Administration and Leadership, Ambulances & Vehicle Ops, Communications & Dispatch, Training

Detroit’s Efforts to Improve EMS Response Includes Dual-Role Fire/EMS

Issue 1 and Volume 41.

Three years ago, the Detroit Fire Department (DFD) was barely able to keep apparatus running and crews responding to 9-1-1 calls. While city firefighters raced from one blaze to the next, a separate EMS division responded to more than 100,000 medical emergencies annually.

Critically underfunded, response times to EMS calls were terrible. Detroit firefighters, who at that time didn’t do medical first response, focused solely on the extraordinarily high number of structure fires that regularly tear through abandoned buildings. An obsolete EMS fleet often broke down before EMTs and paramedics could answer the flood of calls from patients waiting for medical aid. At the department’s lowest point, EMS responders covered the city of more than 688,000 citizens with as few as four ambulances, leaving on-duty EMTs and paramedics without a working vehicle to respond to calls.

It wasn’t always this bad. Established in 1860, the DFD once protected a vibrant, growing metropolis. By the 1920s, Detroit was the fastest growing city in the United States, thanks to America’s budding passion for the automobile. At the time, the DFD was likely the fourth largest fire department in the country.1

However, the intervening years haven’t been kind to the Motor City. By 2010, the population plummeted to barely 700,000—a drop of more than 60% from the 1950s—as city dwellers fled for the suburbs.2 Large corporations seemingly vanished overnight. Huge sections of the town became abandoned.

The once-proud fire department collapsed into a dismal array of outdated and rundown equipment, demoralized personnel and cringe-worthy response times.

In 2012, the DFD responded to approximately 140,000 emergency calls annually from 43 fire stations, according to statistics obtained from the department. Just over 5% of those calls were for fires. More than 95% of the structural fires were caused by arson—50 times the national average.

Average response times for medical calls were a stunning 22 minutes. Residents had learned to report a shooting in order to improve their chances of seeing an ambulance. Improper use of ambulances as a “taxi service” was rampant.

On July 18, 2013, the city of Detroit filed for bankruptcy—the largest municipal bankruptcy filing in U.S. history by debt.3 After months of legal wrangling, the bankruptcy court ruled Detroit eligible for Chapter 9 on a whopping $18.5 billion debt.

Recognizing the desperate situation in the fire department, city leaders knew that they had to make improvements and make them quickly. However, change is rarely easy or quick, especially in the fire service. In 2013, an aggressive plan by then-Mayor Dave Bing called for increased equipment and staffing. But for any changes to occur, the city would need something they didn’t have: money.

Financial assistance was sought from corporate sponsors and wealthy local donors. Legendary auto race team owner Roger Penske stepped up and donated 23 new medic units. To maintain the new fleet, the DFD’s Apparatus Division was turned over to the city’s General Services Division.

Next, the DFD needed qualified, trained personnel to fill the EMS seats.

Current Mayor Mike Duggan had already overseen the turnaround of the Detroit Medical Center. After serving as the president and CEO, he ran as a write-in candidate for mayor, pledging to reduce crime and promote economic development and financial solvency. His goal, he said, is to make Detroit a model city.

Duggan’s hands-on, expectations-driven approach was appreciated and supported by the DFD personnel. “He’s the glue pulling the city together and making significant changes to all city services. He told them his vision and what he expected,” says recently retired DFD Fire Commissioner Edsel Jenkins, CPA, MPA. “With him, failure is not an option.”

Detroit Fire Department has hired new ambulance staff

The DFD has hired 100 new employees since March 2014 and the city has budgeted to hire a total of 303 new personnel to help staff 22–27 ambulances per day. Photo Dennis Walus

TURNING THE CORNER

As a businessman, Duggan knew that if Detroit was going to attract people to live, work and play in its city, there had to be big changes to the way the fire department conducts business. When he began making changes, he didn’t just set the direction, he sat in on fire department discussions.

Detroit faced the same issues as other fire departments in large cities. However, Duggan’s approach differed from the traditional focus on fire suppression and lip service to EMS. He believed that one of the key elements for improving medical response times and the quality of patient care was to change the traditional firehouse philosophy. “We had to reshape and redefine the culture of the Detroit Fire Department,” Jenkins says.

The changes required significant involvement of the union. Although Jenkins admits that there are “a handful of dinosaurs,” many of the firefighters are embracing the concept. “Most of them understand that we are behind the times,” he says.

Born and raised in Detroit, Jenkins joined the fire department in 1977. He had seen the bad times get worse, but like most of the other department members, he stayed. Jenkins explains that every firefighter and EMS responder clearly has a heart for the city and the people who live there. They proved their dedication by continuing to respond through the difficult times. Even at its lowest point, he says that less than 1% of all the employees—about 5–6 people—left the DFD. “It’s a testament to our personnel,” he says. “They love this city and love what they do.”

Structure fires regularly tear through Detroit's abandoned buildings.

The extraordinarily high number of structure fires that regularly tear through Detroit’s abandoned buildings is a major reason Detroit is one of the last major cities transitioning firefighters from single-function to dual-role firefighter/EMTs. AP Photo/Carlos Osorio

THE PLAN

Key to the plan was to hire a smart, passionate and dedicated head of the EMS Division. Duggan didn’t have to look far. He found that person in Sydney Zack, LLM, NREMR. With a master’s degree in employment and labor law, Zack spent several years specializing in fire and police cases for the city prior to being hired at the DFD.

As the second deputy fire commissioner (administrative leadership consists of five civilian commissioners), Zack’s job is to oversee the EMS and Communications Divisions and the changes Duggan envisioned. One of the key changes was the ability to assign EMS personnel to work as field training instructors to the firefighters on fire apparatus.

“These are not unilateral changes. To succeed, you have to have union buy-in. For the first time ever, we’ve been able to do that with them,” she says. Union presidents representing EMS rank-and-file employees and supervisors continue to meet with the DFD leadership team bi-weekly to proactively discuss management and labor issues.

Rebuilding the EMS system from scratch also required establishing key performance indicators. Zack, under the guidance of the city’s new “lean” manager, began to track a series of specific metrics, including response times—both system wide, from call-taker to on-scene time, and by specific unit—out-ofservice time and hospital turnaround time. Each would be examined for areas of improvement. To help reduce the number of system abusers, the EMS Division now coordinates with social services agencies to address ongoing issues.

Detroit’s leadership also recognized the importance of seeking expertise and guidance from outside the city. A number of national experts and consultants were brought in to share best practices and exchange ideas, including Ed Racht, MD, and other team members from American Medical Response (AMR).

As the long-time EMS physician and chief medical officer of AMR, Racht says he’s been fortunate to have experienced many different EMS systems, including fire-based, municipal third service, volunteer, hospital and non-governmental structures. “The challenges facing EMS in Detroit were massive, both logistically and clinically,” says Racht. “Meeting with Detroit’s fire and EMS leadership, it became really clear they’re passionate about not just fixing what’s broken, but becoming a leader in contemporary EMS. The entire EMS profession should keep an eye on not only what Detroit does, but how they are able to do it. I suspect there will be powerful lessons for all of us and the communities we serve.”

Detroit Fire Department added 15 new ambulances to its fleet.

In addition to 23 ambulances donated to the derpartment, the DFD added 15 new ambulances to its fleet in 2015. Photo Dennis Walus

The full-scale plan to reduce response times and improve patient care includes:

New equipment: “Our ambulance fleet has been completely refurbished,” Jenkins says. In addition to the “Penske ambulances,” as they are known around the department, the DFD purchased 21 Ford F-350 ambulances with bodies by American Emergency Vehicles in 2015.

Jenkins didn’t forget the fire side. The department added 10 new engines in 2015, with another six to be delivered this year. Nine more will be purchased at a later date. “Fire apparatus must be fully functional and dependable in order to do additional medical work with EMS,” Zack says.

Additional personnel: Since March 2014, the DFD has hired 100 new employees. The city has budgeted to hire a total of 303 new personnel to help staff 22–27 ambulances per day, plus four roving units called “Romeos.”

Private ambulance providers: Detroit EMS has always shared duties with private ambulance providers. Recently, however, the DFD used a “request for qualification” to negotiate a contract with four private ambulance companies. Their job is to assist during the peak times of 10 a.m. to 1 a.m. Start times are staggered to optimize coverage. As part of the agreement, all private ambulances are now dispatched as Detroit EMS units, similar to the New York Fire Department (FDNY) system, which uses hospital service ambulance as “9-1-1 ambulances.” This allows the DFD to dispatch, coordinate, track and accurately report response times for all 9-1-1 units.

Upgrades to dispatch: According to Zack, the DFD faced some of its biggest challenges attempting to make changes in the 9-1-1 call center. For the first time, call-takers and dispatchers utilize the Medical Priority Dispatch System (MPDS). The program had been paid for several years ago, but was never implemented. Even so, it wasn’t an easy sell, she notes. “You have to get fire and police in the room at the same time. We had those relationships and got the right people in the room talking to each other.”

The new technology standardizes the 9-1-1 intake process, allows important data to be captured and provides crews with critical information on each call, alerting them to potentially dangerous situations. MPDS training began in January 2015 and was launched in July.

With the system-wide changes made in operations and the new personnel, the DFD has reduced response times to a consistent 10 minutes or less, Zack says. “The department sees implementation of MPDS as helping it reach the mayor’s goal of eight minutes on critical care runs,” she says.

Integrating fire and EMS: Typically one of the most difficult of all endeavors, the integration of fire and EMS in the DFD has been remarkably smooth, especially considering the department has had single-function firefighters for 150 years—a decision based on the unusually high number of fires in Detroit, particularly from arson. To reduce the fire load and free firefighters for medical calls, the city is in the process of razing abandoned structures through the Blight Authority. Arson investigations also got a boost when eight police officers were assigned to work with the fire department’s enhanced Arson Squad.

So, while firefighters began receiving medical first responder training, Detroit’s EMTs and paramedics began attending the fire academy. Eventually, Jenkins says, the fire department will respond to emergencies with 43 ALS fire engines and trucks, plus another 29 BLS-certified engines.

Detroit medic units run with one paramedic and one EMT. Zack says that won’t change once the department is fully integrated with the fire side.

The cost of the training is covered by Federal Emergency Management Agency (FEMA) grants. EMS employees are used as field training instructors to provide expertise and guidance for the firefighters during medical calls.

Along with the new ambulances, the four Romeo units serve as quick response SUVs staffed by two EMS responders. Eventually they will include firefighters. “This is one of the integration tools to get firefighters to start working with EMS,” Zack says.

Cross-trained responders will also see a bump in pay. “The mayor wants to be fair,” Jenkins says. “Pay will be addressed in the next round of negotiations,” he noted.

As of August 2015, all new hires will be dual-trained. And, beginning in 2017, applicants must be dual-function responders as a condition of employment. “There are a lot of moving parts going on with this restructuring right now,” Jenkins says. “Within another year, we will start functioning as one, unified department.”

SECOND DEPUTY COMMISSIONER SYDNEY ZACK

Detroit Fire Department Second Deputy Commissioner Sydney Zack

Photo courtesy Syndney Zack

EMS personnel often take a variety of paths to the profession, but few are as unique as Detroit Fire Department (DFD) Second Deputy Commissioner Sydney Zack, LLM, NREMR.

The 38-year-old Detroit native began her career as a lawyer. Like others in EMS, she brings distinctive skills to emergency medicine and, in the process, has helped to shape the course of EMS at the DFD.

After graduating from the University of Michigan in Ann Arbor, she received her law degree from Wayne State University. Zack worked for several Detroit law firms before landing a plum job with the city of Detroit in 2008. At the same time, she began working on her master’s degree in labor and employment law.

At the city, Zack served as the assistant corporation counsel for the labor and employment law section for just over three years before being promoted to second deputy fire commissioner for the DFD in 2013. While working in the city’s law department she appeared as a management advocate for labor arbitrations, handling civil litigation and advising management citywide on employment policies. It was in her roles as advocate that she solidified important relationships with the leadership of various public safety unions.

EMS attracted her attention because it seemed to be adrift among the other, stronger unions. “There was no in-house advocate for EMS. It was just going on autopilot,” she says.

In addition to the daily management of the EMS Division and Communications operations, Zack oversees employment operations, which includes coordinating human resources transactions, handling grievances and participating in labor negotiations and arbitrations.

Despite her best intentions, Zack knew that she would forever be considered an outsider unless she was able to understand what it was like for the EMS providers on the street. So she attended the first responder certification classes alongside firefighters during the initial stages of the integration process of fire and EMS, eventually passing the National Registry exam. She then took it a step further, just recently completing an EMT course; National Registry pending.

“It was really an eye-opening experience,” she says of her taste of EMS. In her work as an attorney, she had always witnessed cases after the fact. “It’s kind of interesting because now I’ve seen all the pieces together,” she says.

Zack attributes the fast pace of the current changes in EMS at the DFD to a strong mayor and a cooperative relationship with the unions. “EMS personnel have been working to be heard and supported for a long time. That never happened until Duggan came to office,” she says.

She also believes that her outsider status allowed her to see beyond the traditional ways of doing business and develop new approaches to making EMS, and the department, work better. “The goal is to make it better for the citizens and the providers who do the work,” she says.

THE CHALLENGES

Led by a forceful mayor, Detroit is improving in multiple arenas and, most importantly, attracting residents back to the city. The tax base is increasing, local businesses are helping to invest in the infrastructure and EMS is seeing fewer trauma calls. Although it’s early, Detroit appears to be turning the corner. The improvement is impressive, but there’s still work to be done.

Labor negotiations will need to hammer out a plan for compensating firefighters and EMS responders for their dual roles. The DFD must also contend with a mismatched fleet— all but the Penske units are Fords.

As in most organizational recoveries, there have been setbacks. Probably the most public involved an EMT on one of the Romeo units who initially refused to respond to a CPR call involving an infant. According to an internal report dated June 11, 2015, the EMT wasn’t concerned for her safety, but rather was reluctant to “perform CPR for what she perceived to be an extended period of time.” The child died at the hospital and the EMT was quickly fired, but the very public fallout has detracted from the positive changes being made by the department.

Zack can’t comment due to the current investigation, but says the incident is being investigated criminally.

Most recently, Jenkins announced his retirement. He says he’s leaving to join his wife, a Detroit school teacher, who’s also retiring. In an unprecedented move, Detroit has named Eric Jones, a former assistant chief of police and most recently the director of the city’s buildings, safety, engineering and environmental department, to replace Jenkins as fire commissioner.

One of the key elements in repositioning the DFD to better and more quickly respond to medical calls was to change the traditional firehouse philosophy of simply paying lip service to EMS. Photo Dennis Walus

CONCLUSION

Although many fire departments have struggled to keep apparatus on the road and personnel in the seats, no single department has suffered as spectacularly as the DFD. The basics—personnel, equipment and training— that most of the rest of the country takes for granted had to be rebuilt from the ground up.

In December 2014, Mayor Duggan announced that Detroit had emerged from bankruptcy, but admitted the city still faces financial challenges. Those challenges directly affect the fire department. Despite these setbacks, the DFD has made a remarkable turnaround in record time.

Both Jenkins and Zack attribute a large share of the success to Duggan. “He’s one of the smartest people I’ve ever met. He grasps the nuances of issues between fire and EMS. The only way you get to the future is by understanding how all these pieces fit together,” Zack says.

They’re also proud of the way the public has stood by the fire department. The changes that are taking place today, they say, couldn’t have happened so smoothly or so quickly without the confidence of the citizens of Detroit. “We appreciate the support from the public,” Jenkins says. “I love my town.”

Acknowledgment: Thank you to Sydney Zack and the Detroit Fire Department for their cooperation in the development and publication of this article.

REFERENCES

1. Vargas Z. Life and community in the “Wonderful City of the Magic Motor”: Mexican immigrants in 1920s Detroit. Michigan Historical Review. 1989;15(1):45–68.

2. Linebaugh K. (March 23, 2011.) Detroit’s population crashes. The Wall Street Journal. Retrieved Nov. 10, 2015, from www.wsj.com/articles/SB10001424052748704461304576216850733151470.

3. Bomey N, Snavely B, Priddle A. (Dec. 3, 2013.) Detroit becomes largest U.S. city to enter bankruptcy. USA Today. Retrieved Nov. 10, 2015, from www.usatoday.com/story/news/nation/2013/12/03/detroit-bankruptcy-eligibility/3849833/.

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