Like many cities, the District of Columbia has tried different ways to run an emergency ambulance service.
John Pekkanen, writing in the February 2009 Washingtonian Magazine, provides part of the history:
Until the mid-1950s, the District’s emergency medical system—at the time called the ambulance service—was operated by the DC health and fire departments and local hospitals. The hospitals supplied doctors, interns, and physician assistants to staff the ambulances.
In 1957, the ambulance service was placed under the control of the DC Fire Department and firefighters began staffing District ambulances. Many firefighters had little emergency medical training—they performed what’s called “scoop and swoop”: They arrived at the scene, picked up the patient, and went to the nearest hospital.
from What Happens When You Call 911 in Washington, DC HERE
Fire departments provide metro Washington DC 9-1-1 ambulance service. In most places rookie firefighter/EMTs spend their first years on the job riding the ambulance. The progression is primary caregiver, then ambulance driver and finally back-up or infrequent ambulance staffing.
CREATION OF SINGLE-ROLE EMS PROVIDERS
Starting in the late 1960’s the DC Fire Department (DCFD), as well as Alexandria City, Arlington County (VA) and Prince George’s County (MD), hired non-firefighters to staff ambulances. These single-role ems providers were paid a lower salary. At the start they were not covered by public safety worker compensation or disability provisions. Only Alexandria and DC maintain single-role ems providers in 2010.
DCFD started an administrative section to oversee single-role providers, organizing the Emergency Ambulance Division in 1981. The American Federation of Government Employees (AFGE) Local 3721 represents single-role ems providers.
My university trained the first group of single-role paramedics in 1976 – Pekkanen identified the wrong university. We developed an on-campus Bachelor degree in Paramedicine.
Pekkanen’s quote has another inaccuracy, the first physician assistant program started ten years after the DCFD takeover of the ambulance service. (PA timeline)
FALL 2000 SNAPSHOT
University paramedic students were riding DCFD medic units and emt students riding ambulances.
Feedback from the paramedic students, and the occasional medical student on an emergency medicine rotation, was that they are getting great experiences.
DCFD paramedics have a narrower scope of practice than suburban medics, such as no pain control medication. The units are busy and see a lot of patients needing advanced life support (ALS) intervention. Few complaints or concerns from the students, preceptors or my medical director.
A completely different story with the emt students. Inconsistent patient care, as documented in the ride-a-long forms and confirmed at the emergency department.
A constant barrage of x-rated verbal abuse by a single-role emt at one fire station. Creepy behavior by an ems employee toward female students at another fire station.
I meet with the fire station commanders. They tell me that they have no supervisory authority over single-role emts.
The few street ems supervisors cover huge sections of the city. They respond to complex or large ems incidents, get ambulances to clear the hospital and focus on delivery of ALS care.
Meet with a senior fire official. We served on a Washington Metropolitan Council of Governments fire/ems subcommittee. He confirms the station commander information.
I stop emt student ride-a-longs in DC. My perception is that emt-staffed ambulances operate with little supervision or oversight.
Jonathan Agronsky writes in the February 9, 2001, Washington City Paper about a 1999 ems incident he witnessed. His frustrating experiences in A Call For Help resonate with me. (article HERE)
FALL 2009 SNAPSHOT
While the Rosenbaum/EMS Task Force recommendations were issued in September 2007, it takes funding and hiring to implement some of the recommendations.
By Fall 2009 the renamed DC Fire and Emergency Medical Services department (DCFEMS) conducted a promotional exam for EMS Supervisors, increased the number of EMS Supervisors on the street and created three EMS battalion chief positions. Reorganized senior chief assignments to reflect task force recommendations. This administration is focused on EMS delivery.
The pain of organizational change is felt by almost everyone in the fire department. Some think senior staff is rearranging deck chairs on the Titanic.
I think the delivery of ems services is getting better. Which is why we committed to help develop an accredited paramedic training program with the DCFEMS academy.
I am comfortable enough to plan to put my EMT students back on DCFEMS transport units.
Mike “FossilMedic” Ward
Nation’s Capital EMS provides one perspective of an ongoing effort by many to improve the delivery of EMS services in the Nation’s Capital.
January 01, 2010: Singing Pigs, Resistant Cultures and DC EMS
In the first draft, only paramedics employed by DCFEMS could teach. The second draft was better, but required educators to be affiliated with a DC-based ems provider. Most of our clinical instructors work as Maryland or Virginia caregivers.
Daniel wrote 
Advanced Practice Paramedics 2.0
Comments OffAbout 15 years ago the buzz in ems academia was the prospect of advanced-practice paramedics (APP) doing patient assessment and treatment that went beyond the Paramedic National Standard Curriculum. Demonstration projects were set up in remote areas with few medical resources.
While one of the demonstration projects suffered from operational issues, there were larger problems. Medicare and health insurance would not pay for services. The Advanced Practice Paramedic competes with the Nurse Practitioner and the Physician Assistant in delivering delegated advanced care.
THE PARAMEDIC PARADOX
Wake County EMS Director J. Brent Meyers, MD, MPH, wanted to improve agency response to low-frequency/high-risk “red zone” patients that needed an experienced paramedic. He also looked at patients that could avert a 9-1-1 trip to the hospital if they were assessed sooner. He described this “paramedic paradox” at the 2009 Metropolitan Municipalities EMS Medical Directors “State of the Science” conference.
Within community health, Meyers wanted experienced paramedics to perform Well Person Checks. Tasks included monitoring of patients with diabetes, hypertension and congestive heart failure. Arrange direct admission of patients to an alcohol treatment center, an idea adopted from a Memphis Fire initiative.
APPs would also perform ems pre-plans for nursing homes and home health facilities. They would develop fall prevention programs for their patients. All of these activities would reduce the number of 9-1-1 calls for EMS. Unlike the 1994 experiment, Wake County APPs are reducing operating expenses by reducing the transport unit workload through at-home assessment and treatment of chronically ill patients.
SEVEN WEEK ADVANCED PRACTICE ACADEMY
Experienced paramedics were required to read 20 peer-reviewed medical journal articles and pass a written exam, interview and scenario. The didactic covered critical encounters, public health and alternative destinations. Clinical rotations in OB/GYN, infectious disease, cardiac cath, ED, ATC, behavioral health, RN follow-up, pediatrics, 9-1-1 center and Wake EMS PI.
FIRST FIVE WEEKS
Five single APP “Medic” units went into service January 6, 2009. They had their first cardiac arrest save less than four hours later. At the end of five weeks the APP units handled 2309 incidents, including 99 cardiac arrest responses. The top five 9-1-1 responses were for unconscious, chest pain, seizure, fall and motor vehicle crash.
They also completed 54 well-person checks and are compiling case reports showing the impact of well-person checks and direct alternative transportation on ambulance transport workload.
HEMI-POWERED MEDIA ATTENTION
The mainstream and trade media fixated on the shiny new police-package Dodge Chargers … no different than the NC State Trooper vehicles. The real power is in the appropriate utilization of experienced paramedics with additional training. This may be the first example of what the Scope of Practice will bring to out-of-hospital care.
Dr. Meyer’s February 2009 Eagles Presentation (HERE)
JEMS discussion with Skip Kirkwood January 15 (HERE)
JEMS Editor A. J. Heightman January 2009 column (HERE)
Wake County EMS (HERE)
Mike “FossilMedic” Ward