Multnomah County leaders are showing a hint of willingness to reconsider the county’s two-paramedic model amid continuing slow ambulance response times, but a change still isn’t likely to come soon.
American Medical Response, or AMR, is the ambulance service provider for Multnomah County and neighboring Washington, Clackamas and Clark counties. For nearly two years, AMR has failed to respond to calls for emergency medical assistance as quickly as required under their contract with the county.
AMR Multnomah County had 187 full-time paramedics as of Jan. 5. The company said it needs 235 to be fully staffed under the two-paramedic requirement, meaning they are 48 paramedics short.
County Commissioner Sharon Meieran is calling on the county to change its requirement that ambulances are staffed by two paramedics and switch to the one paramedic-one EMT model used in neighboring counties.
At a December board meeting, Multnomah County Chair Jessica Vega Pederson said she had asked county attorneys and EMS staff for information about reviewing the two-paramedic model.
“Looking at the question of whether a two-paramedic model is still a viable model, that is in itself about a nine-month process,” Vega Pederson said at the Dec. 14, 2023, board meeting. “The recommendation back from our team was … if we're going to be looking at the two-paramedic question itself, we might as well be looking at the entire ambulance service plan.”
Meieran said there was no reason for a nine-month study.
“It could be done urgently, it could be done now. It is on the basis of an emergency. The evidence is there,” Meieran said. “People are dying every single day on our streets, and you're not treating it like an emergency.” Meieran continued, adding that the way the policy was being talked about by counter leadership was as if “it’s some school project that doesn’t tie into actual lives.”
As of Jan. 5, the county “has not formally started reviewing the two-paramedic model, ambulance service plan, or the ambulance service contract,” said Sarah Dean, a spokeswoman for the county health department.
Multnomah County EMS Medical Director Dr. Jon Jui has been a strong advocate for the two-paramedic model.
Other counties that use a paramedic-EMT model aren’t comparable to Multnomah County, the county’s EMS leaders say, because AMR is aided by fire departments on almost all of the life-threatening medical emergencies in those counties. In Multnomah County, fire department paramedic and EMT units only responded to 63% of calls that required advanced life support in 2022.
County EMS leaders worry that allowing one paramedic and one EMT to respond to serious calls could lessen the quality of care and mean worse outcomes for patients, but AMR and others say the move is necessary to ensure anyone is available to offer aid in an emergency.
“I would rather have one EMT and one paramedic one minute sooner any day than wait that extra minute for two paramedics to get there,” Meieran said at a Dec. 14 board meeting. “As an ER doctor, for my family, that’s what I would want.”
AMR in Washington County is fully staffed, with 50 paramedics and 76 EMTs. AMR in Clackamas County is short 10 paramedics but fully staffed on EMTs.
AMR paramedics and EMTs don’t support the proposed switch. Teamsters Local 223, which represents AMR workers in all three Portland metro counties, said members agree with Jui’s stance on maintaining the dual paramedic system.
“There are a lot of paramedics who prefer to work in Multnomah County because of the dual medic system,” Teamsters Local 223 secretary-treasurer Austin DePaolo said. DePaolo said switching to a paramedic-EMT model could turn out the same as it did in Sedgwick County, Kansas. Sedgwick County switched back to a two-paramedic model in 2023, four years after moving to a paramedic-EMT model that “contributed to dangerously slow response times, low morale within the department and an exodus of paramedics,” according to the Wichita Eagle.
In a statement in response to questions about Portland Fire & Rescue’s opinion on the proposal from AMR and Meieran, Fire Chief Ryan Gillespie said, “The current status quo of critical ambulance response in the City of Portland is unacceptable to PF&R, and I feel strongly that Multnomah County EMS and AMR should pursue additional measures or pilot programs that may have an immediate impact on reducing Level Zero in our community.”
One piece of a struggling system
Rob McDonald, AMR Multnomah County operations manager, said he told Multnomah County’s emergency medical services leaders in summer 2022 that he could “see the direction of travel that our system is going and the dual-paramedic requirement is exacerbating that.”
“This crisis isn’t going to resolve any time soon,” McDonald said in December 2023. “This system is going to further fracture over the next six months and it could get really, really bad.”
The opioid epidemic and increasing fentanyl overdoses, mental and behavioral health crisis, and a crumbling social safety net are increasing the demands put on emergency medical response systems.
“We don't have good support services for drug addiction, we don't have good support services for the unhoused. We certainly don't have effective support systems for our behavioral health patients in crisis. EMS ends up being the catch all — not just here, but in the nation,” McDonald said. Paramedics are “responding to a lot more calls that are more complicated, and they’re more dangerous to our responders.”
Multnomah County issued a $514,000 fine for AMR’s slow responses in August 2023, but the problem had started more than a year earlier and has continued since.
AMR appealed the fine, arguing that the county is ultimately responsible for conditions that prevented AMR from meeting performance standards. In AMR’s 2018 contract with the county, the county was supposed to determine a set of call types that should fall under Code 2, meaning non-life threatening, and require a response within 12 minutes. McDonald said the county still has not put any calls into the Code 2 category, so AMR is held to the eight-minute standard for many calls that should be in the 12-minute group.
In AMR’s appeal, the company’s attorneys wrote that Multnomah County “has created a permissive environment that encourages illicit drug use through its failure or inability to prosecute drug crimes … its adoption of ‘harm reduction’ policies' … its continued distribution of tents, tarps, and supplies to drug addicts which further enable their self-destructive lifestyle and … other policies which increase overdose calls and do nothing to provide them the treatment and other help they need.” As of November, AMR was responding to an average of 27 drug overdose calls per day, requiring four ambulances.
Multnomah County denied AMR’s appeal in December.
AMR said in January that they “continue to disagree with the county on fines and are pursuing potential remedies.”
Basic Life Support
DePaolo said the union representing AMR workers supports the dual EMT system for Basic Life Support ambulances. That’s a pilot program Multnomah County started in April 2023, to have two EMTs staff ambulances that respond to less-serious calls.
Initially, Multnomah County EMS said that “once an Advanced Life Support (ALS) paramedic assesses a patient and determines that specific criteria is met, the ALS paramedic could request that BOEC dispatch a BLS unit to transport the patient to the hospital,” Bureau of Emergency Communications spokeswoman Jaymee Cuti said. “This pilot program was expanded on Aug. 14, 2023, to allow BOEC to dispatch BLS ambulances on specific, low-acuity calls, at the direction of Multnomah County EMS.”
AMR said in December that most EMTs didn’t want to work on the BLS ambulances.
“The attrition is terrible. They just flee to the next available opening,” AMR Vice President of Operations Randy Lauer said. “They want to work on an Advanced Life Support ambulance. And the way that the Basic Life Support ones are set up in the pilot in Multnomah County, most of the time, a paramedic still needs to do an assessment before they'll call for BLS transport. They don't dispatch the BLS units directly from the 911 Center, hardly at all.”
But the union said the pilot BLS system was growing.
“We hope that BOEC can improve in its ability to dispatch the right calls to the right places — we’re confident that they can,” DePaolo said.
BOEC did not immediately respond to a request for data on BLS dispatches.
AMR has said that the two-paramedic model is an outlier, not used in any of the company’s other 266 operations. But major cities in the U.S. do use two-paramedic models, including Seattle, Boston, Denver, Minneapolis, New York City, Los Angeles County, and others, according to the county health department spokeswoman.
The 911 dispatch system in Portland has struggled for years through the implementation of the ProQA scripts and major staffing shortages. While partners like AMR and the paramedic/EMT union are hopeful that BOEC is improving, all acknowledge that the system in Multnomah County is far less advanced than in other major cities.
Seattle’s system is overseen by the fire department and “involves sophisticated triage with multiple types of responders for a variety of different situations,” Meieran wrote in her June 2023 report to fellow commissioners. “In Portland, we have none of these things.”
The systems in other cities like Denver and New York have also come under fire for slow response times and staffing shortages.
Comparing the local system with other cities isn’t that helpful, DePaolo said. “If you've seen one EMS system, you've seen one EMS system.”
An empty pipeline
Oregon and Kansas are the only two states that require associate degrees for paramedics. Other states have certificate programs, which are faster. Programs shut down during the pandemic, meaning there was no pipeline of new paramedics coming into the field.
Paramedic is the highest level of emergency medical technician licensing, allowing providers to give patients medications and perform medical procedures.
“EMS as a career has lost a lot of its luster over the course of the pandemic,” McDonald said.
In staffing, private ambulance companies like AMR compete with fire departments that offer PERS and better career ladders for advancement. Fire districts are also short staffed, so the districts and companies like AMR are competing for an even smaller pool of first responders.
“Paramedic is really where the pinch point is. EMTs, we're finding we're having no difficulty recruiting,” McDonald said. “That is true not only for Multnomah County but for our area operations. EMTs are eager, they want to really get into frontline work — with the ironic thing being all the frontline work that's burning our current paramedics out is exactly what that EMT wants to get into.”
The first post-COVID class of paramedics at AMR’s paramedic training program in Clackamas County will graduate this spring. Roughly 30 EMTs in the program are receiving full-ride scholarships to become licensed paramedics.
AMR is spending money on scholarships, overtime incentives, and additional services like a river safety program and assisting law enforcement by using ambulances for secure medical transport.
“If we have to write a check to the county for $500,000, we don't have the funds to do those things anymore,” Lauer said.
The union representing AMR workers also said it did not support the county fining AMR. “We don’t think fines are the answer,” DePaolo said. “We don’t think sticks are the answer; we think carrots are the answer.”
A temporary fix
“At the end of the day, no matter what happens, we're going to be proven correct,” McDonald said. “Either we're allowed to make this temporary change and we put the system back in order as we ready ourselves for more paramedics to onboard, or we're not going to be permitted to do this, and the system itself is going to collapse as we're predicting. We'd certainly prefer the former than the latter.”
Though the union doesn’t support a full shift to a paramedic-EMT model, DePaolo said the union was open to hearing more about what AMR leaders said would only be a temporary switch.
“We want to be part of the solution too. We care about our community,” DePaolo said. “We’d like to hear more about (AMR’s) plan, get more details, and talk about the details and impact — and understand that this is temporary. We’re definitely open to dialogue with the employer.”
Paramedics are far busier in Multnomah County than in neighboring counties.
In a June 2023 report to fellow commissioners, Meieran urged the county to temporarily adopt a paramedic-EMT model.
“This is not a time to consider implications for future permanent staffing models,” Meieran wrote. “The evidence in the medical literature is clear in terms of changing the staffing model from a two-paramedic requirement to a one-paramedic/one-EMT system. Our obligation should be to find a way to make it happen, rather than wasting time trying to find ways not to act and pinning our hopes on a pilot that potentially creates more risk, especially in light of the bigger challenges of our current system.”
