PORTLAND, Ore. — Multnomah County's crisis of slow ambulance response escalated earlier this month when chair Jessica Vega Pederson decided to fine ambulance provider AMR over half a million dollars for late arrivals.
The conflict — a concern for anyone in Multnomah County when they call 911 — has been building for 18 months, as AMR has repeatedly missed contractual standards for how quickly ambulance crews are required to respond to emergency calls.
A nationwide shortage of paramedics is at the heart of the problem, but it's not the only issue.
For more than a year, throughout numerous media reports on slow ambulance response times, tragic outcomes and a lack of any available ambulances on thousands of occasions, AMR has stayed mostly quiet — electing to provide short emailed statements, saying the company is working with the county and other partners to find solutions.
Multnomah County's hefty fine changed that. AMR has decided to respond on camera.
KGW investigative reporter Evan Watson sat down with Randy Lauer, AMR's vice president of operations, and Robert McDonald, AMR Multnomah County's operations manager, for wide-ranging interviews on the current state of ambulance services in Multnomah County and AMR's perspective.
Lauer and McDonald explained why they believe ambulance response times will worsen unless county leadership makes a change, and how they believe that people who live in the county are at risk.
The following chronicles AMR's views on what they're calling an ambulance crisis in Multnomah County. Parts of the transcript have been lightly edited for clarity.
The current state of ambulance services
Watson: How would you describe the reality for AMR at this current moment?
Lauer: The system is the closest to collapse that I've seen in my 42 years (in the industry). The national paramedic shortage is like nothing we've seen before ... We need to deploy 50 ambulance shifts a day. Our shifts are typically 12 hours long. We can only deploy 32 today. You look at all the ambulances that are parked in our bay, they should be out on the street. Now, if we could staff them, they would be.
Watson: How do you solve a national paramedic shortage?
Lauer: The only way to solve it is to train more paramedics, and industry wide, the projected supply is way below the needed demand. As the pandemic played out, the paramedic schools closed down for two years and that's had a profound effect. We just had the first post-pandemic class graduate from our own college in Clackamas County. We filled both of the upcoming classes, largely with scholarships. We're sponsoring EMTs, giving them full-ride scholarships to attend paramedic training to the tune of about $18,000 each. But it's what we need to do.
Watson: I want to be clear, you said you started conversations with Multnomah County more than a year ago to avoid a crisis. Are we now in an ambulance crisis?
Lauer: Yes, we are. This system is in crisis and it's getting worse. It's not sustainable the way it is.
Watson: Big picture, whether it's from your perspective or the county's perspective and what needs to be done and these strong-held beliefs, the people who are most at risk of being hurt here are the people in Multnomah County not getting the emergency response they would desperately want, correct?
Lauer: Yes, the patients, the citizens we respond to, they're at risk. Paramedics who respond are at risk because they're burned out and they're fatigued. They're still running all the calls with fewer people, we're losing people through burnout, so it's bad for our patients, it's bad for our employees ... and those things, they don't work well together ... look, Multnomah County is dealing with all kinds of very complicated problems now: the houseless population, addiction, mental health. Those are difficult situations and I know it's been a real big struggle, and I empathize with the county commission and Chair Vega Pederson because those are hard issues. This one is not complicated. There's a simple solution to get paramedic staff and get the ambulance staffing in Multnomah County back to where it needs to be.
The two-paramedic requirement
The biggest point of contention between AMR and Multnomah County is how to staff each ambulance.
County leaders, including longtime EMS Medical Director Dr. Jon Jui, swear by the current two-paramedic system. Jui told KGW he believes two paramedics on each ambulance provide better patient care in high-risk situations.
Paramedics are more qualified and experienced than EMTs, and Jui said that in a city like Portland, that matters.
However, it's much more common throughout the country for ambulances to be staffed with one paramedic and one EMT. When paramedics are scarce and EMTs are easier to both find and employ, AMR leadership says relaxing the two paramedic requirement would increase the number of available crews.
In response to request from KGW, Jui shared various studies that he cites for why he insists on keeping the two-paramedic system. AMR also provided links to various studies that support their argument. Those links are listed at the end of this article.
Watson: If Multnomah County switched to a one-paramedic and one-EMT model, how quickly could that change overnight the number of ambulances you have on the streets?
Lauer: We could staff probably four to six more ambulances tomorrow if they let us do that. Within three months, four months tops, we can have all fifty of those shifts filled. About half of them would be Paramedic-EMT ambulances, and half would still be two-paramedic ambulances. We're at a loss to understand why (the county) doesn't take the win that's available right in front of them. As paramedics become available, we're going to continue to aggressively hire and start putting that second paramedic back on ambulances, but the paramedic-EMT solution is the bridge to that point when paramedic (availability) recovers, which could be years yet.
Watson: The one paramedic and one EMT model is more common ...
Lauer: Multnomah County is unique in the United States in having a two-paramedic requirement. We did a deep analysis of our company. We're a national company and have 267 operations that provide 911 ambulance response. Of the 267, 266 have a paramedic-EMT requirement. The only one with two paramedics is Multnomah County. That by itself statistically tells you this is extreme.
RELATED: 'We could fix this': Multnomah County's 2-paramedic requirement and the clash over 911 solutions
A cost-saving move?
Watson: Now, I need to ask you about an important part of this, if a change were to be made. Based on pay scales in AMR's contract with the county, EMTs are less qualified but also make less than a paramedics. Would this be a change to cut costs and save money from a private company's perspective?
Lauer: That's not why we want this change. We've had a two-paramedic system since 1995, actually back into the 80s, but under contract since 1995.
Watson: Alright, you say it's not the reason you would do it. Is it a contributing factor?
Lauer: No, we don't look at it from a cost-saving perspective at all. However, there will be some cost savings just because of what you said. We can use those savings to fund other things in the city of Portland, the county, that they really want to do. We're perfectly willing that whatever savings we achieve through paramedic-EMT to contribute that money back into the system.
Watson: If you're supposed to be staffed for 50 and you're only staffing for 32 right now, you're not paying for 18 spots. In my mind, correct me if I'm wrong, if you're able to hire EMTs for those 18 spots, even if they make less money than paramedics, you're spending there. How's that part of your calculations?
Lauer: So for those 32, we're spending a lot more. We offer incentives to people who work overtime to cover extra shifts. Overtime payment. We're trying to fill our open shifts however we can, we're spending a lot of money to incentivize people to work. We have a number of part-time paramedics that we're also offering incentives to get them to work more shifts. So we're pulling out all the stops. We're not not spending money — we'll spend money if it staffs an ambulance. If we can spend money on incentives or whatever and get two or there more ambulances out on the street, then we'll do that every day.
Watson: Ultimately, you're saying a suggested change from two paramedics down to a one-and-one model is not about potential cost savings down the road?
Lauer: It's not what's driving this. There will be some, I'm not going to say otherwise, we will save some costs, but we're willing to share those costs, spend that money that we save on something else that is desired or needed to improve the overall system.
Watson: And with one-and-one on patient outcomes ...
Lauer: Clackamas County has the one-paramedic and one-EMT model. So does Clark County. So does Washington County. They all produce good patient outcomes. Multnomah County doesn't have anything special over them other than they require two paramedics.
The impact of AMR's service in neighboring counties
AMR operates ambulance services in Clark, Clackamas and Washington Counties in addition to Multnomah County. While Lauer says those counties all produce good patient outcomes with paramedic-EMT models, those counties still report issues with AMR ambulance response.
In the first six months of 2023, AMR ambulances were unavailable to respond to 850 emergency calls in Clark County. Clackamas County fined AMR $456,000 earlier this year for late response times, later voting to forgive the fine if AMR invested half of it for "workforce support and retention."
In August, AMR expanded into Washington County — a move that Multnomah County Chair Jessica Vega Pederson said was a big reason why she decided to fine the company. Despite plans to have a full staff in Washington County from the start of its EMS service, AMR Washington County is still short-staffed by six paramedics and five EMTs, according to Washington County officials.
Watson: You recently expanded into Washington County, and you're not fully staffed there yet, while still having these issues in Multnomah County. My question would be — has that spread your resources out? Are you spread too thin covering these different counties that you're pulling from one to another?
Lauer: No, it hasn't. We hired most of the paramedics from the former provider (Metro West) and a lot of their EMTs. Washington County is not unionized yet. Our operations in Multnomah and Clackamas County are unionized, so they have the right under their contracts to transfer between operations on a seniority-based system. We have in Multnomah County 12 paramedics who put in a request to transfer to Washington County, and I think there's two or three in Clackamas that want to do the same thing. We said no because they don't have (transfer rights) right now through union contract. But we got notification last week that they are unionized and we're going to start bargaining probably in the next month. So, that's another thing that's going to make the system worse. If we can't prevent those 12 paramedics from leaving Multnomah County and going to Washington County, that makes Multnomah more dire right away. We've really gone out of our way to avoid robbing Peter to pay Paul.
Watson: The chair mentioned that this expansion into Washington County as a main point that led her to this recent fining, implying that it has affected the service here in Multnomah County. Has expanding to Washington County affected ambulance service in Multnomah County or other counties you already serve?
Lauer: Not at all, for what I just mentioned, we've not let people flee or transfer from Multnomah County to Washington County.
Watson: And you will try as long as you can to make sure that doesn't happen?
Lauer: Exactly, but when they become unionized and they have the right to transfer to a different operation like our collective bargaining agreement spells out, then we can't stop that. And that will occur. So there are things on the horizon that are going to make this crisis that the system is in an even deeper crisis. That's one of them. The burnout and fatigue for the paramedics in Multnomah County right now is another one. The picture is terrible right now and it only get worse if the commissioners don't allow this change.
Patient outcomes
Watson: We've been tracking response times, and you're well aware that response times are not meeting what's set out in the contract and that you're not able to get to some of these emergencies within 8 minutes. But you also mentioned that you agree with Vega Pederson in that no patient outcomes have been altered by the slower response. How are you so confident that patient outcomes haven't been affected over this last year with you not getting to scenes as quickly as you'd like?
Lauer: I'm not totally confident, I just don't disagree with the chair's statement because we haven't done a deep analysis on patient outcomes. There's always been a sort of disconnect getting patient outcomes anyway, the outcome is from the hospital or the emergency department. What did they find? What was their diagnosis? Did we improve that patient's position or condition or did we not improve it? So we haven't done that data analysis.
Watson: But it's one of those things that the longer this continues, if it hasn't already, the more likely that patients could be harmed by ambulances not getting there as quickly as required.
Lauer: If response times mean anything, then it will have an effect at some point. If somebody is suffering a cardiac arrest and it takes an ambulance two minutes longer to get there, that's not a good thing. If somebody is in cardiac arrest and it takes the ambulance 20 minutes to get there, that's a really bad thing. Whether or not we're experiencing those bad outcomes now ... they're going to come, we're going to start having bad outcomes.
A solution? A compromise? Risk for the future
Watson: Could there be a compromise here of a couple of years of allowing a paramedic-EMT model to allow that paramedic shortage to hopefully improve until more paramedics get trained in order to potentially revert back to the two paramedics that the county wants so much? But at least give us a grace period to get our staffing up?
McDonald: That is actually, you just described exactly what we are proposing. We don't want this to necessarily be a permanent solution now ... our proposal is to try and get from here in this fractured crisis to a sustainable model and the only way forward is to incorporate EMTs in our deployment.
Watson: So that proposal is specifically for a couple of years? Is that something you've laid out or offered the county, saying "Let's do this for X amount of time?" What does that look like?
McDonald: Yeah, I believe we've been perfectly clear that it's temporary. I don't think we've ever put dates and timelines on it because there's so many unknowns. Again, you look back to when we signed this contract in 2018. We didn't have a paramedic problem. The country didn't have a paramedic problem. Well, flash forward to today and we clearly have a problem and the fact that our county wants to languish in an antiquated EMS system that's decades old while everything is crumbling around them, it's confounding to me.
Watson: Could that be something you offer, specifically? Say, let's look at one or two years and then we can revisit response times and how those have hopefully improved and have another conversation then.
McDonald: Absolutely, in fact I would actually go further than that. Let's try this for 18 months to 2 years and start measuring data now. Let's show proof of concept and whether this is the course of action and it's right, let's do that. Start the data dive now.
Watson: Even if two paramedics provide better care, and I understand your position that you don't agree with that, but currently with two paramedics per ambulance right now there aren't enough ambulances on the street and response times aren't good enough. However if you switch to one-and-one you get more crews on the street and you can respond quicker —quicker response is associated with better immediate care. If the ultimate goal here is to provide the best patient care possible and get to all these places as quickly as possible, how do you compare and contrast those two things together?
McDonald: The best way I can answer it, and again this is me oversimplifying, Evan, is a local fire chief who said "I'd rather have a paramedic and an EMT in eight minutes than two paramedics in 25 minutes, no matter what the acuity of the call is." The EMS system as it stands right now is ready for this change, clamoring for it.
Watson: Should members of the public here in Multnomah County be concerned knowing that in those moments of crisis and emergency, when seconds and minutes matter, this is a situation that is not on track to improvement?
Lauer: I think they should. I think we need to be totally honest with the public, totally transparent every step of the way. The fact is that with the system in crisis the way it is, and with it going from crisis to catastrophe pretty quickly, it is going to (make an) impact, and they're going to call 911 and expect an ambulance in eight minutes and it's not going to get there for a long time after that. All while they're with their loved one or whomever who is in dire straits. We don't want that. I mean, we all got into this career to help people in crisis. We see people on their worst days. We don't want to make their worst day worse because it takes us a long time to get there.
Watson: Their health and recovery could be at risk.
Lauer: Exactly. We just urge (Multnomah County) to make this change. Make it immediately. Let us start adding more ambulances. Improve the response time. Get to people faster, reduce the fatigue and burnout in our paramedics, and get back to a sustainable system. The system today is not sustainable.
As promised, below are links to the studies cited by both Multnomah County EMS and AMR in defense and in opposition to the two-paramedic system, respectively.
Studies provided by Multnomah County EMS Director Dr. Jon Jui:
- The number and level of first-contact emergency medical services crew and clinical outcomes in out-of-hospital cardiac arrest with dual dispatch response (Kim)
- The association between the number of prehospital providers on-scene and out-of-hospital cardiac arrest outcomes (Lupton)
- Impacts of emergency medical technician configurations on outcomes of patients with out-of-hospital cardiac arrest (Fang)
- The effect of the number and level of emergency medical technicians on patient outcomes following out of hospital cardiac arrest in Taipei (Sun)
- Volume versus outcome: More emergency medical services personnel on-scene and increased survival after out-of-hospital cardiac arrest (Warren)
- Optimal paramedic numbers in resuscitation of patients with out-of-hospital cardiac arrest: A randomized controlled study in a simulation setting (Tsai)
- EMS in Taiwan: Past, present, and future (Chiang)
- The prehospital emergency medical service system in Korea: its current status and future direction (Park)
Studies provided by AMR:
- Effect of paramedic experience on orotracheal intubation success rates (Garza)
- Impact of ambulance crew configuration on simulated cardiac arrest resuscitation (Bayley)
- Do ambulance crews with one advanced paramedic skills officer have longer scene times than crews with two? (Kelly)
- The effect of ambulance staffing models in a metropolitan, fire-based EMS system (Cortez)