Jacob Barker
St. Louis Post-Dispatch
ST. LOUIS — It took 38 minutes before an ambulance arrived to transport Rodney LaRue to the hospital last September.
He had been flung from his motor scooter near the intersection of Arsenal Street and Ivanhoe Avenue after colliding with a minivan. A firetruck was on the scene in minutes, with personnel that could offer some emergency care but couldn’t transport him.
By the time an EMS ambulance got LaRue to the hospital nearly an hour later, he was in critical condition. Later that evening, he died.
The incident was a glaring example of how the city’s Bureau of Emergency Medical Services is struggling to meet demand. While labor shortages are challenging employers everywhere, the staffing problems in EMS existed even before the pandemic.
Now, they’re worse.
In April, more than half of the city’s 55 paramedic positions were vacant, according to budget documents. Between staffing issues and wear and tear on the constantly running vehicles, only 10 of the city’s 12 ambulances are running “on a good day,” said one employee.
EMS systems across the country are struggling to stay staffed. But the problems in St. Louis EMS, a division of the St. Louis Fire Department, aren’t new. They were called out eight years ago, when EMS was much closer to full strength.
A little-publicized report, recently obtained by the Post-Dispatch, outlined critical problems at EMS even back then.
“The current system is not meeting the community’s demand for service and is performing with exceptionally long response times and frequent inability to respond,” concludes the 2014 report, commissioned by the city and authored by the Center for Public Safety Management, a consultancy formed by the nonprofit International City/County Management Association, known as ICMA.
That was hardly a new conclusion to Charlene Deeken, who worked closely with the fire department during her more than 20 years at the St. Louis Public Safety Department, where she retired as deputy director last year.
“Quite frankly, we have run them ragged for a lot of years,” Deeken said of EMS. “Now it’s compounded by the fact that there’s so many vacancies.”
Public Safety Director Dan Isom referred questions to St. Louis fire Chief Dennis Jenkerson.
Jenkerson, who was chief when the ICMA report was conducted, takes issue with some of its conclusions. But as far as EMS service being under-resourced, he said he agrees “100%.”
Every year that he’s served as chief, he said, he has asked for one of the report’s recommendations: a minimum of six additional ambulances to bolster EMS’s fleet of 12.
“I need more units,” Jenkerson said of EMS. “And manpower. But we haven’t been able to convince anybody to increase our manpower.”
In response to the staffing shortage, Jenkerson said the department in recent weeks inked an agreement with two private ambulance operators to station six ambulances in the city limits.
“I’ve got to take a little bit of the workload off of these people who’ve been going nonstop for a minimum of two years with COVID,” Jenkerson said. “When you ride a medic unit and you work a 12-hour shift and you’re handling 12, 15 sometimes 20 calls in that 12-hour shift? Way too much.”
A new class of about 12 paramedics is being added to the ranks now, Jenkerson said, lowering paramedic vacancies to about 20. And he’s looking at reshuffling firefighters to make sure there are at least two firetrucks staffed with a firefighter who has a paramedic license. They can provide on-scene treatment until an ambulance can transport a patient to the hospital.
Meanwhile, the department has been assigning firefighters, many of whom have EMT or paramedic licenses, to EMS shifts, or offering overtime to fill holes in EMS staffing.
The secretary-treasurer of the union that represents both city firefighters and EMS workers, fire Capt. Dan Clark, called the use of firefighters to fill EMS staffing holes a “Band-Aid.”
“At the end of the day, to keep EMS going, it’s got to be some decent pay raises,” Clark said. “We’ve been preaching more manpower and more ambulances for years. This is not a new problem.”
‘The turnover is huge’
Ambulance crews were overworked well before the pandemic, according to the ICMA report, which the city reportedly spent upwards of $200,000 to commission. But the report received virtually no publicity after it was completed. The only reference easily found on it is an article from the Labor Tribune in 2012, before the report was finished, that criticized the firm hired to produce it as anti-union.
Some of the lack of publicity was timing. It was completed in September 2014, just as the region was engulfed in unrest after the fatal police shooting of Michael Brown in Ferguson.
But fiscal — and political — realities also hamstrung the administration of then-Mayor Francis Slay. The recommendations in the report would have been expensive to implement and some likely would have drawn opposition from the St. Louis Fire Department and the influential firefighters union.
Broadly, the report painted a picture of a fire department with more firefighters than similar cities and fewer fires to fight in an age of fire-resistant construction and materials. Meanwhile, the EMS bureau lacked the ambulances, personnel and attention from fire department leadership to handle what had become the dominant driver of calls: medical emergencies.
Thomas Wieczorek, a principal at the Center for Public Safety Management who co-authored the St. Louis report, said tension between firefighting and EMS divisions isn’t unique to St. Louis.
“The two functions normally have conflict in the department, or we see it, and EMS is usually consuming more and more of the time of fire departments,” he said. “Most fire departments concentrate most of their resources on what’s in their name, the ‘fire.’ And the EMS is consuming most of their available time.”
In addition to adding six ambulances to the city’s 12-ambulance fleet, the report recommended cutting the city’s 30 fire stations by nearly half, to 17, with new stations built in strategic locations. That, the report said, would allow for a gradual reduction in the number of firefighting personnel from the 448 firefighters and 114 fire captains authorized in this year’s budget — more than four times the amount of EMS positions — to 360 total. Firefighting apparatus could also be cut from 36 to 24.
The number of stations and firefighting personnel “exceeds,” the report said, “industry recommendations and comparisons to similarly sized communities.”
Jenkerson, though, said the city’s fire staffing is necessary to maintain four-minute response times, a standard that insurance companies can use to set premiums.
The demands on the EMS bureau, the ICMA authors found, were far heavier than on the fire prevention side of the department. The report analyzed calls for service in the fire department a decade ago and found nearly 74% of calls from July 2012 through June 2013 were EMS-related. Fire calls accounted for about 20%, or about 16,200 total, when canceled calls were excluded. Just 5% of total department calls were related to actual fires, and a quarter of all fire calls were false alarms.
Deeken, the former public safety director, emphasized that “the professionalism on the fire side of the equation is top-notch.” But actual fires have plummeted for decades.
“A genuine fire, there just aren’t as many,” she said. “If you’re a fireman for the city, you don’t have to work nearly as hard as if you’re a paramedic for the city, and so the turnover is huge. And turnover is not huge in fire.”
EMS is “always rolling, always,” Deeken said. “Whereas, there’s engine houses that don’t get a call all day. Or if they get a call, it’s medical.”
Jenkerson disputed that some engine houses never get calls. And he said some fire risks have increased. The new, mostly wood, four or five-story apartment buildings popular now “look like giant matchstick boxes. It’s all they are.”
“The lightweight construction is hampering the ability of firefighters to put out fires,” he said. “And if you’re not there quickly, you won’t put it out.”
In any case, the ICMA recommendations would have required new fire stations be built to cover the city in a strategic pattern — rather than the configuration built over the last century for a city with many more people and occupied buildings — and constructed to handle reshuffled equipment. Consolidating some stations and building new ones to replace those that were built in an era when horses still worked for the department isn’t something Jenkerson opposes. It could be done incrementally, he said.
But the city didn’t have the resources at the time. The Slay administration had commissioned the report in an era when the city faced constant budget shortfalls, so it was always looking for efficiencies across government. But implementing the recommendations would have been “extremely controversial and extremely expensive,” said Slay, who had spent considerable political capital just two years before pushing through reforms to an increasingly expensive firefighter pension program.
Citizens don’t like the idea of closing fire stations close to their homes. Firefighters are popular. Their union is powerful.
“We never saw a pathway to doing anything with it,” Slay said of the report in a recent interview.
‘Should have gotten that raise’
Some of the report’s findings sound similar to issues still going on today.
It repeated calls to consolidate the city’s disjointed 911 dispatching service, where police dispatchers field all calls and then must relay them to either fire or EMS dispatchers. Mayor Tishaura O. Jones’ administration recently created a new, general 911 dispatcher position, but its plans to consolidate the 911 dispatching service have taken longer than expected.
Staffing issues were noted, too. The ICMA report observed paramedic and EMT vacancies in the double-digits for much of the study year a decade ago, reaching as high as 19.
“It is recommended that the department focus on recruitment and retention strategies for its employee pool and as well streamline the hiring process so that a more efficient replacement schedule is in place,” the report said.
The problem has grown: Out of 119 total paramedic, paramedic crew chief and EMT positions, 38 were vacant this spring, according to St. Louis budget documents. Only 25 of 55 paramedic positions were filled.
“Our EMS systems across the country are struggling,” Wieczorek said. “They’re all competing for the open body, the available body, and finding the qualified applicant that will deal with the stress. You’re dealing, especially the last two years, with a lot of death and dying.”
But one fire department employee said department leaders, most of whom come from the fire side, haven’t pushed hard enough to tackle the turnover and staffing issues identified in the ICMA report. The person, who asked to remain anonymous to speak outside of approved channels, recounted a joke among some in the department: “Don’t let progress get in the way of tradition.”
“The same people who were here 10 years ago are still here,” the person said.
Asked whether changes had been made since the report, Jenkerson at first said “none,” but corrected himself. He reiterated he has pushed for more ambulances and staffing for years, and he pointed out he went through EMT school and was an EMT instructor in the department. The stress of the job, he said, sometimes “boils over in the employees.”
Jenkerson attributes much of the dissatisfaction to the exclusion of EMS from the pay raises that Proposition P, passed by voters in 2017, gave to firefighters and police.
“I was furious,” Jenkerson said. “They’re part of the Fire Department, they should have gotten that raise. So that didn’t sit well on the EMS side. And you know what, I don’t blame them.”
The experience city EMS workers gain working a tough, urban environment makes them a “hot commodity” for other departments or hospitals, he said, which can pay more. Often, they’re lured away.
“I very much sympathize with the EMS side of the department,” Jenkerson said. “But until I can guarantee them more money, I’m going to have a hard time holding onto them.”
‘Let’s do something else’
The fire department took in the city’s EMS service from the health department in 1997. But 16 years after that, the ICMA report found “there has been little evidence of seamless integration.” The bureau of EMS “has never been fully embraced by the Fire Department,” the authors added.
“It was apparent to the ICMA study team that there is an overarching separation and tension between the St. Louis Fire Department proper and the Bureau of EMS,” the report said.
One paramedic for the city’s EMS service wrote a letter to the Post-Dispatch three years ago, before the pandemic, regarding the number of paramedics leaving the service. He cited low pay, not being included in Prop P’s raises for police and fire and a “lack of respect and poor treatment from management.”
“It is not the trauma of the job causing us to leave,” he wrote. “It is being constantly overworked and underpaid, treated like second-class citizens and having trucks that are constantly breaking down.”
Clark, the union official, said some of that division was improving, but the exclusion of EMS from Proposition P “relit that fire.”
Jenkerson and Clark said a new job classification for a “paramedic firefighter” could begin breaking down the wall between fire and EMS. The classification could offer higher pay and a chance for promotion for fire privates waiting to make captain. Some shifts they’d ride an ambulance. Other shifts they would ride a firetruck.
“I think they should be one integrated service,” Jenkerson said. “It needs to be done.”
Deeken, the former public safety official, long advocated for a hybrid department. Many firefighters are already certified as paramedics or EMTs. They often show up to medical calls in million-dollar firetrucks, but can’t transport people to the hospital, she said. Move some firefighters to ambulances — and buy more ambulances — to improve response times in the city. Other departments do it, she said. No one has to lose their job.
“You might have to move some fire stations, you might have to combine some and do double houses in better-located places with some capital money, which as far as I’m concerned, the city is swimming in right now,” Deeken said. “Maybe push has come to shove. That’d be a good thing.”
“Clearly,” she said, “it’s not working. Let’s do something else.”
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