A Difference in Culture

Last week Dr. Juliette Saussy’s resignation letter as medical director from DC Fire/EMS went viral. Rather than pencil whip the clinical skill verification for 700 provider’s National Registry recertification, she quit. She described a “toxic culture” at DFEMS and named names, from the fire chief, city council, the union, and crews who don’t answer their radio.

It is ironic that current DCFEMS chief Gregory Dean came from Seattle, whose fire department is widely regarded as the best EMS system in the world, and has a culture that expects excellence from its EMS System. Culture was a recurring theme in Seattle/King County EMS Medical Director Mickey Eisenberg’s book In his book Resuscitate! How to Improve Cardiac Arrest Survival in Your Community.

Since the 1970’s, Dr. Mickey Eisenberg and Dr. Leonard Cobb have been on the cutting edge of cardiac arrest care and airway management.  When Seattle Fire paramedics arrive on a cardiac arrest, there is an expectation that the patient will survive. In DC that patient would be an outlier.

In 2008, a few fire chiefs and several medical directors ago, a JEMS article titled From Worst to First? described how DC was going to transform its EMS system by becoming a “fully integrated all-hazards agency.” This was despite a previous blue ribbon committee’s recommendation to separate EMS from fire, and it has not worked out well. There have been almost daily stories about long response times and abysmal patient care in the seven years since then, and as Dr. Saussy pointed out in her letter, more incidents that do not make the news.

Here are a few examples of cultural differences:

  • Seattle publishes, and even advertises, their arrest survival rates and paramedic response times in annual reports. Dr. Saussy writes that these are not measured, or accurately measured in DC.
  • Paramedics in Seattle are selected among firefighters, many of whom are paramedics who become firefighters only hoping to have a shot at being part of the elite Medic 1 program. In DC EMS is a primarily a role forced upon people who don’t want it, a JV team for a fire position, or a resume builder for one of the surrounding counties. A few dedicated medics who provide good patient care are stuck in the middle, who do the best they can in a broken system.
  • In Seattle, Dr. Eisenberg apparently has influence in operations. He believes in having as few paramedics as possible to maintain skill proficiency, and having them dedicated to medicine. In his book he writes:

“Dual training an individual to be both a firefighter and a paramedic, then expecting stellar performance in both jobs, reflects a hope based on what is probably a flawed concept…The point is that paramedics must be allowed to learn the skills they need and then to hone them as professionals. This is not to say that they can not work within fire departments, but only that, except in emergencies, they should not be asked to perform the duties of firefighters.”

In DC, a search is underway for a medical director willing to work in its current structure, which has failed. It is said that if you want to get rich, do what rich people do. Residents of Seattle have a rich EMS system. Residents and DC have a system that keeps trying get rich quick schemes that keep failing. Nothing will change until the culture does, and the pressure to do so will have to come from forces outside city government.



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