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EMS News in Focus
by Arthur Hsieh

Possible solutions to San Francisco’s EMS problems

There are plenty of options for a proactive agency to explore, evaluate and implement

By Arthur Hsieh

Earlier I had commented that the problems San Francisco faced in its EMS system were too large and complex to be fixed by merely throwing money at them. A combination of population changes, declining healthcare finances and rigid government thinking contribute to a problem that has been ongoing for three decades. 

I was taken to task by an EMS1 reader who felt that I offered no suggestions, which is true. There are folks who are far smarter than me who could weigh in on this issue.

But, I don’t have to; San Francisco itself has tried several innovative ways to manage its call volume:

  • It had a successful diversion program that reduced the number of high frequency callers to the 911 system. Using a medic/social services worker team, chronic 911 callers were identified and matched to appropriate resources within the health department. As a result, many of these patients reduced or even stopped calling 911. Unfortunately this program was eliminated.
  • A sobering center was established to divert those who were intoxicated, but not injured or ill, to a facility that could monitor them, freeing up precious emergency department beds.
  • For a while, city paramedics treated, then release acute asthma patients after a more detailed evaluation. A similar program provided alternative transportation to a hospital or clinic for patients who did not require ambulance transport.

Given the rapidly evolving nature of community paramedicine, there are other ways to adapt to field patients, rather than simply adding more workers to the department. That’s real change that is permanent and meets the needs of the community.

Then there is the need to closely look at how the city views its EMS system. Is it the primary role its fire department, or is it subservient to fire suppression services? A review of the department’s budget shows that the vast majority of money is spent on the latter. It’s also likely that the turnover rate of its EMS division is much higher than that of its fire suppression. Perhaps the department needs to be restructured so that resources are spent in a way that better matches resources to needs. 

There are plenty of options for a proactive agency to explore, evaluate and implement. It’ll be interesting to see if  this department takes a chance and remakes itself during this time of crisis.

About the author

EMS1 Editorial Advisor Art Hsieh, MA, NREMT-P currently teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. Since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook author, has presented at conferences nationwide, and continues to provide patient care at an EMS service in Northern California. Contact Art at
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Jamie Bingham Jamie Bingham Thursday, July 17, 2014 10:56:04 AM Art, I think you're articles bring light to many topics that need to be discussed within EMS circles, and I enjoy all of them, unfortunately the way we act in EMS has always reminded me of our political climate. We have REAL issues, and you do bring them up, and these are things that need to be discussed, but instead of addressing them as a whole, just like in politics, we can put them aside and be bought off and ignore the real issues if we talk about something that gets' our "goat up.". We tend to have an apathy unless we discuss certain thing like adding something to our repertoire - ie..expanded scope, RSI, etc. or taking something away (if you want to get people commenting and fired up talk about NOT intubating in some situations). I tend to ramble in this forum, but we really don't have many avenues to express our personal concerns. This always saddens me because we as a profession and as individual medics tend to self judge ourselves on what we "get to do" and not our knowledge or or even the invaluable street education we pick up with experience. Paramedics are always second rate to even the lowliest RN even if both have similar 2 year education paths and as we know, the pay difference is phenomenal (and even within our own profession private side EM professionals are much lower on the scale than fire-ems professionals.) And even though medics aren't adept at "care plans" and making hospital corners, we/they are specialists and in every other profession but ours specialists tend to make more money. A critical care nurse makes more than a floor nurse. I think it's again, because of our own apathy and willing acceptance to look the other way so long as we can talk about some new skill, or adding something to our EMS tackle box. Like the political analogy I made earlier, and just like serious issues, such as say the lack of fathers in homes of what's now 70% of one ethnic culture in the US is a serious issue - so long as someone says to us "it's those rich white republican oil barons fault you're struggling"(usually preached by a rich millionaire politician from a golden pulpit and limo) we can get emotional and forget issues more pressing. EMS is the same. We have real issues - I say one is the lack of real respect and the pay disparity in EMS. But so long as we talk about intubation - either doing more of it or taking it away - we can deflect real issues. If we talk about fire based EMS versus private, non-fire based EMS we can get people worked up and fired up to comment instead of asking ourselves why the RN on the helicopter is getting $30 and hour and the paramedic beside that RN is getting $15 an hour when both have 2 year degrees (and some medics and RN's do have 4 year degrees of course) but once again we have deflected a real issue away. I guess what I mean is this. For my entire career in EMS almost exactly as long as yours (30 years) we have discussed the same issues over and over again and never solve any of them - in a grand sense anyway. Every few years we bring up, once again, that "expanded scope" paramedics concept. Someone somewhere tries it, it lasts a short while then is cut or fades out. We discuss and maybe try, like in San Fran - the treat at home and not transport idea - it works for a few and fades out. We talk about the volume of "unnecessary" 911 calls and how to stop it. We're forever trying to fix response times- the medic in the rapid response vehicle or the bicycle medic, blah blah blah........same topic different year...... While those type of issues do matter, we just keep seemingly talk in endless circles about them. Why can't we talk about how to make paramedics on par with the RN's, in both respect and pay, and close this incredible pay gap, especially if we're looking at similar schooling length. I am not suggesting we're perfect equals, because we're not, but the disparity is too huge to say it's a non-issue. Why can't we discuss the PROBLEMS with system status systems - the sitting in hot units all day (these systems seem to much more prevalent in the South and in the stifling heat out West (Phoenix, SoCal), the back injuries, the constant unit break downs, the running the unit all day (usually to keep the AC or heater on) and the diesel emissions floating into the air, and such. Why do we have to keep circling the proverbial wagon and discuss the same old same old? that of expanded medics, treating at home, not putting everyone on a backboard.......I've heard these same things, things that have NEVER been fixed or stuck, since I was an 18 year-old know-it-all who really knew nothing medic. Look, I bring this up because I think this is important and not due to sour grapes or bitterness, though the pay disparity, while not affecting me personally now, will still, and I guess will always bother me. I enhanced my education and earning power so I am not complaining because someone has something I want - that is more pay - and that option of going back to school is always there for other medics too, but that doesn't make the pay or other issues right, nor do I understand why my fellow colleagues will just ignore them over and over again. Jamie Bingham PA-C, MPAS, EMT-P
Diana Sprain Diana Sprain Thursday, July 24, 2014 3:13:28 PM SF EMS does have issues. Back when there were multiple ambualcne companies handling overflow and the ems services was handled by the health dept, I think it was more efficient. Tie and time again, the costs and problems have increased when fire service takes over ambulance services. Privates can do it more effectively and cheaper. Maybe it's time for SF to give ems back to the privates.
Gary Saffer Gary Saffer Thursday, September 18, 2014 3:10:56 PM You know, they could like go all retro and separate the EMS system from the fire department. Exactly what is the excuse the chief has for not buying even one new ambulance despite money being allocated for it in 2012? That is just the tip of the iceberg I'd guess.

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