Politics and conflicts mire EMS service in Georgia
Many of the problems trace back to the lack of clear state rules for determining who is selected to provide emergency transport services and how they are vetted
The Atlanta Journal-Constitution
ATLANTA — A crew of Paulding County emergency workers was racing the clock just before daybreak one August day to save Jason Brady’s life.
As he gasped for air, medics and first responders urged the autistic Dallas man to slow his breathing. Then, they tried to devise a way to get him down a stairwell to the ambulance.
But, after more than 20 minutes of effort, the 39-year-old stopped breathing and went into cardiac arrest. The crews started CPR then spent another 14 minutes at the scene working to revive him. He was later pronounced dead at the hospital.
That set his sister on a four-year quest to find out if the crews could have saved her brother. “The way he died, I could never let it go,” Jennifer Doxakis said.
Ultimately, the Georgia Department of Public Health asked the medical director of the ambulance company to investigate. That internal investigation found that the paramedic in charge violated company policies and protocols. Too much time was spent at the scene, and documentation on what went wrong was poor, it found. But the state held no one accountable.
Brady’s death points to how the state fails its duty to ensure the quality and reliability of Georgia’s emergency medical services system, an Atlanta Journal-Constitution investigation found. State standards are vague and oversight weak, leaving the system vulnerable to breakdowns, political pressure and conflicts of interest.
DPH leaves it up to ambulance company officials to determine the quality of care provided by their medics and to investigate complaints. When questions come up about whether response times are reliable, or if there are enough ambulances to serve a population, the agency doesn’t address the issues head-on.
Meanwhile, the system can shield ambulance executives from criticism that help arrives too slowly or that patients don’t receive the care they need. The public often has no way of knowing about the quality of ambulance service until a tragedy occurs.
Many of the problems trace back to the lack of clear state rules for determining who is selected to provide emergency transport services and how they are vetted.
DPH ultimately chooses ambulance providers, but the agency leaves it to 10 regional councils to recommend the provider in a designated area.
In making their recommendations, DPH tells them they are to consider “economy, efficiency and benefit to the public welfare.”
That broad standard invites subjectivity, critics say.
“How do you ensure that? How do you enforce that when an ambulance company doesn’t meet what it has contractually put in writing? The state doesn’t hold them to it,” said Charles Perdomo, EMS manager for Fulton County, who has served as a fire chief in Oregon and retired from the Miami-Dade Fire Rescue in 2012.
“Often, business interests are considered more important than human life,” he said.
Those councils of paramedics, fire chiefs, physicians and ambulance service executives can endorse a service based on little more than subjective information and promises of results that later don’t materialize.
Those seeking the business often are not even required to prove they have the manpower or resources to do the job. That creates situations rife with conflict, said Terence Ramotor, regional director for American Medical Response, a private ambulance service that currently provides service to DeKalb County.
“There are no standards, so whatever you submit, there are no mechanisms to hold the service to the proposed standard,’’ he said. “Theoretically, you could propose an unrealistically good proposal, and if you play your politics right, the council can award you the service area.”
At times, a provider on the council can isolate competitors and sway decisions, critics say.
The voices of local governments can be drowned out by the selection committees. And the only data available to evaluate performance may be in control of the executives from the ambulance service itself, not an independent oversight agency. After selection, if local governments are not satisfied with the service, they often offer little recourse.
The Department of Public Health (DPH) says it is working to address some concerns of critics like The Georgia Ambulance Transparency Project, based in Atlanta. For example, DPH says it plans create a statewide searchable database so the public can check on providers that are lagging their peers on responding to emergency situations.
DPH spokeswoman Nancy Nydam said the department is also working on new rules for choosing providers. She wouldn’t elaborate on specifics.
‘These look good’
Response times are a hot-button issue as numerous communities across the state have complained of life-threatening delays.
Critics say the lack of independent and uniform information on how ambulances are serving their communities is eroding public confidence. Currently, it is up to ambulance executives to establish a method for reporting response times, and critics say some will present the figures in a more favorable light to avoid public scrutiny and win business.
In Fulton County, fire officials say they can’t rely on the response times compiled by Grady EMS, which serves the city of Atlanta and south Fulton County, because the data is not from a neutral party.
A Grady report of Atlanta response times provided to the AJC showed average response times as low as 7.04 minutes on calls for some days in the final months of 2018.
“These look good,” Jolyon Bundrige, a paramedic and deputy chief of EMS for the Atlanta Fire Rescue Department, said. “I don’t think that it is happening, but they look good.
“I just can’t verify it.”
He said his department is purchasing a new computer-aided dispatch system to fact-check Grady’s response times.
Officials at Grady EMS in Atlanta say their equipment that captures response times is state-of-the art. But Cliveita Caesar, director of 911 Communications at Grady EMS in Atlanta, said she welcomes Bundrige’s effort to establish an independent system.
“We’re transparent now, but that’s just another level of transparency,’’ Caesar said.
The Georgia Ambulance Transparency Project wants state lawmakers to set acceptable response times for all operators in the state.
Some services say they would be open to uniform standards for all providers, public and private. “All I ask is that everybody is graded the same way,” said Pete Quiñones, CEO of Metro Atlanta Ambulance Service. “We all have the same start and finish times. Everyone is on the same sheet of music.”
However, it’s unlikely that DPH will step in. In response to questions from the AJC, Nydam, the DPH spokeswoman, said it was “not feasible” to apply a standard rule on response times.
That decision must be left up to local communities, she said. Each must establish its own priorities based on its special set of circumstances, which include population, density, geography and accessibility to medical facilities.
DPH and critics agree that the public is better served when EMS decisions are made by local communities. In a best-case scenario, elected officials in those communities should be held accountable for the decisions.
But Georgia’s weak system has hampered accountability and created conflict for regional councils that choose local ambulance services.
Consider the Northeast Georgia Region 10 Council, where a battle over ambulance service has been going on for about two years. Conflict began when the city of Winder wanted a dedicated ambulance service rather than depending on Barrow County EMS.
The council voted 18-2 to stick with the county’s service. Then earlier this year, the DPH commissioner rejected the council’s recommendation, saying the Barrow zone should be opened up to proposals from outside vendors. Dr. J. Patrick O’Neal said his decision was based on the state standard of economy, efficiency and benefit to the public welfare.
Local EMS officials, though, condemned the move, calling it “the ruling of one man” over a 20-member council.
Then a few weeks later, O’Neal flipped and decided to uphold the council’s vote.
Now, DPH is being sued by the city of Winder, which wanted to hire a private ambulance provider.
O’Neal, who retired in April, did not respond to a request for comment.
In Augusta, another legal battle is raging between the private ambulance service serving the city and the fire chief, who is also chairman of the East Central Georgia EMS Council and who wanted his department to take over service for the Augusta-Richmond County zone. The private company sued when the council said it would consider other proposals for the Augusta area.
Other local governments say they feel powerless to have their concerns addressed at the councils. Joseph Barasoain, the director of EMS for Fulton County, said that the dominance of ambulance service representatives on the Region 3 council puts local government officials at a disadvantage.
“If you ask some of the fire chiefs in south Fulton County, at the end of the day they will tell you that the system is broken,’’ Barasoain said. “It’s insane to me.”
Some ambulance providers themselves are uneasy with their roles on the councils.
Ramotor, the AMR executive, said until last year his company had a representative on the Metro Atlanta area council. But he says he doesn’t believe it is appropriate to weigh in on decisions that ultimately may draw more business to his company. And he doesn’t want to debate EMS alongside of fire chiefs and other officials that are his customers.
“That’s a major conflict,” Ramotor said. “I don’t want to be part of it.”
Other ambulance executives on the local council have a different take. Quiñones, with Metro Atlanta Ambulance Services, said he is careful not to position himself at the center of contentious issues that may raise questions of conflicts of interest or to vote when his company stands to gain.
“That’s how it should be,” Quiñones said. “You shouldn’t be allowed to vote on your own zone.”
But not all ambulance representatives take that hands-off approach. And even if an ambulance executive doesn’t vote, that person has a seat at table where votes are cast while a competitor may not, said Sam Rafal, an EMT and retired educator in Athens.
“I call it insider trading,” said Rafal, also the founder of the Athens-based WhenEverySecondCounts.com, an organization advocating for greater accountability in EMS services in Georgia. “It is a competitive advantage given to a company that is withheld from another company.’’
Lawmakers urged to act
A bill sponsored by Rep. Bill Werkheiser, R-Glennville in the past legislative session would have addressed some of the concerns about conflicts and accountability.
One aspect of the bill would have banned ambulance executives from serving on committees that made decisions about exclusive contracts. The bill also would have required regional councils to meet in public. Some had created subcommittees that could bar the public, Werkheiser said.
The bill didn’t get out of conference committee during the session.
“You know it’s a bad look when you try to provide some oversight and transparency and people fight that,” Werkheiser said.
Doxakis said DPH also needs to establish an investigatory arm of EMS experts who don’t have ties with local ambulance providers. “The way the office is set up,’’ she said, “it’s not equipped to handle complaints against one of its own.”
In her brother’s case, she contends that medics wasted precious moments ordering him to put on his shirt and get into a stair chair at their home. She contends that no medical equipment was brought into the house to help his breathing.
“They didn’t listen to his lung sounds,’’ she said. “People were just waiting around. There was no sense of urgency.”
Metro Atlanta Ambulance Services was the provider for her brother. Quiñones said that two medics, two Paulding firefighters and a battalion chief did everything they could to save his life. The delay in getting Brady into the ambulance was because of problems extricating the 6-2 foot, 280-pound man from the second floor. Brady was also combative and covered in sweat, Quiñones said.
“He couldn’t be grabbed,” Quiñones said. “If we had the same scenario again, would it have been done any differently? Probably. At the same time, these people walked in not knowing what to expect.”
He noted that the company’s medical director required that the paramedic supervising the call undergo rigorous training.
In its response to Doxakis, DPH said it recognized that medics were on the scene 46 minutes before transporting Brady and that the paramedic in charge didn’t bring any equipment into the home. But the agency said it wasn’t clear whether equipment was available or if Brady’s health and safety were jeopardized. DPH also noted that it doesn’t set the standard of care for EMS personnel but leaves that to each ambulance service to determine.
After so many years of digging in to what happened, Doxakis doesn’t find any of that answer satisfactory.
“The system fails all of us,’’ she said. “What happened to my brother didn’t have to happen.”
EMS providers rarely sanctioned
The Department of Public Health doesn’t do much to sanction ambulance providers that respond to emergency calls.
The department, responsible for the licensure and oversight of providers and emergency medical professionals, said it was unable to generate reports that provide details on the number of investigations and disciplinary actions it has conducted.
But it provided information showing that in the last few years it has revoked the license of one ambulance service and suspended licenses of two others. A total of eight paramedics had their licenses sanctioned.
(Source: Georgia Department of Public Health)
Who transports patients to hospitals in Georgia
Critically-ill patients who call for an ambulance can be transported in a number of ways.
In one model, local fire departments operate the ambulance transports. The departments may hire EMTs and paramedics who respond to emergencies and take patients to hospitals. In some cases, firefighters who hold additional certifications as EMTs and paramedics respond and provide advanced medical care. These operations tend to be part of a local government.
In another model, a hospital system runs the ambulance service, which employs the medical staff, paramedics and EMTs. These operations can involve both for-profit and nonprofit operations.
In a third model, private companies operate ambulances and hire the medical personnel to serve patients and transport them to hospitals. These are private, for-profit operations.
Even when a hospital system or private company operates ambulances, firefighters respond to medical emergencies and because of the ubiquity of fire stations, often are first on the scene. The first responders can provide CPR or other life support while waiting for the transport.
©2019 The Atlanta Journal-Constitution (Atlanta, Ga.)