Fire Service Steps Into the Breach During Private Ambulance Strike
When a private ambulance company was hit by a 63-day strike, the fire services in Miami and Dade County, Fla., stepped in to maintain emergency medical service.
Planning for the possibility of a strike started last March 12 when Chief D. A. Hickman of Miami, chairman of the Dade County Mutual Aid Organization, called to order a meeting of the board of governors to discuss the situation facing the Randle-Eastern Ambulance Company.
At that time, Randle-Eastern was the exclusive provider of emergency ambulance service for all of Dade County under a county contract. This contract required Randle to provide ambulance service 24 hours a day with a maximum 15-minute response time anywhere in the county. Randle-Eastern was subsidized by Dade County and its operation was monitored by both Dade County and the State of Florida.
To provide response times within the specified limits of the contract, Randle-Eastern was operating 39 ambulances within the 1998 square miles of Dade County (289 urban, 685 rural, and 1024 other).
Dade County is a highly urbanized area with approximately 1.4 million residents. This county is made up of 26 cities, all of which have their own political hierarchy. Most have their own police departments and nine provide their own fire and rescue services. At this time, fire services in Dade County were operating 30 fire/rescue emergency medical care units and providing advanced life support in a fashion possibly unique to this area. Initial requests from citizens for emergency medical service routinely required the dispatch of a fire/rescue unit and a RandleEastern ambulance. Usually the fire/ rescue units arrived in four to six minutes, and the Randle-Eastern ambulance in less than 10 minutes. With this double-barreled attack on sudden illness or serious injury, we were able to instantly mobilize 69 emergency medical service vehicles that were staffed by 170 professional EMTs (on-duty personnel).
A review of data for June 1974 through May 1975 showed that Randle-Eastern responded to more than 50,000 incidents, which resulted in 36,000 transports—144 to 163 patients transported each day during March, April and May. This data gave us a handle on the number of transports we might expect. Because most fire/rescue units were capable of transporting at a higher level of care than Randle-Eastern ambulances, these units traditionally had been uged to transport the critical patients (around 2 percent or less), and were not reflected in daily averages.
In Dade County, an emergency medical service ordinance requires each emergency medical rescue unit to be manned by a minimum of two advanced level paramedics, while Randle meets the state requirements of one basic level EMT attendant and a driver with American Red Cross advanced first aid credentials. We felt that there was a good working relationship between the fire service and Randle-Eastern management and employees that resulted in high-quality EMS care and transportation for citizens.
At our meeting, the Mutual Aid Organization plan, which provided mutual aid for fire and disaster, was amended to include assistance for emergency medical service.
To further plan for the imminent strike, four committees of mutual aid members were formed:
Operations committee: Develop a plan for handling requests for emergency medical service assistance in cooperation with the police department, local hospitals, medical associations and the Health Systems Agency of South Florida. Quantify resources, manpower, vehicles, and equipment on a countywide basis.
L,egal committee: Explore legal questions, such as transportation to the nearest hospital in lieu of patient’s request for a specific hospital. What would be the ramifications of releasing a patient to a police officer, who is not an EMT, for transportation? What about professional liability insurance coverage under these circumstances?
Public information committee: Solicit public cooperation and prepare releases. Educate the public about the problem to reduce unnecessary calls.
Communications committee: Explore methods of screening calls and devise a system of interdepartmental dispatching and status reporting.
It was recognized that a strike by ambulance company employees expected at midnight March 31 could present financial problems to local governments because of the burden of overtime pay and the purchase of equipment. It was suggested that this was an in-house matter for each chief to discuss with his city manager. It was unanimously agreed that each city would try to handle all emergencies and transportation of the sick and injured within its boundaries. When these resources were exhausted, members could request aid from the Mutual Aid Organization.
These were the sticky issues at this point:
- Ambulance company employees were members of the Transport Workers Union. The fire fighters belonged to the International Association of Fire Fighters. What would happen if fire fighters were ordered to man RandleEastern ambulances?
- Patients ordinarily were taken to the hospital of their choice. Because of patient and physician relationship, this is how the Dade County Medical Association preferred it to remain if at all possible. Under the circumstances, fire chiefs were more inclined to take patients to the nearest hospital capable of handling the patient’s illness or injury.
- Where would funds for communications (mutual aid center) come from (hot line to each fire department, status board, etc.)? How could we screen calls better to eliminate needless responses?
- Would state and county laws regarding criteria for personnel and vehicles be waived during a strike?
- Could municipal boundaries be ignored during this emergency? Could some units respond routinely to cover territory in other jurisdictions? Could manpower be lent to upgrade other cities’ capabilities?
- How would citizens react in areas where fire/rescue units were already overutilized?
Most of the serious questions raised were resolved at our next meeting.
Because of the possibility of a confrontation with the Transport Workers Union, all thoughts of using RandleEastern ambulances were scrapped. An inventory of fire/rescue resources proved to be encouraging. We found that 42 vehicles with stretcher transport capability could be put on the road.
Many fire fighters skilled in basic life support and advanced life support were rediscovered in the fire combat force and were later used to man additional emergency medical service units. Engine companies continued to supplement rescue units as necessary.
The police departments pledged their support and agreed to respond on request to transport stable patients who could sit up. Many public service aides were used from 7 a.m. to 9 p.m. daily. These PSAs are employed by the police department to handle non-emergency police work, such as parking enforcement, minor violations, report writing, etc.
At this point, we felt that we were in good shape except for peak hours and the possibility of a major incident with a large number of casualties.
Decisions by paramedics
It was decided that during the Randle-Eastern strike, it would be the responsibility of fire/rescue paramedics to decide whether emergency transportation was necessary for patients. If not, they were to recommend alternate modes of transportation, such as police cars, or refer the patient to the Yellow Pages, private autos, taxis, etc. All patients needing treatment or observation during transport to a medical facility would be transported in a fire/rescue vehicle. This would include patients with prophylactic I Vs, medicated patients, semiconscious or unconscious patients, irrational patients, poisoning, overdoses, patients with unstable vital signs, etc.
It was decided that, during the strike, all patients would be taken to the nearest hospital emergency room capable of handling the illness or injury. The president of the South Florida Hospital Association and chairman of the Dade County Medical Association’s emergency medical service committee were contacted and assured us of their cooperation. A letter was sent to all members of the Dade County Medical Association and South Florida Heart Association, explaining the situation and requesting assistance.
The Medical Examiner’s Office informed us of its actions to increase its ability to handle DOAs, which were previously handled by Randle-Eastern.
Randle-Eastern management appeared before the Mutual Aid Organization and said they would be able to staff about 10 units with supervisory personnel for emergency service. However, it was decided that all dispatch centers would refer citizen, hospital, and nursing home requests for routine ambulance transportation to any of three local companies listed in the Yellow Pages. No emergency calls would be referred to Randle-Eastern by fire/rescue because of the uncertainty of its ability to provide service.
To upgrade mutual aid communications, Miami installed hot line capabilities to all dispatch centers in the “war room” (mutual aid center) and a status board was made to show all medical rescue units’ status. Also, a decision was made to function in the following manner:
- All dispatches of units were to be reported to this office.
- All requests for mutual aid were to be handled through this office.
- A high-ranking officer from each dispatch center was to be assigned to the mutual aid center (decision maker).
- Veteran emergency medical rescue officers were assigned to assist in screening calls and act as police department liaison from 8 a.m. until midnight daily.
Research of state and county laws revealed that all regulations were set aside during a crisis such as a disaster or strike. Full support was offered by the state Division of Health and a special resolution was passed by the Dade County Board of Commissioners.
Dispatch zones changed
Plans to set up predetermined automatic dispatch zones outside jurisdictions were approved. This allowed emergency medical rescue units from one jurisdiction to automatically respond to designated areas in another jurisdiction. This plan actually reduced response time to citizens in many cases. One city had a quality modular ambulance with basic life support capability that responded to an area of only 1 square mile. Two paramedics from other jurisdictions were assigned to this ambulance along with telemetry, defibrillator, drugs and IVs, and this unit’s territory was quadrupled.
A special news release was prepared for all radio and TV stations and several interviews were set up on local news programs. Coverage was outstanding and the reaction of the citizens was in the best American spirit.
At midnight March 31, RandleEastern employees went on strike and it was necessary for fire/rescue to assume the responsibility of all emergency transportation for 1.4 million residents. We were put to the test on the second day of the strike when a major fire broke out in a hotel in downtown Miami shortly after midnight. Ten persons died in this holocaust and 15 persons were taken to the hospital. The orderly transport of patients and move-up of two other municipalities to handle other calls in Miami were accomplished without incident. All the planning paid off!
Fewer calls than expected
Actually, there were fewer calls for emergency service than anticipated. After one week, the “war room” operation was geared down to a two-man operation and some of the EMS vehicles with limited capability were put in reserve. Early in the strike we reviewed our guidelines for emergency transport to the nearest hospital and began to allow citizens to be taken to the hospital of their choice as long as distances were not excessive and pressure on the system allowed this luxury.
During the 63-day strike, we answered more than 10,900 emergency requests for aid, 200 times other municipalities handled calls in predetermined dispatch zones and over 100 mutual aid requests were handled.
Regular contract ambulance service was resumed last June 2, but there were many modifications as well as a close look at emergency medical costs by budget analysts. In general, fire/rescue is transporting a much higher percentage of patients, not just criticals (2 percent prior to strike, 25 percent afterwards). We have maintained good response time, handling time, and turn around at hospitals. This has resulted in significant savings to Dade County but increased costs to cities.
Better screening of calls has been a positive result of the strike and this has resulted in fewer needless calls to our units in the field. This experience has also improved our ability to handle disasters inasmuch as our “war room” will remain and can be easily activated in future disaster situations.
The late U-Thant, former secretary general of the United Nations, once said, “It’s no longer resources that limit decisions; it’s the decisions that make resources.”
Every fire administrator in MiamiDade County believes this statement. We can be proud of the decisions which resulted in a plan for emergency medical service transportation even though there are several variations of emergency medical service in this community.
The fire fighters have gained another measure of respect for their actions, which were in the best interest of all the citizens.