‘Only one pathway forward’: AMR stresses short-term fix, Multnomah County chair refuses to budge

PORTLAND, Ore. (KOIN) — American Medical Response — better known as AMR — is short nearly 60 paramedics. They’ve been fined by Multnomah County for slow response times. Sometimes they have no ambulances to send to the growing number of emergency calls. The burnout among first responders continues, with no immediate relief in sight.

Multnomah County Chair Jessica Vega Pederson said her priority is to “take the action needed to make sure paramedics get to life-threatening emergencies within 8 minutes 90% of the time.”

But that hasn’t happened for nearly 2 years. Currently, AMR crews are only getting to calls fast enough 60% of the time.

Patients in recent months have been taken to hospitals in TriMet buses, fire engines, fire SUVs and police cars because the nearest available ambulance was a dangerous distance away.

AMR Operations Manager Rob McDonald said it’s not realistic to maintain Multnomah County’s dual paramedic requirement right now, during a nationwide paramedic shortage.

For decades, Multnomah County has required a 2-paramedic system to boost cardiac arrest survival rates. While in office as chair, Vega Pederson has insisted maintaining the dual paramedic staffing standard for that specific reason.

The national and state norm is the 1:1 model — that is, one paramedic, one EMT per ambulance.

“We want to turn over every stone. We want to make every effort to try everything we can try. But I think we’re at the point now — and we’re confident we’re at the point now — where there really is only one pathway forward to sustainability in EMS in Multnomah County,” McDonald said.

That pathway, he said, is “going to half of our total deployment being paramedic and EMT, rather than dual paramedic.”

If Vega Pederson authorized the switch for half of the ambulances to move to the 1:1 model, AMR said they could immediately have 6 more ambulances out a day and be fully staffed in a few months.

Last week, Portland Fire’s interim chief, Ryan Gillespie, wrote a letter to the county’s medical director and health operations manager imploring local officials to address AMR’s response times.

In the letter, first reported by The Oregonian, Gillespie urges Multnomah County to change its two-paramedic requirement to a one-paramedic-one-EMT requirement, adding that the current “status of ambulance service in the City of Portland is unacceptable and is putting lives at risk.”

Temporary change?

McDonald said AMR would embrace this as a temporary change.

“We want this to be temporary, too. We’re not trying to completely redesign the system on a permanent basis,” he told KOIN 6 News. “What we’re really trying to do is just survive and without this move, I don’t know that the system will survive this year.”

But Vega Pederson doesn’t see it that way. She said she is not interested in temporary changes.

“It is on AMR to be able to staff up and to provide the services that they’re contracted to do for us to be our EMS provider,” the Multnomah County chair told KOIN 6 News.

She blames the fire department, the local and national paramedic shortage and the ambulance contractor for falling short.

“I think that we shouldn’t have to be coercing AMR to do anything,” she said. “They are a business. They are a for-profit business to operate nationwide, who is contractually obligated to provide the services, right? They get paid by the service fees that they’re able to charge to people when they do this.”

AMR said, historically, they’ve been profitable in Multnomah County. Public records show AMR’s margins are dropping in the county since the pandemic ended.

In 2018, they closed with $2.3 million in profit. But in 2022, their annual statements revealed around $293,000 profit.

McDonald said the main reason they ended last year profitable was because they were short-staffed — that is, they had fewer people to pay.

“This system is in critical condition and the inactivity is so disconcerting because this isn’t something that’s going to get bad in a month or two months,” he said. “It’s bad now and it could get so, so much worse in the coming months.”

While paramedics, firefighters and dispatchers work desperately to keep the system functioning, Vega Pederson is talking about pilot projects and studies.

“To change our current contract and to look at the changes to our Ambulance Service Plan, which does require two paramedic model, that is absolutely something that I’m open to doing. It is not a short-term solution,” she said. “We are at the point where we have to take a look at the entire system and really see what’s going to be a good long-term solution.”

There are several possibilities under discussion, including a full Ambulance Service Plan assessment to produce recommendations, including potential revisions to the staffing model. However, she would not go into specifics.

The 1:1 model

Even the Multnomah County Medical Director recognizes the county’s 2-paramedic model is failing. On January 1, he authorized ambulances from neighboring counties staffed with the 1:1 model to transport patients with life-threatening emergencies when a 2-paramedic AMR ambulance in the county is delayed by 5 minutes or more.

During the ice storm, those delays were often measured in hours.

At the height of the storm there were only 5 ambulances covering the entire county of more than 800,000 people. Fully-staffed, there would have been 16 ambulances. During the day fully staffed, there should have been 25.

McDonald said that, as an organization, AMR “has done everything they possibly can to educate the medical program director, to educate the county chair that the only path forward to sustainability is to convert our deployment to 1:1.”

Multnomah County leaders have not presented any evidence the 2-paramedic staffing model offers any benefits when response times are delayed.

In the on-camera interview, Vega Pederson notably omitted any mention of cardiac arrest or survival rates. This shift in stance follows a recent KOIN 6 investigation revealing that Clackamas County has consistently higher cardiac arrest survival rates over the past five years with their 1:1 model. Additionally, it was found that PF&R responded to 99.9% of cardiac arrests in Multnomah County in 2023, resulting in three paramedics being dispatched to the scene.

“I think ultimately what we have, though, here in Multnomah County is that we don’t have a fire (department) that’s responding to all of the ALS calls, the advanced life support calls,” Vega Pederson said. “So we need to continue to have a 2-paramedic model.”

The Multnomah County EMS Office does not require fire agencies to respond to every call, only calls where they might be needed.

“This is also a question for the fire agencies,” Vega Pederson said. “Currently, they do not go out on all of Multnomah County’s calls, which is the protocol for counties that use a 1:1 staffing model.”

KOIN 6 checked with Clackamas and Washington Counties that operate with the 1:1 staffing standard. The neighboring EMS officials said they do not require their fire departments to go to every single medical call.

Meanwhile, Portland Fire & Rescue confirmed they go to all the high priority calls they’re dispatched to and required to respond to by the Multnomah County EMS (MCEMS).

But AMR is required to respond to every single advanced life support call. With increasing frequency, they can’t.

For her part, Jessica Vega Pederson understands the frustration.

“I understand the concern and the worry that people have when they’re calling 911, if they need help and they’re not able to get an ambulance, they’re not able to get a transport that they need,” she told KOIN 6 News. “That is really critical. That is a system that is not working.”

But at this point, collaboration on this issue is not in sight.

What paramedics think

The county has pushed AMR to use their school to hire more paramedics. AMR has invested around $750,000 in full-ride scholarships to train 35 new paramedics. But graduation is 2 years away.

Multnomah County started a pilot program in 2023 to help speed up response times. It staffed a fleet of ambulances with 2 EMTs for less serious calls, but it hasn’t worked. Vega Pederson said that was because AMR couldn’t hire enough EMTs.

EMTs, AMR and the union said it’s not an attractive job opportunity. Most EMTs want to work on the front lines to gain experience at serious calls. So they’re going to neighboring counties that staff their ambulances with the 1:1 model.

Vega Pederson has also urged AMR to assign paramedics to work in Multnomah County. However, the paramedic union contract prevents AMR from doing that. Though, AMR said they have denied more than a dozen requests for paramedics to leave Multnomah County to work in Washington County.

“That may change should they complete and bargain their union contract, in which case we’ll be obligated to allow those transfers,” McDonald said. “At this point, I have 14 people on that list that I will not be able to stop from transferring to Washington County should they unionize.”

Paramedics seem to be split on the issue. Some feel very strongly they want to maintain the dual paramedic system through this shortage. But others are exhausted and are open to the idea of a temporary switch.

Publicly, the union has supported the dual paramedic system but has not offered ideas for how to speed up response times.

If Multnomah County were to allow AMR to implement the 1:1 model, McDonald said “we’re open to any conversation” about renegotiating the billing rates for patients. However, the company wants to reinvest any cost savings into creating a nurse navigation program at the 911 dispatch center, like the one that’s seen success in Clark County.

It triages minor medical calls that may include transportation to a local clinic, urgent care or ER. The patient and a licensed nurse make that decision together.

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