Judge Nixes Ada EMS Ordinance

The GUARDIAN is a little late on this one, but an August 17 decision from 4th District Judge Kathryn Sticklen could cause the Ada County Paramedics to seek some first aid.
In what apparently was billed as a “test case” law suit, the county filed suit against the Kuna Rural Fire District for running their own ambulance service outside the rules established by the county. The county apparently failed the test.

The county had previously passed ordinance #647 which gave the Ada County EMS sole rights to establish the rules for anyone else providing such services. Judge Sticklen overturned that ordinance.

The original GUARDIAN STORY ran in December 2006.

In a nut shell the court ruled that Ada County has no statutory basis for attempting to limit or regulate any fire district in the provision of EMS services. Ordinance
# 647 outlined many stipulations the County was trying to enforce within its borders many of which are the responsibility of the State Department of Health and
Welfare, EMS Bureau.

Comments & Discussion

Comments are closed for this post.

  1. Colleen Fellows
    Aug 24, 2007, 11:20 pm

    It’s about time. Judge Strickland’s order finally puts common sense at the forefront of public safety. For over four years Ada County has held people’s lives and welfare at risk while holding tight to their turf battle, with their eleventh hour passage of ordinance #647, in order to maintain sole control of ambulance service in Ada County. While the county posts their average response time to emergency requests, they fail to note the outliers for response times. It is these outliers in the timing that mean the most in terms of lives lost. It is fine to say that they have an average response time of say, 5 minutes to a given location, but I would hate to be the poor soul that is 45 minutes out experiencing cardiac arrest during evening rush hour. The fact is, response times for Ada County paramedics may have been sufficient 20 years ago, but today’s growth and traffic congestion have rendered it unsatisfactory. When the geographic locations of Ada County paramedic stations are limited to a few sites, and growth has spread in the far reaches of the county, things must change. During the initial legal battles over primary responders, the Boise Fire Department attempted to employ paramedics on their trucks, since many times firefighters arrived to the patient’s location much earlier than Ada County Paramedics and were at times told to hold tight for twenty plus minutes until Ada County Paramedics arrived. What may be only a few minutes on the clock, are precious minutes in terms of the “golden hour” of medical response. When Ada County told them the move to install paramedics on fire trucks was illegal, the Boise Fire Department offered the use of empty garage bays in Eastern Ada County for the use of Ada County ambulances in order to reduce response time and improve public safety. Once again, Ada County officials shot this down. Kuna, in the best interest of its citizens, decided to provide their own ambulance service that was capable of responding to life threatening issues in a timely fashion, only to be sued by the Ada County Paramedics in what amounted to a fight by Ada County to retain as many tax dollars in their ambulance taxing district as was possible, regardless of the cost it would have, and did have on lives of those effected by slow response times. For all concerned, that would be the living, be happy that the courts have seen fit to overturn the Ada County Paramedic’s self-serving attempt of controlling life saving operations with their end run passage of ordinance #647. You may live to applaud it.

  2. I agree with Colleen and kudos to judge Strickland

  3. Sounds like the arrogance and lack of common sense of our county government is being held in check. I applaud the citizens and their local government that has challenged the Ada County Commissioners. Lets hope that Ada County will be intelligent enough not to force the citizens to pay for their mistakes further with a legal challenge.

  4. Steve Edgar
    Aug 25, 2007, 7:25 pm

    Legislation through Law Suit is a dreadful way to govern. “See you in court”; words at the end of the hearing (Peavey-Derr’s) in which this topic was debated prove to be an albatross around the BOCC’s necks. I wonder how much this “test” case cost the County taxpayers.
    In light of the elevated concern about Ada County Leadership; revenue shortfalls, and property management skills, this EMS “test” appears to similarly lack fiduciary responsibility. Let us all hope that, in the future, the elected officials listen to and HEAR the citizens. The unsound content of this EMS Ordinance was brought to light in the public hearing yet the BOCC bull headedly ignored their constituents and proceeded with a flawed logic and flawed course of action. The common theme here is that of ignoring the citizens – it carries through from this EMS issue to growth issues and enforcement of Comprehensive Plans, The Treasure Valley Air Quality Plan etc…
    While the County initiated the suit, a great debt of gratitude is owed to the Kuna Rural Fire District for not backing down on this one. Thank you.
    PS. For those who live in the west end of the valley, I have been told we will see EMS embedded there soon, but for now we still do not have any service above where we were ten years ago. Meanwhile our Ada County EMS levies keep climbing, not to mention the EMS fees associated with every vehicle registration. Maybe with some unencumbered competition in the valley for this critical service (provided by Fire Districts and private contractors) it will force fiduciary responsibility upon the agency and county; in a free market environment you manage costs or go away.

    Steve Edgar

  5. This topic was blogged to death a few months ago. When will we wise up, make them fire fighter paramedics,put them on fire trucks and do away with Ada County EMS?

  6. Colleen Fellows
    Aug 26, 2007, 1:42 pm

    The problem with paramedic services is that currently, Ada County EMS is the only ambulance service that can transport patients from incident sights. Ada-Boi ambulances are a private critical-care transport service only, for use between hospitals and long-term care facilities etc. Due to confusion during dispatching, I would suggest that multiple emergency ambulance companies could cause trouble. The last thing we need is an “I thought you called the ball” situation. In the case of Kuna, the lack of Ada County EMS stations in their vicinity of Ada County warranted their move to a city provider. What is needed throughout Ada County is two fold, the assurance that the first responder, be it an ambulance or fire truck, have a paramedic on it (I believe at this point Boise Fire Dept. now has a paramedic in place at all times). Equally, if not more important, ambulance stations need to be dispersed throughout the County in order to reduce response times.

    While it is important that paramedics be on fire trucks as well as ambulances, without the ambulance on sight, the patient can’t be transported to the hospital. As much as I love the folks on the big red trucks, we still need the guys with the gurneys to get us to the ER.

  7. Has anyone actually looked at the science behind paramedic fire engines. What we need is more timely BLS resonse, more readily available BLS response (Law Enforcement AEDs Anyone?), and more BLS transport ambulances to free up ALS ambulances, and highly trained/highly experianced paramedics in those ALS ambulances.

    That is what the SCIENCE says, not what the propoganda says. Sure having someone there with “paramedic” on their shirt may make you “feel” better, but does it actually “help” you? Does it save lives? Impartial science says…”no”…and there is some thought it may make things worse.

    There is a study due to be published that looks directly at ALS first responders (Paramedics on fire trucks) and it found that measurable (never mind the immeasurable goal of “quality care”) data sets of IV success, intubation success, and other critical skills all went DOWN for ALS first responders.

    So riddle me this…Why does LA City , which has a 4 minute response time for Paramedics on engines, have such a poor cardiac arrest (and intubations) survival rate? they have THOUSANDS medics in that city.

    Why does KING County and SEATTLE FIRE have such high cardiac arrest (and intubation) success rates when they DONT have paramedic engines?
    It is no wonder that the best ALS services in the NATION, with the HIGHEST documented success rates, dont use ALS first responders and dont have a lot of ALS Ambulances?

    When you answer that question with your own research…then ..THEN…you will see the truth, and that truth DOES apply HERE in Boise.

    As much as we hate all things Kalifornia, do we really want to immitate their EMS system? Especially when it looks so good but does so poorly?

    In addition, all the latest science from the AHA specifically shows that the first 4-6 minutes should only be for BLS in cardiac arrest. ALS makes NO (zero, none, zip, nada, nicht, nein, NONE) difference with out EXCELLANT BLS. And if you are too busy “Getting your skills in” then the important stuff is neglected.

    Remember there is MORE to quality care than scene times. Its about (as one poster said in another toic) a systems approach.

    All this does is take the ability of forming a SYSTEM away from those who want a system to work for the patient, and put it in the hands of those who want to use it to justify jobs, wages, and turf.

    I dont know the technicality of the descision by the legal system, but this will do nothing but hurt the system approach, and increase the resentment and turf battles the fire services have for ACEMS.

    One wise man said once…”May have been on the losing side, still aint sure it was the wrong one”.

  8. Clippityclop
    Aug 27, 2007, 10:36 am

    The reason King County (Seattle) out of hospital cardiac arrest survival rate is so high has to do both with the extraordinarily large number of the citizenry who are trained in effective CPR/AED use, as well as the fact that the King County paramedics are perhaps the best trained in the nation thanks largely to the efforts of one man, Dr. Michael Copass — he has run Harborview ER for years and is the Medic One doc. A great system needs excellent first responders (that starts with the public, frankly) and excellent paramedics. I love seeing AEDs (automatic external defibrillators) in more and more public places, but the public needs to feel comfortable using them (they’re designed to be very easy), and comfortable performing basic CPR. For those of you out there who have never taken a CPR class, be part of the solution and sign up.

  9. Clippityclop,

    You are making my point, they are the best, and ACEMS (or anyone else here) will never field that type of finely honed system with finely honed paramedics, WITH THE FRAGMENTED SYSTEM the fire services are trying to bring about.

    Ask anyone in the King County/Seattle system, they will all say that the education and system set up by Dr. Copass is the key…the in not sending paramedics on minor calls so they stay proficient at the critical stuff, as in using a LOT of BLS units for the BLS calls, as in FOCUSING on BLS response, as in not having paramedics on fire engines where their skills degrade.

    Everything I said in the above post (with the exception perhaps of Police AEDs) is in current practice in the King County/Seattle Area.

    How do they accomplish this? Because ONE system is in place that ALL agencies work under. EVERYONE there works the same way under the same rules. The King COUNTY system…not the Seattle system, not the Evergreen system….this is what ACEMS was trying to do here, but the unions feel threatened by it..and now we see where we are.

    Without the ordinance, the fire services will never work with ACEMS to make a better system. Not when they can dismantle it into 7 different ones instead.

  10. Nemo is correct that a systems approach to the provision of emergency medical care is needed in Ada County. That does NOT mean that the Ada County commissioners should prevent the fire districts from participating in that system or the process of creating and perfecting it, however.

    The bottom line is that Ada County needs better leadership from elected officials whose highest priority is looking out for the good of the people.

  11. Clippityclop
    Aug 27, 2007, 12:53 pm

    Your King County goal works if you assume that a proportionate number of folks here in Ada County are as skilled in CPR as they are in King County. That isn’t the case. Also, ACEMS response times in rural areas are lacking, and getting worse with poorly planned growth.

    As a consequence, many Ada County residents in the hinterlands just don’t have the same level of service enjoyed by others.

    I think that Dr. Copass whould be the first one to tell you that it’s about the patient, not about turf battles disguised as quality of care. If Kuna or any other municipality can provide a skilled and effective paramedic service that cannot be provided as timely by ACEMS, what’s your issue? Do you have evidence that a rural paramedic system is inferior, particularly when the option is a delayed response? If you’re truly concerned about quality of care for all Ada County residents given our current contraints, I suggest you work toward a achieving a high standard among all paramedic groups, urban and rural, through joint training and continuing medical education.

    If at some point in the future ACEMS has the ability to respond to these outlying communities in a timely fashion, then perhaps consolidation makes sense and it’s time for the Copass system. Until then, and as always, patient care comes first. And that’s about as Copass as it gets.

  12. Nemo is right. Boise Firefighters ( the union, not necessarily the fire department) desperately want to be paramedics and have for years. Why? Because actual fires are few and far between and getting rarer due to sprinkler systems in buildings.

    I don’t have a dog in this fight, other than as a citizen. But I do know that giving more and more money to the BFD for paramedic services may not be the best use of TAX dollars. Since I already pay into the paramedic pot of tax dollars, the quickest thing that will happen if BFD becomes paramedics as well is that the commissioners will withdraw money and resources from Boise and put it into other cities and county areas. Then I will get no return on the AC EMS dollars.

  13. Very interesting comments…..

    The fact is, there is no “system” in place – the ambulance district tax goes directly to the County and no matter how much the fire districts provide EMS, they will never get a dime of that tax money until they are willing to be a part of the system and play within the system. There is not one entity that can oversee the system and write the rules. Its all about the power and money.

    If people want paramedics on every corner, then they need to be willing to pay for that service – but in this day and age of tax cuts and “keep government out of my life” attitude, it will never happen.

    Fire Services across the country have been trying to justify their budgets and unfortunately EMS is their rationalization for existence. As the study was mentioned, ALS engines actually increase death rates in a community (houston study). But “paramedic engines” is the fire service mantra.

    Other systems have done the paramedic engine thing for over a decade – and it never showed any monetary savings – despite what the fire chiefs may say – nor any increase in survival rates.

    Until this state gets rid of ambulance districts and forces consolidation of the various tiny fire district and gets serious about providing an emergency service SYSTEM, the battle will continue.

  14. Sara, I’m not getting in this one, except to say fires in Boise are NOT few and far between. They have gone up most years in the past decade. The vast majority of fires are people’s houses that do not have any sprinkler systems. For fire numbers go to the city’s web site, but please, don’t make up false facts. It muttles the debate.

  15. Boisean,

    Sara was referring to both the national trend in fire services nationally, as well as the reason there is a national push (dare I say an offensive) by the fire service to take over EMS.

    In regards to Boise, certainly there has been a busy year, but when you exclude non structure fires (i.e. grass, dumpster, and car fires, as well as fire calls that weren’t fires…), and you look over the past years, over all there has been a decrease in real structure fires (i.e. second alarm fires, not training burns, not “smoke in the kitchen”)This year will likely be shown to be an anomaly at best.
    Sarah bringing up this isnt clouding the issue, its shedding light on it.

    In this age of decreasing budgets and public sentiment against property tax, fire departments are looking to the future and DONT like what they see.

    People will, in a crunch , shut down a fire station, or down size an engine crew. BUT, suddenly when that fire crew is their Paramedic response. THAT is something EVERYONE feels a need for. So suddenly the same engine , now with a paramedic, becomes a sacred cow and no one will dare suggest shutting it down. That is the tactic.

    In addition, having “paramedic duties” is now a bargaining chip and rationalization for contract negotiations from the union point of view.

    Finally, in Boise right now, there is a PUSH by the union for 4 man engine companies. By adding paramedics to every unit, they get their 4th man.

    Here is the ironic thing, there is a very real role for any of the fire services in the EMS system proposed. They play a vital role in the king county/Seattle system. They are the BLS providers that screen the BLS calls to be sure they dont need ALS, and to assist ALS units. They are essential in this role. But PARAMEDICS don’t belong on fire engines except in rare cases. it is a WASTE of a perishable resource, that is much better used going only on ALS calls, in an ambulance (or what ever color) and maintaining their critical skills.

    Back on Track: Regarding the impact of the judges decision on the ordinance, with out the ordinance there is nothing to prevent the union from having its way, and fragmenting the system further. There is NO HOPE of a SYSTEM with out a single voice and authority (Like the King County Medic One System, like ACEMS was trying to recreate)..and this ordinance was the only hope for producing that voice.

    The fire departments will never give the systems approach more than lip service. Not to the level that is needed to recreate a HIGH QUALITY, FINELY TUNED, HIGH PERFORMANCE EMS system like this area (Boise, Meridian, Kuna , Star, eagle) deserve.

  16. Clippityclop
    Aug 28, 2007, 8:30 am

    Amen, Sharon Ullman! You understand the issue very well. The King County/Seattle model is a wonderful goal, but it takes an educated public, fast and coordinated response times and most importantly, a Dr. Copass. You cannot begin to imagine his level of dedication to the Medic One system, not to mention Harborview ER, and trust me, his equal is not here in Boise.

    We simply cannot legislate a Medic One system — it must evolve under dedicated leadership who sees patient care as job one. That leadership should be involved with training and coordinating with other fire districts that ACEMS does not serve, until such a time as one system can successfully function.

  17. Clippity clop,

    For once you and I are closer in opinion but let me ask you, why is no one pointing the finger at the fire districs for their role in preventing a truely great EMS system from fluorishing?

    ACEMS is doing their part…when does anyone say to the fire service…STEP UP AND DO THE RIGHT THING (And if the King County example is to be followed, Paramedic Engines AINT it!!!)

  18. (sorry, hit the wrong button)..

    Anyway, while there were better ways to go about forming a system collaboratively, those means were attempted, and at every turn the fire districts have said one thing and done something else, keeping their eye on the dissolution of ACEMS.

    In this type of enviroment, what else was left but legislation?

  19. Clippityclop
    Aug 28, 2007, 4:54 pm

    You simply can’t legislate Medic One into existence. I suspect that if you had the right leadership medically and meaningful support from the County Commissioners, local fire districts would jump at the chance to be part of a cutting-edge system. My guess is, they know when something’s politically driven and not patient driven. I suspect most Ada County paramedics feel the same way. Make patient care and service to ALL of the community job one, and I suspect juridictions will want to cooperate. Ask any paramedic of fire fighter what they value and I’ll bet “turf” isn’t it.

  20. Nemo,

    You know quite a bit about the fire service responses. Haven’t you interviewed more than once for a paramedic/firefighter position in the fire service.

  21. I’m sorry, but this ruling is so narrow and short-sighted – merely shows how much power the little fire district commissioners and fire chiefs have in this state.

    Cities across the country have this same ordinance and have developed a true EMS system – able to monitor and control the quality and prevent the “fly-by-night” services from functioning. Government needs to be able to provide this level of control. I find it funny that you can control which cable company comes into your city, but you can’t control the EMS.

    And lets look at these fine fire districts – they are taking a tax money and providing a service that is above and beyond their original intent – if they have enough money to staff paramedic ambulances, maybe you should ask to lower the district tax and have then stick to fire.

    Maybe there will be an appeals court with a little more common sense and able to see the big picture.

  22. Well, dont see how it pertains, but I have been in the fire service…but the basis of all of my comments are freely available to anyone (in public safety, health care, or the general public) providing they do a bit of research from objetive sources.

    For those who don’t usually deal with the fire service let me explain the unspoken innuendo…
    A (VERY) common response of the fire service to its detractors in the public safety community is that the “Haters” are that way because “they arnt good enough to get on the fire department” or “Your not part of the brotherhood, you wouldn’t understand.” SO the implication is that I am a “hater” because I couldn’t cut it, not because my points have validity.

    BAck on topic…

    It has been my observation that this BOCC, and the BOCC in general, has been far more supportive of a systems wide approach..and would eb far more receptive of a Dr. Copass, than the fire service. As anyone will tell you in the King County area, Dr. Copass has to routinely bash the FDs figurative heads as well. And Dr. Copass’es vision of EMS so far has been so far and away ahead of any other EMS in the nation, it is unfathomable to many just how different (or just how successful) such a system is, or how it would look in their own area.

    So, Clippity and others…It is obvious that the fire services neither want, nor will support anything other than the “Standard” fire service approach to EMS (Paramedic ENGINES) for reasons discussed.
    It is also apparent that The fire service will not work with ACEMS on any significant change to the current EMS system, or even to maintain the current EMS system.

    So Short of “giving up”, letting the system we have today become another cali-clone….what else but legislation will ever make the fire services go along for a real progressive EMS?

    Even if Dr. Copass himself were to show up today, without the political and legislative authority to “knock some heads” and get everybody playing together (like a bunch of kids on the playground…sometimes you got to knock some heads together, and pull a few ears too!)that the ordinance would help establish…the fire services here would thumb their noses at Dr. Copass just like they have at ACEMS for 20 years.

    Because Dr. Copass’s ideas (and ACEMS’s ideas) don’t mix well with standard FD strategies, FD traditions nor union labor political priorities.

    Too much accountability, too little hero worship.

    I hope that Ada Coutnty appeals the decision, or the people wake up and put some grass roots pressure on the fire service to be a positive force for meaningful change, not the adversarial factor they have been in the past.

    Again the ironic thing is that there is a meaningful role for the FD in a Copass like EMS system. Equally important, or more so. It just doesn’t involve paramedic engines. And it involves too much cooperation and too little union agendas

  23. Clippityclop
    Aug 29, 2007, 5:49 pm

    Sadly, your commentary does nothing but politicize and polarize, and combined with your stereotyping, will not further your goals. You will never legislate Medic One — that program takes the kind of medical leadership that existing paramedics and fire districts will kill themselves to follow because they want to be the best at serving their patients and are clear that first-rate patient care is what the program is all about. If paramedics or fire districts have lost sight of this, then they’re in the wrong profession and may want to rethink their career choice. I bet that given the chance to pull together for all of the right reasons under excellent leadership, they’d do it in a heartbeat. A wise leader would make any perceived competition an advantage.

  24. I think Nemo and others are speaking about two different things.

    There are the fire departments and there are fire fighter unions. They are not necessarily in agreement on many many things.

    Fire Departments are creatures of cities and/or districts and as such are theoretically committed to providing good service for as few tax dollars as possible. I say theoretically because it seems anymore that most politicians are big taxers and big spenders. It’s so easy to do that with other people’s money.

    Firefighter unions are not into the mindset of spending less money. They are designed to suck out as many tax dollars as possible. They see the wave of the future is medical services. Most of the calls in the Boise department (70%+ and higher) are for medical reasons – NOT fires. This rationale is used for two purposes, one is to get a higher rate of pay for a more specialized training and two, as Nemo says, to add another person to the current 3 man truck.

    It may be we get to a different way of delivering paramedic services in this County, but again, understand that we are already paying taxes to the county for paramedic services. I would hate to end up paying for something I can’t even use.

    This is not new. This has been a goal of the union for over 10 years.

  25. I would urge everyone to read Ada County Ordinance #647 for themselves and you will be able to see that the County is clearly not taking a cooperative systems approach that Nemo pitches. Below is a link so you can read it for yourself. It is pretty clear that the County sought a trump card and rushed to pass it prior to Judy Peavy Derr’s exit from office.

    I am troubled by some of the misleading and false comments posted by Nemo and others in reference to the efficacy of fire-based EMS. There is plenty of research backing up the common sense approach of utilizing the existing infrastructure that fire departments possess. According to the American Heart Association, survival rates for patients with life threatening medical emergencies are dependent upon two predictors. First is the response time of the EMS system, and secondly, the service level provided by the responders. For medical emergencies such as airway obstruction or cardiac arrest, survivability depends on response times no greater than 4-6 minutes. Considering the average time required to activate the EMS system and dispatch units is 1-2 minutes, this leaves a required response time of 2-4 minutes to arrive and provide adequate care to potentially survivable patients. The American Heart Associations claims are strongly supported by the survivability data collected in Ontario, Canada during the Ontario Pre-hospital Advanced Life Support Survey (OPALS 2005).

    In 1992 the Journal of Emergency Medical Services produced a report from the Emergency Care Information Center. The study analyzed responses from 468 EMS personnel from 10 different EMS systems. Each of the subjects responded to a questionnaire that was designed to determine factors in the emergency medical care work environment that contributed to job stress and satisfaction. The study produced data measuring the effect job stress has on patient care. Table 3 on page 16 of appendix 20 compares the instances of clinical errors and patient complaints by cross-trained/dual-role firefighter paramedics versus single-role paramedics. It reveals that the average number of incidents per shift for dual-role paramedics was .99 % compared with 1.69 % for single-role paramedics. Patient mistreatment was 1.94% to 3.91% respectively. According to the study, cross-trained/dual-role fire fighters were nearly 40% less likely to make stress induced clinical errors and 50% fewer stress induced instances of patient complaints than single-role paramedics. When an EMS system is stretched as thin as we see with ACEMS in terms of budget dollars and response efficiency, the employees and patients both suffer.

    Don’t forget the County’s own Blue Ribbon Task Force advised them to utilize the fire department infrastructure and consolidate EMS and fire. In 2007 a coalition comprised of representatives from the Congressional Fire Service Institute, the National Fire Protection (NFPA), the International Association of Firefighters, the National Volunteer Fire Council, and the International Association of Fire Chiefs released their white paper study advocating the use of fire based EMS. Below is a link to download the study in its entirety.
    Why should the taxpayers of Ada County pay to duplicate infrastructure of a separate EMS operation. The County has been clear in their actions against consolidation of services. The cities and fire districts should therefore move towards providing their own cooperative fire based transport system. Without the transport revenue from the cities and fire districts the County cannot continue operations. This will force the necessary change that needs to occur.

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