It might seem ironic to some that Minnesota, a state not known for diversity, is the birthplace of one the most diverse EMS departments in modern day U.S. history. It might also seem ironic that its inspiration, the diverse Pittsburgh EMS agency–called Freedom House Ambulance Service, was dissolved during the height of its support by prominent clinical leaders due to politics.
It’s certainly an ironic twist of fate that 45 years after training its first class of low-income African Americans, Freedom House was reborn. The new Freedom House Ambulance Service, this one launched in St. Paul, Minnesota, was created by a collaboration of area organizations recognizing a need to not only diversify its mostly Caucasian workforce, but also to provide an occupational opportunity for populations in underserved communities.
The rebirth of the St. Paul program was illuminated by powerful speeches from three of the original Freedom House Ambulance Service members at the spring 2012 St. Paul Fire Department (SPFD) EMS Academy graduation, but the groundwork and spark for the new Freedom House Ambulance Service began much earlier.
Birth of the Original Freedom House
It was 1966. For African-American communities like the Hill District of Pittsburgh, unemployment was epidemic. Social services were nonexistent. Calls for emergency medical assistance were returned with silence, delayed responses or inadequate care.
These conditions were unacceptable to community activists Phil Hallen and James McCoy. Together, they proposed a program that provided economic opportunity and emergency medical care to a community that had neither.
They enlisted the expertise of Peter Safar, MD, a prominent anesthesiologist. Safar, a pioneer of resuscitation techniques, was fueled by the death of his 11-year-old daughter from an acute asthma attack and a passion for bringing advanced emergency care to the patient in his research and practice.
The convergence of these forces birthed an audacious, community-based, employment and training program that was the seed of paramedicine and the home of one of the first (and most diverse) ALS training programs in the U.S.–Freedom House Ambulance Service. However, the Freedom House program has often been neglected in EMS history.
Freedom House Enterprises recruited 25 young African Americans from their community. This included several veterans returning from Vietnam and others who carried the burdens of poverty, drugs and alcohol abuse. They began training the first class of students in 1967.
With Safar involved, the program was rigorous, requiring long days in the classroom and lab. Safar noted early on that some of the students lacked basic skills in reading and math. However, as a testament to their persistence and the commitment and quality of the instructors, many of the students obtained their general educational development (GED) degree and continued with their medical training well after Freedom House.
Safar never swayed from his vision, and the Freedom House recruits had the support of the faculty, their community and each other. Their loyalty and drive to succeed carried them through the challenging program, which consisted of more than 160 hours of preparatory training in anatomy, physiology, medical ethics and advanced resuscitation techniques.
The year-long program also required six weeks of hospital-based training in the operating room and emergency department, the intensive care unit, the morgue and medical wards. The recruits also were required to attend medical rounds and lectures with residents, something many EMS programs don’t incorporate even today. They were trained, mentored, monitored and evaluated on the job, where they responded to emergencies under the watchful eyes of, and in consultation with physicians.
Freedom House Ambulance and the unexpected success of the once-underemployed and impoverished recruits realized Safar’s vision of bringing bring critical lifesaving care to underserved patients.
Special Premier of the Documentary ‘Freedom House’
A special 90-minute documentary on Freedom House Ambulance, sponsored by Jones & Bartlett Learning, will be presented from 7:30 to 9 p.m. March 7 at the EMS Today Conference & Exposition in Washington, D.C. Registered attendees will be admitted free to the premier at the Washington Convention Center. Q&A to follow.
Early Freedom House Operations
Freedom House Ambulance Service started with two donated police “wagons” and operated on a shoe-string budget. They responded to more than 5,800 calls in their first year, transporting more than 4,600 patients, mostly from within the African-American districts of Pittsburgh.
Word of this novel program spread rapidly through the community, particularly after the 1968 riots following the assassination of Martin Luther King, Jr. In fact, Freedom House medics worked together in an unprecedented collaboration with the largely white police force to provide emergency care to the sick and injured in communities devastated in the wake of the riots.
The activities of the Freedom House Paramedics are some of the first accounts of paramedics providing ALS skills in the field, and this timeline could arguably place Freedom House paramedics as the first in the nation to provide this level of care.
By 1973, with new grant funding, Freedom House was able to obtain its signature orange-and-white ambulances, which were packed with the latest medical equipment. They continued to carry model advancements in emergency care while providing compassionate care to a once-abandoned community.
As the public began hearing about this new service, the cry “send Freedom House” led to a further expansion of the service into other regions of Pittsburgh, where Freedom House paramedics often encountered racial tensions.
The expansion continued, and the service hired an increasingly integrated workforce. In 1974, Safar assigned a young critical care resident, Nancy Caroline, MD, as the new medical director of the Freedom House ambulance service. Caroline often rode out with the crews, advising them by phone and catching a brief nap at their station on a stretcher between shifts.
Caroline was mentor, teacher and friend to many of the crew members during her tenure at Freedom House Ambulance. She led the service through advancements in the areas of disaster medicine and critical care in the streets. She even obtained a Department of Transportation grant and developed the first paramedic textbook Nancy Caroline’s Emergency Care in the Streets, which became one of the most widely used, and popular, paramedic textbooks for years.
End of an Era
Despite the involvement and support of clinical leaders, like the outspoken Safar and the young and ambitious Caroline, the political winds were shifting in Pittsburgh. A newly elected mayor chose to replace the Freedom House paramedics by funding a city-run ambulance service.
To preserve the original community-based service, Safar insisted on a written agreement that “grandfathered” the Freedom House paramedics into this new service. But once in place, this agreement was systematically dismantled, leaving only a fraction of the original personnel. Many original members, like paramedic pioneer John Moon, remained and advanced through the ranks despite encountering racial barriers along the way. Others took their training and experience elsewhere, becoming leaders in public health and safety in other major cities.
Fast Forward
There’s no shortage of EMTs or paramedics in St. Paul. In fact, the Twin Cities of Minneapolis and St. Paul have three strong paramedic schools, and EMS employers report a large pool of applicants. Why then would it be necessary to launch a new and unique recruitment and education program for EMS in the area?
The answer is a lack of diversity. Although official statistics from most Twin Cities ambulance services are not kept, Minnesota EMS leaders acknowledge that less than 2% of paramedics in the Twin Cities are non-Caucasian.
Although many EMS agencies have escaped public criticism for their lack of diversity, the St. Paul Fire Department (SPFD) has been scrutinized for this over the past decade. The entrance test and hiring practices have been the subject of several contentious lawsuits and many newspaper stories. In response, SPFD has been proactive in the recruitment and hiring of diverse candidates.
SPFD may actually be the most diverse ambulance service in the state. Today, the department boasts 80 members of diverse ethnicity (18%) and 19 women (4%) out of its 435 members.1 Some might even ask if 18% diversity is enough. After all, isn’t the state of Minnesota 85% Caucasian?
The non-Caucasian populations of St. Paul and Minneapolis are 37% and 44%, respectively.2,3 This includes large Hmong, Hispanic and Somali groups–each of whom have unique language, cultural, and healing practices. At the time of publication, SPFD has yet to hire its first Hmong firefighter/EMT, and other local providers have no black or Hispanic EMTs or paramedics.
The reality is that the issue of diversity in EMS requires a deeper contextual perspective and rests on more than just skin color. If serving our communities with excellent medical care requires better understanding of these cultures, couldn’t we just educate the current workforce?
Becoming more culturally competent should be the goal of any healthcare provider, and wouldn’t we also want to hire at least some personnel who are already fluent in both language and cultural practices of these groups?
Sadly, if you ask a Hmong, Hispanic or African-American child from a low-income family in the inner city what career they might dream of, “emergency medical services” is simply not on the top of their list. Unfortunately, even if it was, their guidance counselors might be quick to point out that low pay, difficult access to expensive training, and a competitive job market make other careers more attractive.
The educational reality in our inner-city schools is an economic and racial catastrophe. Minnesota’s black and Latino students have some of the worst reading and math scores in the country (45 and 38 points lower than their white counterparts).4 Inner-city youth of diverse ethnicity have a higher likelihood of ending up in the penal system than in college.
It’s not just a matter of appropriate representation and good patient care. Having a labor force that is representative of the communities that we serve allows economic opportunity for all of the city’s residents. It can also save taxpayers millions if we reverse the path of one young person who might otherwise be disenfranchised from education and employment as a whole.
If even one of these youth at risk embraces a career, earns a living that supports their family, and avoids jail, there’s an average cost savings of $20,000—30,000 per year in court costs and governmental assistance for food and shelter; the savings to the taxpayer are significant.5
So you can now see why SPFD’s visionary Chief Tim Butler, jumped at the chance to work with the city’s already successful St. Paul Parks and Recreation Department Youth Job Corps (YJC) and Inver Hills Community College (IHCC) to start an innovative new EMS program.
YJC places low-income youth in summer jobs around the city. In 2009 a surplus of youth and the dollars to pay them brought the Parks and Fire departments together. The initial idea was to have YJC workers helping clean fire stations, much as they help dig ditches for the highway department or clean parks facilities. Instead, Butler suggested that these funds be used to train interested applicants as EMTs.
The EMS Academy provided free EMT training and an hourly pay of $7.50 per hour for low-income city residents under the age of 24 who qualified for YJC. These students wouldn’t otherwise be able to afford the training, books, and certification exam costs.
With all of the EMT classes at the time being offered in suburban colleges that required difficult commutes, the EMS Academy became the first EMT class open to the public inside the city limits.
When the program began to experience serious challenges in coordinating the needs of low-income youth, additional partnerships became critical. The Community Action Partnership of Ramsey and Washington Counties provides a social worker who can help troubleshoot emergency food, medical, and shelter needs. Adult basic education specialists from the St. Paul Public School’s Hubbs Center help inside the classroom providing instructional support, pre-course work and remediation.
EMS Academy Diversity by the Numbers
Eighty-one EMT class graduates have a NREMT first-attempt pass rate of 85%.
>> Forty-two percent (42%) of the participants are African-American.
>> Fifteen percent (15%) are Hispanic.
>> Eleven percent (11%) are Asian.
>> Eleven percent (11%) are Caucasian.
>> Nine percent (9%) are Native American/American Indian.
>> Ten percent (10%) are multicultural.
>> Two percent (2%) are other.
>> Fifty-four percent (54%) are female.
Success–But What Kind?
The SPFD hiring list is created nearly every four years and is highly competitive, with 3,000 initial applicants vying for a small number of openings. After the first three EMS Academy classes, the employment statistics and rates of graduates continuing to college painted the program in a good light. However, it also became apparent that the graduates were securing jobs in many healthcare venues, e.g., emergency departments and nursing homes, but not inside the EMS workforce.
Area ambulance services indicated they were passing over EMS Academy EMT graduates because of their lack of experience. The program was at an impasse.
In 2012, an amazing thing occurred. Three of the original members of the Pittsburgh Freedom House Ambulance Service delivered inspiring graduation speeches for the St. Paul Fire Department EMS Academy spring class.
Seeing the similarities in the Pittsburgh and St. Paul projects, Butler approved a request to rededicate Station 51, which had been converted into a training academy, as Freedom House Station 51 in honor of the original members of Freedom House ambulance.
During the original members’ St. Paul visit, a recently released documentary by Gene Starzenski was screened in a closed door summit of EMS leaders. The meeting provided insights as to the systemic barriers that inner-city youth face when seeking employment in Twin Cities EMS agencies.
Seeing that competent EMT graduates weren’t being hired was difficult for administrators. Although employers often cite the lack of diverse qualified candidates, the new, more rigorous requirement of qualified and experienced candidates was an even bigger challenge. Graduates’ lack of training, coupled with shrinking grants from foundations, prompted novel action on the part of the EMS Academy. Regions hospital, a local Level 1 trauma center which provides medical direction for SPFD and IHCC, had a pressing need to transport stretcher bound discharged patients home. The combination of these needs propelled a landmark event in Minnesota EMS: The creation of the SPFD non-emergency BLS ambulance scheduled transport service.
A New Freedom House Transport Service
In July 2012 SPFD, in line with Mayor Coleman’s youth initiatives, the St. Paul Department of Human Rights, the Parks Department, Regions Hospital and IHCC received City Council approval to launch the EMS Academy YJC-BLS unit.
Inver Hills instructors volunteered to coordinate additional training, scheduling and field supervision. Two college ambulances were leased to the city for $1 to minimize start-up costs. Regions Hospital and Allina Health EMS funded uniforms, pagers and other operational needs.
The local EMS community embraced the idea and viewed it as a beneficial partnership and “feeder system” for diverse employees. Allina and HealthEast Medical Transportation, two local private ambulance services went as far as supporting it with additional donations and run referrals.
Ten graduates of the EMS Academy were hired back at $7.50 per hour (without benefits) in a temporary YJC job class with St. Paul Parks, and placed under the supervision of SPFD for training. On July 9, 2012, the BLS service was officially launched. The new service has completed more than 500 runs in its first six months of operation.
The funds generated by the ambulance service are able to wholly sustain the operation of the BLS ambulance service, and excess funds are used to support future Academy projects. In addition to providing a multilingual and culturally diverse ambulance service to St. Paul and receiving accolades from patients, the crew has found remarkable success securing jobs. Of the original 10-member crew, seven now have jobs as EMTs with local ambulance services.
All SPFD BLS unit workers are required to attend classes to further their EMS education, with the goal of attaining paramedic certification. Beyond those working for the BLS service, roughly 50% are pursuing further their education and 70% have found jobs in a medically related field.
Access Gene Starzenski’s documentary on the Freedom House website. www.freedomhousedoc.com.
Summary
Freedom House is our national EMS legacy. It was a revolutionary idea born out of the convergence of political forces. It’s our EMS history, but it isn’t found in our textbooks. Today we labor over the need to build workforce diversity, create community paramedicine and increase physician interaction during paramedic training. Freedom House had all of those things, yet we have collectively forgotten.
Freedom House isn’t about being the first. It’s about believing in the power of each individual to achieve success. It’s about building a system of clinical excellence and responsibility to the public.
The original Freedom House paramedics became known for their advanced medical care, but to those they treated, they were known for their compassion and commitment to public service.
References
1. Hallman C. (Jan. 30, 2010). St. Paul wants more black firefighters. In Twin Cities Daily Planet. Retrieved from www.tcdailyplanet.net/news/2010/01/30/st-paul-wants-more-black-firefighters.
2. Reilly K, Santiago T. (Summer 2012). St. Paul Trends Report. In St. Paul Department of Planning and Economic Development. Retrieved from www.stpaul.gov/DocumentCenter/View/60943.
3. U.S. Department of Commerce. (Jan. 10. 2013). Minneapolis (city), Minn. In U.S. Census. Retrieved from http://quickfacts.census.gov/qfd/states/27/2743000.html.
4. Minnesota School Boards Association. (n.d.). Achievement Gap in Minnesota. In Minnesota School Boards Association. Retrieved from www.mnmsba.org/Public/MSBA_Docs/achievementgap.pdf.
5. U.S. Department of Justice. Federal prison system operation cost per inmate. In U.S. Department of Justice. Retrieved from www.justice.gov/archive/jmd/1975_2002/2002/html/page117-119.htm.
Resources
>> Bell RC. The Ambulance: A history. McFarland: Jefferson, N.C. 2008.
Participant Profiles
Tianna Ross: Prior to the EMS Academy, Tiana didn’t consider becoming an EMT and didn’t have a clear idea of what to do after completing high school. She helps care for her brother as if she were a single parent. Near graduation, one of her guidance counselors told her about the summer EMT class that paid an hourly wage. Ross signed up with the program and, despite a rocky start, completed the EMS Academy. She now works on the BLS service. When asked about how she has changed as a result of the Academy, Ross states, “When I was in high school I thought that I was just going to get a job in retail or fast food and I was going to stay there for the rest of my life. And since this program, I know I’m not going to be working a dead-end job. I know my future is bright, and I know that good things will come to me.”
Clarence Fraser: After a brief attempt at a college football career, Clarence returned home to cope with his attention deficit hyperactivity disorder. Although his academics improved, he was forced to withdraw because he couldn’t afford the school’s tuition. He enrolled in the 2010 class of the EMS Academy and is now one of the senior members of the BLS service. Fraser is completing his advanced EMT classes and aspires to become a paramedic at St. Paul Fire.
Koua Xiong: The Twin Cities are home to the largest concentrated Hmong population in North America. One of the early calls the BLS service took was for a Hmong man who didn’t speak English. Luckily, Koua Xiong was on the call. Koua, a crewmember of the BLS service, understood his cultural and personal needs. Koua remarks, “I was happy I took the call. I knew from the start that any of my co-workers would have difficult conversing and explaining what they were doing.” He learned about the EMS Academy in a local Hmong newspaper. When he first started the EMT course, his reading levels were at seventh grade. After EMT certification 10 weeks later, he tested at an 11th grade level. He now works on the BLS service and with Allina Health EMS, and he’s finishing up his associate’s degree and paramedic curriculum.
