Out of their triage

Shaminika Proctor was having trouble breathing. Her grandmother, Rita Proctor, found the 13-year-old in her bedroom, opening the window, trying desperately to force fresh air into her lungs. Rita tried to soothe the hyperventilating girl, who had recently been diagnosed with bronchitis, begging, “Shaminika, please, try to slow your breathing down.” She grabbed her own asthma equipment and tried to help the frightened girl. When the child finally collapsed in her arms, she called 911, asking that an ambulance be sent to the Proctor home, which is on Cedargrove just off Gratiot on the city’s East Side. It was April 1.

According to Rita Proctor’s account — and an internal Detroit Emergency Medical Service incident report obtained by Metro Times — a basic life-support (BLS) ambulance arrived within minutes. It was staffed by two basic emergency medical technicians (EMTs), the lowest level of emergency medical licensure recognized by Detroit EMS.

The EMTs did all they could with their limited equipment. One of them “bagged” Shaminika, using a face mask and bag in an attempt to force air into her lungs, while the other ran out to get a stretcher. Their BLS ambulance lacked the fast-acting drugs or advanced equipment that might have made a difference in such a circumstance.

Before the stretcher could be retrieved, an EMS Echo Unit — an SUV that stocks drugs and is staffed with trained paramedics, but which cannot transport a patient — roared onto the scene. One paramedic rushed in — without any of the medication, which she was supposed to have with her. She ordered the basic EMT to stop bagging and to help her carry Shaminika out, frantically dragging the patient, a heavy girl, by the legs, even though the stretcher was on the way. The basic EMT helped carry the girl as far as the living room.

Rita Proctor recalls, “It really was very chaotic. And they were even kind of upset, hysterical-like to me. The way they turned around and went to hollering at me, ‘How long she been like this?’”

By the time Shaminika lay on the living room floor, she had no pulse. According to the incident report, the charged-up Echo paramedic said, “‘We are not going to wait’ and again tried to pick up” the patient. “At no time” did the paramedic “attempt any ALS care or intervention up to this point,” the EMT’s incident report states.

When the stretcher was retrieved and the crew carried the fading Shaminika out the door, they dropped her, her grandmother says. Out on the lawn her body fell from the stretcher again.

After they got the child into the BLS ambulance, it didn’t leave immediately, although the report does not specify a reason or the extent of the delay.

“They stayed out in front of the house about 15 or 20 minutes,” recalls Rita Proctor. “I couldn’t go and talk to them because I had the other children with me, so I asked my boyfriend to go to the hospital with them.”

After getting a call at work from her mother, Shaminika’s mother, Angela, rushed to St. John Hospital, arriving shortly after Shaminika. She knew something was wrong when she saw a chaplain. She was informed that her daughter was dead.

The Proctor family didn’t know that the first ambulance to arrive did not carry any advanced equipment or medication —not even a tablet of aspirin. They were also unaware that the paramedic on the Echo unit — the nontransporting unit that carries advanced life-support equipment — rushed in without her drug box.

Though Rita Proctor could clearly see the agitation and confusion playing out in her living room, she couldn’t have known that such confrontations are not an unusual occurrence in the day-to-day operations of Detroit EMS.

On a high-demand day, Detroiters in life-threatening situations face the possibility that the ambulance that arrives to help them will not be carrying a paramedic, any drugs or advanced life-support equipment.

Some EMTs and paramedics say this is because Detroit’s fleet has gone from 21 full-time advanced life-support (ALS) ambulances and four part-time ALS units — all carrying medication, advanced airway equipment, heart monitors, intravenous kits, and at least one skilled paramedic to use them — to only 13 ALS units. The agency has converted eight ALS ambulances to BLS units, which have no drugs, limited electrical therapy, simple airway equipment and bandages, and are staffed with basic EMTs who cannot administer advanced care. Added to the fleet were four Echo units, which are staffed with two paramedics and the drugs and advanced emergency medical gear, but which cannot transport a patient.

Such changes, initiated last October, reflect a total of 25 vehicles on the road. But some of the people who make the lifesaving runs say the number is illusory. They say the eight BLS units are cause for concern, and that their deployment is causing bitter divisions on the force, which is a division of the Fire Department. Morale is unsteady, and the busiest season, summer, looms ahead.

Welcome to the “realigned” Detroit EMS.

Introduction of Echo units was originally touted as a reform that would improve emergency services to Detroiters. But interviews with people who work within the system, and an examination of internal documents, suggest that poor planning, shaky implementation and inadequate staffing have resulted in uneven patient care. The EMS Division was so committed to all-paramedic, non-transporting Echo units, even in the face of unworkable staffing shortages, that it was willing to beggar its own once-all-ALS ambulance fleet to make it happen.

According to paramedic Rob Calandro, 34, who has been with Detroit EMS for 10 years, “This system is absolutely in no way increasing the amount of care that citizens are getting at all. It’s actually taking away care from them because you’re taking four [Echo] units that could be transporting patients and having them do nothing. … I’m really concerned that the citizens aren’t getting the service that they could be getting.”

In 1970, a report titled Emergency Medical Services for an Urban Area commissioned by the city determined that the “minimum of ambulance vehicles required to insure adequate service for the City of Detroit is estimated to be 22.” This number was considered enough to handle the typical number of annual ambulance runs, nearly 50,000.

Times have changed. Detroit EMS, which until January had 21 full-time ALS units — and as many as 25 ALS ambulances when enough staff was available — currently responds to upward of 120,000 calls per year.

In 1999, a report prepared by the International Union of Operating Engineers, Local 547-EMMTTA, stated, “It is an inexcusable and an unarguable fact that the Detroit Fire Department has failed to provide the citizens of Detroit with a properly functioning EMS system.” This same union report urged the “immediate upgrade of all full time ambulances … to the Advanced Life Support level of care within the current confines of the budgeted manpower positions at this time.” It was a demand that that the department’s BLS rigs, without advanced equipment and staffed by basic EMTs, be upgraded to ALS rigs.

By 2000, Detroit EMS, under the leadership of Superintendent Gary Kelly, had done just that, converting Detroit EMS into an all-ALS fleet of ambulances. Paramedics welcomed the move.

As Faye Falconer, 40, 10-year Detroit paramedic, recalls, “When we went all-ALS, we thought everything was looking up. We were getting like the other cities, giving good care.”

In a city known for dispatching errors — mistakes that sometimes sent BLS units to serious medical emergencies — the all-ALS system guaranteed that all ambulances had the equipment and trained personnel to deal with any problem, from a trip-and-fall to a heart attack mistakenly dispatched as a trip-and-fall.

Detroit staffed these units with one paramedic and one basic EMT, and EMS scrambled to keep up with retiring staff and attrition from burnout. (Oakland County, for instance, requires two trained paramedics on every ambulance.) But Detroit EMTs and paramedics were generally upbeat when yet another reorganization of Detroit EMS was announced in January 2003.

Fire Department Commissioner Tyrone S. Scott and Mayor Kwame M. Kilpatrick laid out ambitious goals for the understaffed, underequipped emergency service. The reorganization included several promotions, put all ambulances on 12-hour shifts instead of staggered shifts, divided the city into four sectors, and announced the introduction of the Echo units. Many exciting promises were made about what these units would do.

The new Echo units were the centerpiece of reorganization. The Echo units, essentially SUVs stocked with advanced life-support equipment and initially staffed with at least one paramedic, were designed to treat patients on the scene, but not to transport them. Between the January 2003 announcement and the actual introduction of Echo units in October, the units’ many benefits were touted.

Officials said the units would ensure early arrival, respond to large medical emergencies, handle low-priority runs when all other units were busy, and ease the pressures of “system saturation” when no units are available. The units could provide extra support on the scene, call off transporting units when they weren’t needed and decrease response times.

Yet, early on, some EMS staffers were curious about the rationale. Doubters were not encouraged by the bumpy implementation.

According to papers obtained by Metro Times, the leaders of the Fire Department knew they wouldn’t be able to deploy enough Echo units to ease system saturation.

In an April 15, 2002, memo to Council President Maryann Mahaffey, Fire Commissioner Tyrone C. Scott proposed the goal of deploying two of the new units, “one Echo Unit east and one west.” But a Dec. 6, 2002, memo finds Commissioner Scott saying that EMS required three additional ALS ambulances and eight Echo units to end the no-units-available status that plagues EMS during the warm months.

And EMS Superintendent Gary Kelly, the man largely credited with creating an all-ALS system in 2000, seemed concerned about the reorganization. A Dec. 10, 2002, memo from Kelly to Commissioner Scott warns, “I have been trying to get an audience with you for awhile now. I have long considered serving you in an advisory capacity as one of my duties. I must comment on what I believe to be the direction that your administration is going in as it pertains to EMS Division. I have serious reservations …” All further text in the memo, obtained by Metro Times under the Freedom of Information Act, was redacted by the city’s Legal Department.

One month later, a memo of response from Commissioner Scott takes an aggressive posture. The Jan. 10, 2003, missive suggests that Kelly had been resistant to the reorganization. Scott writes, “As you have been previously briefed, the plan to reorganize existing resources in your Division has reached the critical stage. … This Administration expected you to demonstrate the necessary leadership to support the reorganization plan. It appears you are not in step with this team effort. … Note: Consider this written assignment a direct order.”

A few days later, the city found that the EMS union was unhappy. According to a Jan. 13, 2003, synopsis of an EMS Division meeting with a union delegation, one concern raised was that Echo units would be on scene having completed patient care, but without ambulances available for transport. The synopsis explains, “Personnel very concerned about angry bystanders on scene.” Behind this simple comment lies a frightening scenario: The prospect of arriving, providing the extent of ALS care that can be done in the field and yet having to wait for a transporting unit to rush a patient to a surgeon.

Put in more explicit terms, paramedic Falconer explains, “If you got an Echo truck on the scene with this dead baby, all they [the bystanders] know is, ‘Why y’all ain’t going yet?’ They are not going to understand if you’ve got to wait for a transporting unit to take their baby to the hospital, who ain’t breathing. [Or] you got grandma, and all grandma’s 23 great-grandsons are on scene. You got grandma on the ground, you’re doing CPR on grandma, … Now, what you going to tell her big grandsons when y’all ain’t moving?”

Such fears would prompt EMS to drop the idea of dispatching an Echo unit unless a transporting unit could be dispatched simultaneously, effectively canceling the proposed gain of first-touch emergency service with Echo rigs when no units are available.

It was October, after a busy summer, before two Echo units would roll out on the city streets.

As implementation staggered forward, important decisions were being made regarding the staffing of the new units. Internal memos indicate that, as early as April 2002 and as late as January 2003, the EMS Division had intended to staff the Echo units with one paramedic and one basic EMT, which was the minimum necessary to satisfy the state Bureau of Health Systems and Detroit’s Detroit East Medical Control Authority.

But by June 2003, a memo from now-cooperative EMS Superintendent Kelly to Commissioner Scott explains, “We are presently pursing a configuration using two (2) Paramedics per Echo unit.”

Putting two paramedics on each Echo unit would strain the all-ALS staff beyond state and local requirements of at least one paramedic per unit.

A Sept. 26, 2003, memo from Capt. Rodney E. Allen observed that with four Echo units staffed with two paramedics, “we will only have 83 remaining AEMMTs [paramedics] to staff the Alpha [ALS] units.” The one-page report briskly details the staffing demands and the resources available, concluding that the staffing shortage would necessitate knocking at least four ALS ambulances down to BLS.

What’s more, as early as January 2003, the EMS Division knew that staffing shortages that would make it impossible to maintain the all-ALS fleet while adding the Echo units. A Jan. 24 e-mail from EMS General Manager Cheryl Campbell to Commissioner Scott stated, “To maintain 25 FTE [full-time equivalent] ambulances and 4 FTE ECHO units the Division needs another 33 people. This number also includes an adjustment for attrition.” Scott replied, “Copy that …”

By May, EMS officials were looking for ways to staff the Echos with two paramedics while cutting corners elsewhere to make it happen. As implementation limped along, one possible solution to the shortage was to convert some ALS units to BLS units. This was a subject of concerned discussion between Commissioner Scott and EMS Superintendent Kelly.

In a May 23, 2003, memo, Scott told Kelly, “It is imperative that you … identify 4-8 medic units that can be converted to Basic Units, resulting in paramedics working with paramedics and basic technicians working with basic technicians.”

Clearly, Scott had doubts about downgrading some of the EMS Division’s all-ALS fleet in order to staff the Echo units. A June 2, 2003, memo from Kelly to Scott refers to a May 28 conversation in which Scott advised Kelly not to pursue converting ALS units to basic. The memo from Kelly replies that converting ALS units to BLS units “may still be necessary, in order to double the number of Paramedics assigned to the Echo units.”

Such lavish staffing for the untested Echo units causes Sherry Kurek, a 15-year Detroit EMS paramedic who rides in an ALS rig, to remark in disbelief, “On my ambulance I can run a paramedic and a basic, but an Echo unit can’t? Why? Somebody’s got to drive that thing. Do you need a paramedic to drive?”

Key decision-makers had every reason to feel squeamish about these changes. Not only would downgrades go against previous union proposals, but they would go against the early promises of realignment — namely introducing the Echo units to enhance the level of service.

And yet, the plan was to become a reality. A Sept. 30, 2003, interoffice correspondence from William L Green, Assistant Superintendent EMS Division, announced, “The creation of the four (4) ECHO units has necessitated changing the following units to Basic Life Support, Medic 02, Medic 19, Medic 20, and the reopened Medic 24.”

When October arrived, two of the new Echo Units rolled into service, forcing the EMS division to eliminate two part-time ALS ambulances and to knock down four other ALS ambulances to basic life support.

Donald Bayer, 37, a paramedic with Detroit EMS for five years, describes his first reaction, asking, “Why downgrade the level of care? … There are 43 active duty firehouses in the City of Detroit. Nobody would think of taking equipment away from them. Why is it OK for this to happen to EMS?”

Jerald James, 33, EMMTTA representative and Echo unit paramedic, estimates that only 70 percent of all runs require a patient to be transported. Such explanations elicit a heated reaction from Bayer, who says, “Let me put it this way: If you’re that 70 percent, you don’t want to be waiting for a truck. And it’s one thing about statistics: They’re statistics, they’re not cold hard facts. … Sometimes an ambulance takes two, three patients in the same truck. I took … eight patients in the same unit, because no units were available, all Code 1, all intubated. I was doing mouth-to-tube on little infants … from a house fire. I called for five additional units and they didn’t show up. See, where’s that statistic?”

With the conversion of eight ALS ambulances to BLS, the sweet hope among the ranks began to sour. A rift developed on the force due to the way the two-paramedic Echo crews behaved on the street. Memos seeking and accepting applicants for the Echo program indicate that paramedics had been trained to believe that they were “elite and unique within the EMS Division” and in charge of “high performance units.”

Asked about the decision to staff the Echo units as an elite, all-paramedic rig, Commissioner Scott tells Metro Times, “You have the ‘internal customer’ and the ‘external customer.’ And our ‘internal customer’ was relaying back to us that there were some problems between some — not all — paramedics and basics working together. … The paramedic … may feel that they’re doing all the work and the basic may or may not feel like they’re able to do anything, they just drove. … And when you’re dealing with the public in an anxious-filled moment I’ve got to have my people feeling like they’re comfortable working together first, so that it doesn’t hamper patient care. So to rectify that we thought we’d get folks with the same skill-sets working together.”

Having some units with the same levels of licensure together may avoid clashes within the rigs, but, as seen in the case of Shaminika Proctor, “internal” hostilities sometimes flare up anyway. Many paramedics interviewed by Metro Times describe emergency scenes that turn into seniority battles, with senior paramedics on Echo units giving orders — rather than help — to other paramedics and EMTs on the scene. Where before paramedics and basic EMTs had worked together on the same rigs, suddenly there were “elite” paramedics lording their authority over those with less seniority, even when they arrived late.

Falconer says, “I see the change in the people on the Echo units. They’ve gotten really cocky. That’s just attitude. I don’t know if it’s big-head-syndrome or what but you can see the change. … I don’t see this company surviving like that.”

Kurek belives that some Echo paramedics are exploiting EMTs. “And it’s not supposed to be like that,” she says. “Everybody’s supposed to put their hands in and carry the patient, carry the equipment. … They were told by Cheryl [Campbell] that they were the elite, and their license ain’t no different from mine.”

In addition, critics allege that Echo paramedics are in action less, and often have less to do on the scene.

Kurek carefully qualifies that, saying, “If you’ve got a cardiac arrest, they’re working their butts off.”

But many agree with Falconer, who observes, “It’s like you’re getting a break when you’re going to Echo, and I’m still working just as hard as I was.”

Calandro agrees, saying of Echo duty, “It’s a lot easier. They don’t have to carry any of the patients. They just come in, they assess.”

Perhaps the sorest spot in the realignment is the downgrading of eight advanced life-support ambulances to basic life support. This means that if an Echo unit cannot make the scene, less training, less equipment, and less life-saving medication reaches patients, sometimes when they need it the most.

BLS units are staffed with basic EMTs. While their license may not be as impressive as a paramedic, Detroit’s EMTs often have enough hard-earned experience to be equal to demanding situations, and excel at CPR, giving oxygen, carrying patients on backboards and working quickly with their paramedic partners. Quite a few of them are qualified to be paramedics themselves, though they need the paperwork and testing to make it official.

The BLS ambulances have at least an oxygen tank, an automatic external defibrillator, simple airway equipment, blood pressure testing equipment and a bag of bandages. But while basic EMTs may have the skills, they lack the tools, and when they find a patient in critical condition, they must “load and go” to rush the patient to an emergency room or a surgeon.

Many paramedics complain that by using BLS units in a system where, in the warm months, there are times when no units are available, it’s almost guaranteed that patients who need quick-acting medication will not get it. For instance, the drug box contains Albuterol, which acts quickly to reverse airway constriction in an asthma attack. In such cases, even load-and-go can be fatal for a patient.

Falconer says, “A person who can’t breathe cannot wait that five minutes they have to get to the hospital. … [When rushed to the hospital] they have to get out the truck, get into the hospital, then go into a recess room, the doctors are pulling off their clothes, starting IV’s, asking questions, then they order the Albuterol treatment. So they still have to wait another eight minutes in order to get it if they don’t get it in the truck.”

The drug box also contains Epinephrine, useful in reversing allergic reactions that close up airways. Kurek explains that in cases of anaphylactic shock, often induced by allergic reactions that constrict the throat, “you can get there and give them Epi [Epinephrine] right away. I mean, quick! That’ll save somebody’s life. That person may not have time to go through transport to a hospital. That type of run, and asthma attacks, the early drugs are what you need. … If you’ve got somebody that they’re losing their airway through it closing up or filling up with fluid, that basic unit is not going to be able to do anything. Oxygen ain’t going to work ’cause it ain’t gonna get in.”

Another medication BLS units lack is Narcan, an agent used to reverse heroin overdoses. Properly administered, the substance can pull an overdosed patient out of respiratory arrest quickly.

But according to Jason Hawkins, 32, an Echo paramedic and EMMTTA communication chair, “what heroin overdoses really need is oxygen,” which is enough to bring them around.

“And he’s right, absolutely,” Kurek agrees, “But that’s not going to happen with anaphalactic shock or an asthma attack or a diabetic that’s not responsive. A basic unit can’t do anything there but transport, and a transport by a basic unit on a run like that could make things a lot worse, because they can’t give that Epinephrine for that anaphalactic shock, they can’t give that Albuterol for that asthma attack.”

Falconer adds her voice to the chorus, saying, “Heroin overdoses don’t breathe. Narcan reverses that. You can ‘bag’ them, you can ventilate them, yeah, but if you bag them, most of our bags are one-person and don’t have a good seal, so you’re not getting a good ventilation rate. … They need ALS: They either need the Narcan, or they need to be intubated,” an advanced procedure BLS units cannot do.

The list of drugs not available on a BLS unit goes on: Valium for prolonged spasms that sap strength and hinder circulation, nitroglycerin for extreme hypertension and congestive heart failure, sodium bicarbonate for cardiac arrest, lidocaine for cardiac dysrhythmias, Adenosine for high heart rates. BLS units also lack glucometers, which can ascertain whether a diabetic is in shock, and whether an IV drip of sugary D50 can bring them back in an instant.

Echo paramedics insist that the outlook for care is good. Paramedic James passionately describes one recent incident, recounting, “Just Monday there were no units available and I was on an Echo unit and I was on scene. There was no units available. Had I been in a transporting unit I may not have made that scene … I was able to … start an IV, do a 12-lead EKG on this patient, give her oxygen, recheck her levels, check her glucose levels, before a transporting unit became available. The family definitely appreciated the fact that we were there within five to seven minutes from the time they called. It may have taken time for a transporting unit to become available.”

When the ALS units were downgraded, management hoped to have Echo units assist BLS units when advanced procedures were needed. Evidently, management hoped that Echo units would be able to rush to the scene of medical emergencies and stabilize patients before BLS units arrived to transport them.

But after October 2003, EMS workers on basic transporting rigs saw that this was unlikely at best.

“That’s the way it’s supposed to work, but it doesn’t always work that way,” says Calandro. “We’ve been on runs and had our patient already packed up and they show up and we didn’t even know they were coming.”

Muddying matters further, dispatchers were given simple, one-page flow-charts dictating how to dispatch the new Echo units.

“Dispatch isn’t informed,” says Kurek. “What I understood was they just got these papers to read. They were supposed to be called down for training on how to utilize the Echo units and they weren’t. So, of course, where does the blame fall? On dispatch. And it’s really not their fault. And everybody out there is upset with dispatch for the way they’re dispatching runs, but it’s not their fault. All they have is a piece of paper. They haven’t been called down and told.”

General Manager Cheryl Campbell admits that dispatchers were never convened for special training, but insists that they were briefed many times, and that calling them out for special training would not have dovetailed with their eight-hour work shifts.

Also, because of union demands that Echo units not be placed at risk of being on-scene with angry bystanders, missing from these simple charts was any mention of management’s original intention to “deploy ‘Echo Units’ to respond when all ambulances are busy on other calls.”

Instead, Echo units were to respond in tandem with transporting units, a strategy that does little to ease “service saturation,” as two units are doing the job of one. Such strategies miffed many EMS workers, who complained that such dispatching simply took more units out of service and inflated run-volume statistics.

As Falconer tells it, “When it first came about, it wasn’t thought through. Everybody jumped for it because it sounded good, … it sounded like, ‘OK, this is going to be cool. We got somebody there to stabilize the patient.’ … But it doesn’t work out like that because, first of all, there’s not enough of them … and they’re getting dispatched wrong. … You’ve taken all these units away, all these paramedic units away for these four Echo units, but you still have to have an advanced unit respond with a basic unit. You’re still taking two trucks on one patient.”

Kurek observes that such practices skew perspectives on how many calls Detroit EMS handles. She notes that when an Echo unit is dispatched with a basic unit, one emergency call is suddenly recorded as two runs.

Another sore spot is that ALS units, such as Echo units, are best used when responding to medical runs — difficulty in breathing, cardiac arrest, shock — but are ill-suited to respond to trauma runs — vehicle accidents, shootings, broken bones. The best thing for a trauma patient is to be rushed to a surgeon who can get to work on physical injuries, but Echo units can’t transport.

Calandro points out, “Having a drug box isn’t going to make a difference in a car accident, … unless you were a diabetic that passed out behind the wheel or something.”

Kurek adds that when Echo units were introduced, “I talked to Cheryl [Campbell]. … She had told me that they were going to respond only to medical runs, chest pain, difficulty in breathing, … abdominal pain, headache, unconscious, … nothing that’s trauma-related, nothing like assaults, stabbings, gunshots, hit in the head with a hammer … Just medical care where they need drugs, electrical therapy. … At that point, it made sense, because it could work doing that. But when we started seeing the units out there, it wasn’t working that way.”

Kurek explains that on a trauma call, Echo units “can’t do anything. In most instances it doesn’t pay to start an IV, that’s not the No. 1 priority in a trauma patient. Most bad trauma is just ‘load-and-go.’ If you need to do airway or whatever, you do that en route. Why have a unit [Echo] there that can’t transport? That doesn’t make any sense. You need to get there and be able to take him, not stand there and try to make it look like you’re doing something because you can’t take him anywhere.”

Indeed, dispatching flow-charts obtained by Metro Times show that Echo units are to be dispatched to trauma calls with BLS units when no ALS transports are available.

What’s more, for a crime scene or a barricaded gunman, documents show, Echo units are not to be dispatched until police are en route or on the scene.

Another notable detail is that this tandem dispatching of Echo and basic units only applies to priority 10 and priority 20 calls (known on the street as code 1 and code 2), and that Echo units are not to be dispatched to less-important priority 30 (code 3) runs. This essentially negates promises made in a Feb. 20 press release, which stated, “The Echo units can also take more low priority runs, freeing up more ambulances to take higher priority runs.”

Also, since they cannot respond to priority 30 calls, the likelihood of Echo units being able to “call off ambulances dispatched to a scene that does not require hospital transport vehicles” falls equally flat.

Even if Echo unit paramedics would like to call off an ambulance, they can’t do that when patients demand to be transported. As Kurek explains, “You can’t tell them, ‘No,’ and if an Echo unit goes there, they can’t tell this guy no, so they gotta call for a transporting unit, and it doesn’t mean it’s going to be a basic unit, because a lot of times it’s going to be an ALS unit.”

Not only are Echo and BLS units dispatched in tandem, such flow charts leave open the inexplicable possibility that Echo units may be dispatched with ALS ambulances. Not only does this exacerbate service saturation, it occupies two ALS-equipped units on a single call. The permutations of dispatching guidelines had become so complicated that, by the time they first went into service, the Echo units were hardly the “high performance units” they were intended to be. They couldn’t be dispatched alone, they couldn’t be dispatched to low-priority runs and they couldn’t be dispatched to violent scenes unless police were there or en route, though BLS units could be sent to wait in position.

In addition, the Echo units often accompany the ambulance to the hospital, which places both units out of service for as long as a half-hour.

Of this, Bayer says, “There should be no reason why an Echo unit gets caught up in a transport. … Once that [transporting] unit arrives, throw the guy in the back and then [Echo can] go right back in service and handle the next call.”

Ken Parker, an Echo paramedic, hotly insists that though Echo units do accompany ambulances to the hospital, it often means that both units are back in service earlier, and he adds, “Guidelines are just guidelines. I think we’re losing sight of the fact that … it’s not something that’s etched in stone. … Under ideal situations, yes, we’d prefer to have a Echo unit and a transporting unit dispatched simultaneously. And that’s how the guidelines are written. But that’s only a guideline. If there is no unit available — and I’ve been working on Echos since January — I can tell you that you get dispatched.”

As the realignment took root, medics and basics soldiered on the best they could.

According to Calandro, “We weren’t allowed to question it.”

Some paramedics found themselves riding in basic units and getting stuck in traffic, unable to perform advanced procedures. Echo paramedic Jerald James claims that the dangers of being compromised by traffic or weather are overstated.

Rob Calandro sees it less dispassionately, explaining, “At least if it’s an [ALS] unit, you have more options if you are compromised in bad weather or traffic than you do in a basic unit. … I picked up an overtime day, it was on a basic unit. We had a guy, it took us a while to get there because we came from a distance, because, of course, there were no units available in the area. … We drive across town, we get the guy. Now, we have no intubation equipment, we have no drugs, we have no monitor, we drop a thing called the Combitube, which is a decent airway, … we’re doing the CPR, we get down Eight Mile and go to St. John’s Main, and there’s a train.

“Now we’re stuck and this is the world’s longest train … It was probably about 12 to 15 minutes of train. … We were back there doing CPR, his wife’s up in front losing her mind, screaming, and, you know, what are you going to do? At least on an advanced life-support unit you could still be giving the same treatment that they’d be giving at the hospital. … In a basic unit, you’re basically just oxygenating tissue until somebody can give drug therapy.”

The patent did not survive.

In January, the EMS Division rolled out another pair of Echo units, deactivated another two part-time ALS ambulances, and stripped another four ALS ambulances of their equipment, turning them into BLS rigs.

One year before, an EMS directory had listed 25 ALS ambulances — 21 full-time and four part-time. Since January, Detroit EMS has run only 13 ALS units, eight BLS units, and four Echo units.

EMS union representative James grows passionate about the need for two-paramedic Echo units, “The staffing issue was a very serious concern from the membership when it came to providing a bare minimum to the citizens of Detroit. Southfield doesn’t get the bare minimum, no one in Oakland County gets the bare minimum. Why is it acceptable here in Detroit for our citizens to get the bare minimum of what the state requires?”

Overlooking that the EMS Division still staffs its 13 transporting units with the bare minimum, and perhaps hinting at the internal rancor in the workforce, the Echo paramedic insists, “If I’m working with a paramedic, while I’m intubating, he can start that IV and draw those medications … because he knows what’s on my mind. If I’m working with an EMT, he does not. … I don’t want an EMT standing next to me that’s not going to help. … I’ve been on multiple cardiac arrests with EMTs and I have not saved lives. I’ve also been on cardiac arrests with Echo units where we’ve got a returned pulse and spontaneous respirations. So the addition of that medic standing next to me has saved lives.”

Unfortunately, these anecdotal claims are not backed up by scholarship. Jerry Overton, president of the American Ambulance Association, says, “No studies show that two paramedics are better than one.”

One pledge delivered upon was lowered response times, which were down in 2003.

Though the Echo units can’t take full credit for this, as only two were in service a scant three months out of that year, they may have had something to do with it.

James, the union’s Echo paramedic representative, says, “The design of Echo units, at least in theory, is that they’re here to cut response times — and they are.”

As those who listened astutely to the State of the City address know, Mayor Kilpatrick showered the EMS Division with praise, declaring, “The Detroit Fire Department, under the leadership of Commissioner Tyrone Scott, has made dramatic progress in protecting citizens and providing more efficient emergency care. In the past year a realigning of EMS has cut response time to 6.3 minutes per run. That’s down from more than 10 minutes when we took office.”

Those are impressive statistics, and, according to documents obtained by Metro Times, they’re completely inaccurate.

A EMS bar graph obtained under the Freedom of Information Act, titled “Response Time Average 2002 vs 2003” shows that, from the time a citizen places a call to 911 to the time EMS arrives on scene, it took an average of 14 minutes and 31 seconds in 2002; and it took an average of 12 minutes and 59 seconds in 2003. These numbers are nowhere near the averages in other cities, which usually hover between six and nine minutes.

The only number approaching the mayor’s “dramatic” figure refers to the moment the ambulance receives a call from a dispatcher until the time it arrives on scene, which averaged 8 minutes 57 seconds in 2002, and 7 minutes 57 seconds in 2003.

(According to Commissioner Scott, the mayor was actually referring to average Echo unit response times, not average times for all responding units.)

It is possible that response times would dip lower as a result of Echo units, as two units are racing to one scene — certainly one unit will get there before the other. But this rankles some EMS workers, who complain that it’s not worth tying up two units to bring one number down, especially when Detroit EMS has a chronic problem with having no units available in the summer. This prompts Bayer to ask, “When there were no units available with 29 [the peak-hour 2002 maximum figure] trucks, how aren’t there going to be no units available with four Echos out there and we only have 21 trucks?”

Summer is coming up fast.

Outside the city, the reorganization of Detroit EMS has attracted attention, not all of it unfavorable.

Richard Serino, the top man at Boston EMS — after which Detroit is said to have modeled its use of Echo units — reacted to details of downgrading ALS units to BLS by remarking, “That’s not our system.”

Of the reorganization, Monroe Charter Township Fire Chief Larry Merkle, who is familiar with Echo units, says they could be used to get staff on the scene as soon as possible, but of the full-paramedic staffing exclaims, “Wow, that’s a big cost to have two paramedics on each rig. That’s a lot of money.”

Sgt. Mike Perez of the Ingham County Sheriff’s Office, which has run an Echo Unit to offer fast response in hundreds of square miles of farmland, observes, “Keep in mind, there are costs associated with staffing and licensing and equipment. It costs less to outfit a basic ambulance and there’s less cost for the licensure. That may have factored in.”

Mark Fournier, chief of EMS for Warren, seems more ambivalent, saying, “What’s confusing is they’re tying up two vehicles. If they can’t get the staff, it sounds like the best alternative. But if they have staffing issues, that’s what needs to be addressed. … Who’s suffering because they don’t have advanced life support in all corners of the city? The guys on the street, they probably feel they’ve lost some patient care.”

Lt. Bruce Bay, acting EMS coordinator for West Bloomfield Township, chuckles a bit grimly when questioned, as he was a former Detroit EMS assistant field supervisor in the ’70s. He offers, “It’s an interesting concept, but I don’t know how they’ll facilitate transport because it’s still going to tie up a transporting unit if they need transport, although some can be triaged at the scene.”

At last, according to Overton, “The idea is to focus on patient care and getting appropriate resources to the patient, and in a trauma call you’ve got to have the transporting unit there.”

Overton’s sentiments are echoed by many unhappy with the reorganization, that patient care, not response times or bold management moves, are the heart of the matter.

Falconer says, “We still give good care on a basic and an advanced level, I just think that everybody’s not getting the same level here, and that’s not right. … I have family here. My brother was just shot. My grandfather passed … not too long ago. … I wouldn’t want my family transported on a basic unit, especially if it’s something serious. …”

Back on the East Side, Angela Proctor dandles her granddaughter, Shaminika’s baby, Sequoia, on her legs, soothing Shaminika’s excited brother Melvin, who sits nearby. A fan whirls overhead causing a string of helium balloons to dance gently in a corner. Stuffed animals crowd on the surfaces of furniture, and banners with prayers written on them line the walls. Despite the uplifting messages and cheerful dolls, Proctor’s face is understandably clouded. As she holds a smiling photograph of her daughter — an academic achiever who dreamed of one day being a pediatrician — her silence speaks louder than words.

The cause of her daughter’s death is still pending, and she is in touch with a law firm. She may sue the city.

If the city has to start paying out, perhaps those are the sorts of statistics that will shake the EMS Division out of its echo chamber.