.

The paycheck is different, the benefits are different. People have just a different perspective on the job in these public agencies sometimes. But here, the students go from public to school and then back to public. So a lot of them are sponsored by the regional EMS agencies when they’re here.

Miller:  One of the big issues that was threaded in my conversations with both Paul Lewis and Randy Lauer is the question of EMTs versus paramedics. How is the training for them different?

Schappe: Well, the training for them is actually very different, only in its depth. So essentially, an EMT traditionally is a very skills-based program and it’s a much shorter program of study. We do it in two terms, and I say “traditionally” because this is changing rapidly, especially right now and especially in the State of Oregon. It was very much skills-based, younger students learning how to learn and learning how to do things like splinting and taking care of medical emergencies in ways that don’t have a lot of risk for patients. There’s a really great risk versus benefit ratio for basic life support. Then when you move to advanced life support, you start pushing poison into people’s veins directly. And so the risks go way up.

Miller:  When you say “poison,” things that, if not dosed correctly, could kill you, but if dosed correctly, could save your life?

Schappe: Exactly. The only difference between a poison and a medication is dosage. So medication errors change the nomenclature. They change it from being something that’s therapeutic to something that can be life threatening or can at least harm patients. So there’s a lot more background education, anatomy and physiology and pathophysiology and all the things that go into understanding how these medications work, as opposed to a basic life support level. The medications that they’re utilizing are extremely low risk and they’re not directly injected into patients for the most part.

So that piece is very different. However, the thing that I would really stress is the foundations of medical education. Basically gathering data from patients through patient assessment and history, communicating effectively in order to get that information, and generating trust and then doing the most effective interventions for most patients. That all occurs at the EMT level. At the paramedic level, essentially the way I describe it is, it just increases the size of a practitioner’s toolbox.

Miller:  In terms of very basic things like how long it takes to get these different levels of accreditation and how much money you might have to spend, what’s the difference?

Schappe: Oh, the difference is vast. You’re looking at less than six months to become an EMT and you’re looking at, in a state like Oregon, between two and three years to become a paramedic. And personally, I really think there’s more than one question being asked. I think that what Randy was saying, it really comes back to what do we want? I mean, do we want an ALS-level practitioner arriving on a critical medical scene within eight minutes? And only one of those people being a paramedic and the other one being a well-trained EMT? Or do we want to wait 25 minutes for two paramedics to show up when we do have some very time-sensitive medical emergencies. And the people who are on scene are waiting for those paramedics may not be ALS-level practitioners, depending on where this is occurring.

Miller:  Well, I mean, when you put the question that way, the answer is a given. That’s not a difficult question for anyone to answer, if those are the only two options. The difference between eight minutes and 25 minutes is probably bigger than the difference between two paramedics arriving at the end of those 25 minutes. Right?

Schappe: I think that’s fair to say.

Miller:  But I guess the question for you is, are those two scenarios the most reasonable ones? In other words is it possible, do you think, to have two paramedics arrive within eight minutes in Portland right now? Randy Lauer says “no.” Paul Lewis and Multnomah County say, “Make it work somehow because paramedics have such better training that you need them for critical calls.” Where do you fall down here?

Schappe: First of all, I think Randy is the only person who’s going to be able to tell you that they’re down 18 shifts a day in Multnomah County. But my students do go and do their internships in Multnomah County and I review all their charts. And I actually was on the phone with a Multnomah County medic last night who is a precepting one of my students. And they did a 17-hour shift instead of a 12-hour shift. And they did 14, 13, 12, and 13 calls in their four day rotation. And he was pretty exhausted. I would say that if Randy could fill those shifts, he would.

Now full disclosure: I’ve known him a long time. I’ve worked for AMR and GMR before this for a long time and I have the utmost respect for Randy. And I don’t think he wants to do anything that’s not gonna benefit the County. I also know John. So I have a sense for what his desires are. But it does feel a little simple to me that if the supply is not there, and there’s no way that we can speed the supply up at least in our region to get our students to go and work in Portland when they finish here when they already have jobs lined up in Central Oregon. So I don’t have a solution other than the one Randy is offering.

I think everybody is probably open to other solutions. But I would just contrast it with the situation in the hospital emergency department. Do we have to have 15 doctors to get a physician level of care? Or can nurses who have less training, under the direction of a doctor, be delivering doctor-level care? Can an EMT and a paramedic on scene be delivering paramedic level care or does it take two paramedics to do that, in addition to whatever the first response level is?

Miller:  Just briefly, going back to the question of the exodus from the field, you were a paramedic in Multnomah County earlier in your career. If you are starting your career out right now, would you still be interested in a career as a paramedic?

Schappe: Yes, I mean, I love the job and the only reason that I went upstream into paramedic education was because I was training one person at a time and AMR approached me about taking over their college that was, then, located in Beaverton. I really do miss treating critical patients. I also remember what the job was like then. And I know it’s different now. It really is. At least in Multnomah County, it’s different because the utilization of those units is so high and the level of violence against the practitioners is so high. I mean, it just wasn’t like that before.

Miller:  Dave Schappe, thanks very much for your time.

Schappe: Absolutely, thanks for having me.

Miller:  Dave Schappe is EMS programs director at Central Oregon Community College.

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