Multnomah County and the ambulance provider American Medical Response sat down this week for a second mediation session to hash out a long-simmering, and sometimes tense, debate.
The county and AMR have been at an impasse for about a year over a shortage of paramedics, and ambulances arriving late to the scenes of life-threatening emergencies. Other counties in the Portland metro area, such as Clackamas County, have also reported issues with slow ambulance response times. Still, few counties have pushed as hard on AMR as Multnomah.
On Thursday, Clackamas County announced it would extend its contract with AMR.
“Having an ambulance available when you need it is of the utmost importance,” Clackamas County Board Chair Tootie Smith said in a statement. “I am pleased to extend the AMR contract for one year. While we are very aware of the regionwide response-time issues, we are taking steps to hold AMR accountable.”
Whether Multnomah County is also ready to reach a compromise with AMR remains to be seen, but the sides sitting down for negotiations indicates each may be open to softening its approach.
OPB “All Things Considered” co-host Geoff Norcross and health care reporter Amelia Templeton sat down this week to discuss the sticking points of those negotiations.
This transcript has been edited for clarity and length.
An American Medical Response ambulance prepares to leave the emergency department at Legacy Good Samaritan Medical Center in Portland, Jan. 11, 2024. In November 2023, Multnomah County fined ambulance service provider more than $500,000 for delayed response times to 911 calls. AMR has appealed the fine and blamed the delays largely on staffing challenges worsened by the county's requirement of two paramedics per ambulance deployed to an emergency.
Kristyna Wentz-Graff / OPB
Geoff Norcross: What do we know about the mediation that’s taking place right now?
Amelia Templeton: Both sides are keeping the details under wraps. That’s how it works. One of the biggest issues though is going to be whether ambulances heading to emergencies need to have two paramedics on board. There are hints that a compromise might be in the works. For example, Multnomah County Chair Jessica Vega Pederson has said that she intended to fine AMR more than $2 million for late service. She said she’d move to collect those fines starting in March, but the county has not tried to collect — and instead is back at the table for a second mediation session.
Norcross: AMR has been lobbying really hard heading into these negotiations for dropping the requirement for two paramedics on ambulances that are responding to life threatening calls. Right?
Templeton: That’s right. The company says it uses one paramedic and one EMT in hundreds of other cities nationwide, and that in most situations, one person ends up driving the ambulance. You don’t need paramedic level training to do that.
The county counters that it’s safer for the subset of patients who are really sick to have two paramedics in the ambulance. County leaders also say it’s a better working environment that provides mentorship for new paramedics and boosts morale.
Related: Multnomah County chair continues to blame AMR for slow ambulances
Norcross: You asked an independent expert about whether it really matters to patient survival, to have two paramedics staffing an ambulance. What did you hear?
Templeton: Yeah, I spoke with Catherine Counts. She has a Ph.D. in health care administration and she’s the quality improvement manager for the Seattle Fire Department. I was really hoping that she would tell me that there’s a clear consensus based on research answering this question. She said, no, it’s a tough one. It’s a “research question.”
Catherine Counts (clip): I appreciate like people are using research for evidence as to why it should be this way. But it’s such a political and a financial question, too.
Templeton: In short, she said there’s a lot of research out there, but it’s ambiguous. And one thing the county has pointed to as evidence that having two paramedics on its ambulances is working right now is that cardiac arrest patients here have a better-than-average survival rate. Those are people who are essentially dead. Their hearts have stopped and need to be restarted.
But Counts said the interventions that are the most proven and most responsible for saving lives after cardiac arrest are quick actions like defibrillation and chest compressions. EMTs can do those things. Paramedics and their advanced techniques do matter, she said, but only if you’re getting those first steps right.
So, there are reasons to be skeptical of the county’s position. And yet, Counts herself believes that when it is feasible, it’s better to have two paramedics on an ambulance working together.
Counts (clip): You have to make decisions on the fly and sometimes you just need a second pair of eyes for that split second decision making.
Related: Multnomah County fines ambulance company for slow response times
Norcross: But don’t AMR’s paramedics have that second pair of eyes? Aren’t fire departments sending teams to most of these serious medical emergencies?
Templeton: They are. There is some nuance and dispute between the county and the fire departments over this point. But I think what a layperson needs to understand is that in any situation where a person is obviously struggling to breathe, bleeding a lot or losing consciousness, dispatch will send a fire rig with an additional paramedic to the scene.
So, we actually have three paramedics at most major emergencies right now.
Norcross: The shortage of paramedics is a nationwide problem. Did you learn anything more about the deeper causes that are at work here?
Templeton: Yeah, I think some of the deeper causes are kind of sleeper problems that the public hasn’t heard as much about. And one of them is surprisingly heavy use of the 911 system by places like nursing homes, psychiatric hospitals, even regular hospitals.
These are all places that are short-staffed. Nursing homes, for example, might have sicker, more complex patients who are going back and forth to the hospital more often. There are fewer options for non-emergency medical transport available, and that’s sort of pushing people into the 911 system.
Related: AMR pressures Multnomah County over ambulance staffing rules
Norcross: So we have mediation between the county and AMR right now. What will you be looking for in any kind of compromise that might emerge?
Templeton: Three things. First, are they doing anything to address that issue of use of the 911 system for non-emergency medical transport? Second, whether there’s any flexibility on that two paramedic standard that Multnomah County has been so adamant about? And then finally, what happens to the county’s proposal, which is that some ambulances should be staffed only by EMTs because the majority of 911 calls are low priority and don’t need any paramedics?