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State of Emergency

Unified emergency medical service comes apart at the sutures

By Tim Johnson · Wednesday, August 18, 2010

Call 911.

A 36-year-old unified emergency medical service, an athlete among competitors, is on the verge of collapse, suffering from arrhythmia and multiple hemorrhages failing adequate life-support efforts.

Whatcom County Council diagnosed the EMS condition as terminal last week and began to draw up a death certificate for the unified, countywide program. After discussion and word surgery, council downgraded the patient to “serious”—a persistent vegetative condition—after learning a number of off-the-shelf remedies had not yet even been tried.

After more than four years of various traumas and injuries, the newest fifth Whatcom Medic One unit has been operating on a part-time basis in areas surrounding Ferndale for much of the summer.

With interlocal agreements between Bellingham and Whatcom County increasingly in tatters, County Council contemplated delivering notice to the City of Bellingham that they would approve a resolution, announcing plans to terminate the interlocal agreement for countywide Medic One service at the earliest opportunity. Hearing that avenues continue to exist for mediating and resolving conflicts, council softened the language of their resolution to note their disappointment in negotiations and put both administrations on notice that they were considering sterner terms.

While support for unified emergency medical service is expressed at the highest levels of Whatcom leadership, a minority of quacks has long sought to pull the plug on Medic One and Whatcom’s unified EMS.

Their crisis of opportunity arrived July 9, following a quarrelsome meeting of the Emergency Medical and Ambulance Advisory Board, a group ostensibly formed to help settle disputes. The meeting didn’t achieve that desired goal and ended with fists pounding on the table and cries of bad-faith bargaining.

A swift volley of correspondence next flew between Bellingham and Whatcom County CEOs, heightening their already strained relationship. County Executive Pete Kremen accused Mayor Dan Pike of employing the city’s website to distort the county’s position on unified EMS. Mayor Pike fired off a heated reply:

“I couldn’t disagree more with your characterization of the city web site content, the EMS program’s history or this administration’s intent,” Pike responded. “It saddens me and should infuriate taxpayers that actions of our county administration and policymakers are—similar to five years ago—threatening the unified, life-saving and award-winning EMS system and leading us down the road toward what could too easily become a duplicative, more expense system.

“I know,” Pike continued, “you have stated this is not your personal intent, but the pattern of behaviors by your staff and a majority of the County Council speak much louder.”

“I must plead ‘guilty,’” Kremen replied drily, “to the county exercising due diligence and good management practices with regard to oversight of the significant funds it provides the Medic One program. We think it is prudent and appropriate to continue to ask questions and seek justification for the expenditure of public funds, especially when Whatcom County will contribute almost $3 million to the city-operated Medic One system in 2010 compared to the city’s projected contribution of just over $1.5 million.”

Yet Kremen’s assessment of relative contribution itself distorts a system that handled roughly 14,000 calls last year, about half of which were logged inside Bellingham city limits.

“County taxes are paid by city residents, too,” explained the Medic One medical director, Dr. Marvin Wayne, MD. “I live in the city and pay a use fee. I also pay county sales tax.”

At its heart, is it a policy dispute between city and county governments that is embittered by a labor dispute? Or is it a labor dispute that is being exploited by administrations, each trying to wrest control of a costly and complex program? Welded together by passions and egos, it’s probably both.

“The county going way back has claimed—with some merit—that they are stepchildren in the running of and funding of Medic One,” Bellingham City Council member Stan Snapp explained. Snapp was a career firefighter and division chief with Bellingham Fire Department. Snapp was there from day one, when Dr. Wayne began to craft Medic One in 1974.

The county’s lasting irritation with Medic One is that it has been—from its inception—an organ of Bellingham Fire Department and the City of Bellingham. The city has tried to build a Cadillac medical-response system on the county’s Kia budget.

“For basically 36 years—we just celebrated 36 in July—we have had an integrated city and county system,” Wayne explained. “The operational entity has been the Bellingham Fire Dept.

“Systems like emergency medical response units operate in a very complex way,” Wayne continued, “but are actually operated by a very simple system: Rather than have 50 chiefs each running their own system, we have one operational entity chief—that’s Bellingham Fire.

“Really,” he explained, “it’s Whatcom Medic One that just happens to be operated by Bellingham Fire Department, in the same way you have St. Joseph’s Hospital operated by an organization called PeaceHealth.”

Award-winning system…

In April, Wayne—an attending physician in St. Joseph Hospital’s emergency department and an associate clinical professor at the University of Washington—was named a “Hero of Emergency Medicine” by the American College of Emergency Physicians (ACEP). Ironically as the future of the program becomes increasngly uncertain, later this year Wayne and his program will be again honored, again by emergency physicians for his three decades of work building a unified EMS.

“Out of 30,000 members, I was selected,” Wayne said. “I don’t believe in ‘me’ awards,” he added. “I don’t consider these awards about me. I consider them confirmation of the quality of the system. They are recognition by the greater medical community of what this system has accomplished.”

“We continue to be positioned to be the best providers of EMS service and—all the districts, I believe—would like to see that continue into the future,” Bellingham Fire Chief Bill Boyd said. “We don’t want to see the system fragmented. Duplicative service is not in the best interests of the citizens. It’s the beginning of the erosion of patient-care, ultimately, which is something we all want to avoid.”

...terrible funding

The history of unified EMS in Whatcom County is as troubled as it is distinguished.

“The county has been vocal for a number of years that it is the only county in all of Washington that contributes to EMS out of the general fund,” Bellingham firefighter Rob Wilson noted.

Other counties with unified EMS have passed property tax levies to fund their services. Not that Bellingham and Whatcom County haven’t tried that over the years.

“Private ambulance service collapsed in Bellingham in 1974,” Wayne said, sketching the early history of the service. “Bellingham Fire was available to fill the gap.

“We had trained 10 employees from the fire department as emergency medical technicians. We got hold of a borrowed ambulance from Lynden, and a borrowed ambulance from the Army base in Blaine, and started an EMS medic system.

“Over a short period of time,” he related, “we got both hospitals involved. The three county commissioners at that time put together an interlocal agreement with the City of Bellingham to create a countywide EMS service, one of the earliest cooperations between the city and county, a long tradition of an integrated system.

“For many years,” Wayne said, “the system was primarily an advanced life support response. If you skinned your toe, you got a paramedic ambulance and a BLS—basic life support—responder wherever it was, wherever was closest. It evolved over time on a cost and efficiency basis. Over time we added ALS—advanced life support—capacity.”

With increased complexity and training come increased costs. By the late ’90s, Bellingham—with its capacity to collect taxes, fees and revenues the county by law cannot—began to pull away from the rural county in terms of the levels of service the city could demand and afford.

“There was a bit of a crisis five years or so ago,” Wayne noted, “when there was little bit of, uh, pissing between the county and city about the way EMS is funded. Almost every county in the state of Washington funds their EMS through a dedicated property tax levy. Not through a sales tax.”

Bellingham had capacity, but the city’s willingness to share services to outlying areas of the county—without being paid for that service—was becoming strained. In late 2003, the city issued notice that they would terminate countywide Medic One service as early as March of the following year.

Seeing the end could be near, county fire districts began planning to add basic life support transports with their own equipment, freeing up some of Bellingham’s more advanced mobile medical units.

Beefing up county fire districts also meant beefing up the collective bargaining and benefits of now-professional firefighters and paramedics. Around this same time, the IAFF Local 106, sensing brethren firefighters needed support, helped Ferndale District 7 launch their own union chapter, the International Association of Fire Fighters Local 3855. Only District 7 is outside the 106th.

“Bellingham said, ‘Look, we’re not going to constrain our system at the price the county is willing to pay; we’re pulling out,’” Gary Russell recalled. Russell is the charismatic chief of Fire District 7.

“Well,” he said, “that was a big hit because there was no backup in the county. All of the paramedics in the county were going back to Bellingham, there was no ALS coverage in the county. So the county said, ‘We need to put together a program so we have ALS coverage.’”

The county brought together fire chiefs, commissioners and the interested public to devise and put together an ALS program, Russell related. “That was the Whatcom County EMS Working Group. Bellingham was going to do just inside Bellingham; they did a study, they felt they could pass the EMS levy, they put the EMS levy up to a vote.”

Confident the city could go its own way, then-Mayor Mark Asmundson offered a city-only property tax levy for Bellingham-only the following year. But stunning nearly everyone—and perhaps because voters intrinsically understood the benefits of combined service and were unwilling to fund anything less—the city-only levy also failed.

“It failed,” Russell observed. “Miserably.”

“A big direct mail came out by a group who called themselves Citizens On Public Safety—a.k.a., ‘COPS’—which was backed by the same people who opposed the Whatcom Transportation Authority levy last spring,” Bellingham firefighter Willy Spaulding related. Spaulding is a 9½-year veteran paramedic with the Bellingham Fire Department and the Local 106.

“They did a good job of getting people to vote down the proposed property tax levy, which put the unified system in jeopardy. We were going to run out of money as a unified system if this levy did not pass,” Spaulding said.

“Suddenly, Bellingham had no money to fund their program,” Russell agreed. “So they came back to the table and said, ‘we need to be together.’ And we said, ‘yeah, we do need to be together.’”

That’s how the city became involved in the EMS program again so, together, the districts could come up with a stable funding mechanism, Russell said. But meanwhile, he said, politics had changed in the smaller fire districts.

“We knew, if we were to succeed in doing this, we had to offer a unified system to the county, and that it had to have support by all county leaders,” Whatcom County deputy administrator Dewey Desler related. “We drafted a resolution and got all the city leaders and county leadership, the fire districts, the unions, everyone involved, to all sign in support of it.

“We felt support had to be unanimous.”

To get that unanimous support for the polls, certain details of how the service would be manage and operated had to be left ambiguous until after the election, Desler related.

There was a general agreement, a general sense of the future of EMS that had been scoped by the working group. Alas, though, five years later few can agree on the exact details of that unspoken agreement.

“We devised a plan where the county, and fire departments like ours, would take on more BLS—basic life support—and transport responsibilities to save the system money so we wouldn’t have to hire more medic units in the field to do that. We did that. We worked hard between all of the fire districts. And the idea was,” Russell said, “that additional support units would come not from Bellingham but from the county fire districts.”

\According to the plan, he recalled, Bellingham would retain the four existing medic units and a chase car. But the new extra capacity, new medic units that were required to keep up with the demand, would come from county fire districts and fire agencies, Russell explained.

“That way there would be diversity in the system, and assets owned by entities other than the City of Bellingham.”

“After the election, we fully intended to sit down and craft those agreements,” Desler said.

This time, in November 2005, the measure passed with tremendous support. Nearly 67 percent of voters supported the .01 percent sales tax levy.

But the agreements that were to be firmed up? That never happened.

Labor pains

“Our understanding was that the union would stay unified, and we would be working side-by-side with county fire districts. We would bring Ferndale firefighters into the system,” said Rob Wilson, president of Bellingham’s IAFF Local 106.

“We communicated to the County Executive that we had some concerns that we didn’t know how the system was going to work.

“The county administration said, ‘That’s fine,’” Wilson said, “‘but there is a danger of confusing the voters, of losing votes, with these details.’

“We had the election, the vote passed. Then we looked forward to the time that we’d sit down and discuss the issues of how it was all going to work. That never happened. Those meetings never occurred,” Wilson said.

“There was general agreement that Ferndale would staff the next unit online,” Spaulding agreed, “but I think we all believed they would come in under Medic One operated by the Bellingham Fire Department under Chief Boyd.

But “it was pretty clear very early on that what was going to happen was Ferndale was going to go ahead and develop their own separate paramedic system, separate from Whatcom One,” Wilson said. “That wasn’t the original deal.”

Russell disagrees.

“That was all agreed to,” he said. “Everyone signed on the dotted line. Because that would have been a deal breaker—if Bellingham had said, ‘No, we’re not going to agree to that,’ we’d have probably gone our separate ways right there. But we all agreed to a .01 percent sales tax, presented under the provision that all new medic units would be coming from the county from future on. The 106th approved of that plan. It went to all of the government entities who signed off on it and signed a resolution in support of it.”

After it became clear to most observers that Ferndale was going to go their own separate way, very soon after the election, things started breaking apart.

“We have 20 jobs through Bellingham Fire out in the county,” Wilson said. “We’ve served that area for over 35 years, and we wanted to continue to own that work. Many of us live in the county, and we want a quality medic service out there.

“We complained to the IAFF, and we started an action for a work jurisdiction dispute,” Wilson said, a fairly common action to resolve a labor dispute. “We believed we had a right to the work. We were willing to bring Ferndale and other fire districts into it, but we wanted it unified under union control.

“We went through many discussions with Ferndale. We went through a mediation, where—unfortunately—after half an hour, they pushed back from the table. We went through, ultimately, an arbitration. That determined that the work belonged to the 106, and that Ferndale needed to work with us and work it out. But rather than do that, Ferndale decided it was going to bail and quit the union.

“Nothing like that has ever happened before,” Wilson said. “Ever.”

Scabs and Gaping Wounds

“What happened here is our people got pushed out of the International,” Russell countered. ”They were told, ‘Either you join Bellingham or you stop this work.’ Our people were caught between a rock and a hard place. County government entities are saying, ‘No, we made this commitment to the fire districts. Either you do it or we’ll find somebody else to do it.’”

Russell stressed he has only minimal involvement with the union and labor disputes.

“My understanding is the union said, ‘We won’t train your people. We won’t give you fair evaluations. We’re going to boycott you,’ basically.”

“As I understand it,” Chief Boyd replied, “this is the only instance in the more than 100 year history of the IAFF that anything like this has happened, where a jurisdiction dispute went all the way through arbitration and ended up with a Local withdrawing from the IAFF. That’s huge. So for the Local 106 to roll over on this, they’re not in a position to say, ‘O.K., District 7, you go your own way.’

“They’d be killed by the national organization; they’d come down on 106 like a ton of bricks,” Boyd said.

Sensing they were without options, District 7 paramedics took their training to Seattle, through Harborview Medical Center.

“They went to Seattle claiming the program was not going to be available for them here,” Wayne complained. “That was not true. They were told their entry into the program would be delayed a couple of months—it was delayed exactly 45 days. They were welcomed into the program, provided they were in the union.

“After they left the union, there would have been issues, but by that point District 7 was already gone,” he said. “There was no reason they had to go to Seattle. There was a program for them here. I guaranteed they would be in.”

While Boyd and Wayne, like Russell, are not closely connected to the union, they admit they believed the labor dispute might have been better negotiated early on, with the county at the table. Boyd defends his men and their training.

“They didn’t train with these guys. They didn’t work together,” Boyd said. “They don’t know what the District 7 paramedics learned in training because they’re trained under an entirely different system, and they’ve never been evaluated by our people. Just to have [District 7] come on board and work side-by-side isn’t going to work.”

Boyd said he believes the labor issues could be sorted out in a few weeks—if outside parties would stop throwing gas on the tinder and stop lighting matches. Even now, new issues related to staffing remote areas like Point Roberts cloud issues with smoke.

Wilson said he thinks the labor dispute is being exploited by the county administration in order to reduce Bellingham’s strength at the bargaining table, and to give the county additional negotiating leverage by—essentially—breaking the back of the IAFF.

“I think the plan is to force the City of Bellingham out of the mix,” he said, “and then the county will not have anyone to hold them accountable for quality of service, other than the smaller fire districts. At that point, they’re going to start pulling back the $1.3 million they contribute into the system and say, ‘Fire districts, the quality of medical care is your responsibility.’”

“You have a couple of people trying to seize control of the system,” Wayne agreed. “I guess you could call them ultra-conservative, but what are they being conservative about? Do they really think dollars are being wasted? I don’t think so. Do they think this is a territorial issue, a turf war between the city and county? Yeah. Are they feeding into it? Yes.

“To say the dispute is ginned up, I’m not sure that’s strong enough. More like rotgut,” Wayne said.

“If the system breaks up, where’s it going to go? That’s my first question,” the program director said. “If it breaks up, the burden will be shifted from the county to the fire districts, because the county does not have the wherewithal financially and functionally. I do not know who is going to run this hypothetical system. Who has the training, the background, the data, the integration of billing systems. Do you really want to rebuild a multi-million dollar structure for someone’s own little private war?

“Are you going to pay for it as a taxpayer? You are. You are going to pay for a split system.”

“We’ve already started down the road to a duplicative system,” Boyd agreed. “District 7 has put in place components of their own EMS system that are outside even the labor dispute issue. They’re doing their own ambulance billing. They’re not contracting to do that through us. Whatcom Medic One is paying their dispatch fees for their paramedic unit responses, even though they are doing the transports and keeping the revenue. They have their own supervising physician that they’re contracting with. They do their own quality assurance, their own medic training now.’

Wayne sketched the next best steps.

“One, we need to lock all the politicians up in a room and let them burn one another until white smoke comes out the chimney. But I guess that’s not very practical,” he said. “We’re not going to get the politics out of it because it is all about politics. The complaints have nothing to with patient care.

“Since we’re not going to get the politicians out of the discussion, the next thing that needs to happen is all the cooler heads need to stay cool. You’re dealing with issues to which people have dedicated their entire lives.

“It’s not the patch that you wear over your left shoulder, or over your right shoulder,” Wayne said. “It is the patch that you wear over your heart that represents the care that we want this community to have.”

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