In EMS, internal politics cause external problems

In this industry, the politics behind some internal policies create a territoriality that isn't just frustrating – it's deadly

As I continue to travel around the country meeting and speaking to the real heroes, the folks who get EMS done, I am touched by the universal commitment they share; a commitment to providing the best possible care for those who depend on them. That commitment makes me proud to be even a small part of this industry.

Sadly, there seems to be a dark side that is equally universal. A side that is not brought up by the participants in the classes I teach, but in private or quiet one-to-one moments in between sessions or over dinner or drinks at the end of the day. Invariably, it begins with cautiously worded questions about the legality (and righteousness) of internal policies and the politics behind them.

Not long ago, I had the pleasure of speaking to a group of EMS providers from along the I-81 corridor through the Shenandoah Valley in Virginia. They described how their system functions in certain areas. It seems that the EMS responsibilities there are shared by both volunteer and career provider agencies. Not uncommon.

I was told that, in some areas, upon first alarm, the volunteer squad has five minutes in which to come up on the air as responding. Five minutes? In my entire career, I never had more than 45 seconds. But I digress. If, after five minutes, the volunteer squad has not marked up responding, another alarm goes out giving the volunteers another three minutes. The patient has now been waiting eight minutes. If, after the full eight minutes, no volunteers have responded, then — and only then — is a career unit dispatched, and then the sometimes lengthy rural response begins.

"So," I asked with great amazement, "the patient can wait for nearly ten minutes before someone, anyone, responds to the 911 call?"

"Yup. It happens all the time" was the discouraged, yet resigned response.

"Shortness of breath?"


"Chest pain?"


"Cardiac arrest?"


Realizing that my hotel was located in such an area, I found myself being extremely cautious.

"It's worse than that." One provider told me before explaining that, in many areas serviced by volunteer squads, there could be two career paramedics stationed in the volunteer house when an alarm goes out, but they are prohibited from responding until a volunteer arrives to drive the apparatus. That's when my twitch came back.

Naturally, I asked how such policies could exist in an environment that is, generally, so committed to providing quality patient care. The answer: politics.

They explained that the various volunteer agencies wielded considerable power and influence within the respective city councils and county boards and they were very, very territorial.

Territorial? Street gangs are territorial. Dogs and lions and killer whales are territorial. How territorial can an EMS provider or agency be when someone is suffering? How is territorial any factor when a child is lying in the street or someone's mother is having an MI? That's how I felt as an EMS provider.

As an attorney, my thoughts were very different. These territorial agencies must know what kind of exposure they have. They must know that preventing an available resource from responding — for political reasons — will not carry the day in court after a child dies, or after anyone dies for that matter. And they must know that depriving the community of readily available resources — for political reasons — is not only unlawful, it is unethical. "It happens every day," one provider said quietly and despondently, "and the community has no clue."

I supposed I should not have been surprised. I have seen it before.

There are fire departments right here in Southern California who run paramedic squads and use private ambulances for transport, yet the private ambulances — equipped with BLS supplies including AEDs — are ordered to hold back if they should arrive on the scene first.

One fire department in Northern California was forced to remove all of its ALS equipment from (Paramedic-staffed) apparatus because the local private ALS provider claimed jurisdiction over dispatching ALS resources or some such nonsense.

I have seen cities refuse assistance from neighboring cities on calls that occur near the municipal border in favor of having their own resources respond from much farther away.

I was consulted after a fire captain refused to allow a BLS ambulance to begin a forty-five minute transport of a critical patient because the closest fire department Paramedic unit was halfway between the scene and the hospital. Rather than having the BLS and ALS resources rendezvous half way to the hospital, the captain ordered that the patient remain on scene — with the same BLS providers — for an additional twenty-minutes longer than the 45 minute transport so that "his guys" could take over.

And the list goes on and on.

I can't help but wonder how things like this can happen? Yet they do happen, every day. I know they do, because I get the calls from nervous providers who are deeply concerned that someone else's decisions could cost them their jobs, or worse.

So, I pose a few simple and very real questions to those of you who are making such decisions or enacting such policies:

What will you tell the sobbing mother when her child is dead because your decisions were political?

What will you tell the media when the obvious and negative consequences of your policies make headlines?

What will you tell a jury when you are on trial because you put politics above patient care.

And, what will you tell yourself when the child in the casket was yours?

That's a hard question, but this is something about which I feel strongly. Like most of you, this issue is something over which I have no direct control. I believe, like most other issues, the first, most important step toward improvement is dialogue. If these issues are familiar to your area, perhaps it's time to address them with the powers-that-be, whether it's the city council, county board, or the community itself.

By doing this, we are not laying blame; we are seeking solutions to critical problems before such problems arise. We are being proactive. We are doing what EMS is meant to do: saving lives.

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